Covid 4/28/22: Take My Paxlovid, Please

Many have made the observation that if you had told people two years ago that we would have a cure (not a vaccine, but a cure!) for Covid-19 that was free, safe and effective, but that no one wanted to take it, and Congress wasn’t willing to fund further purchases, people would not have believed you. And yet here we are.

The White House is trying to fix the situation. I’ll cover the details below.

We haven’t learned much new about China. When we do, it will go into its own post. I did get private supporting evidence that the situation in Shanghai is being characterized roughly correctly.

Executive Summary

  1. Paxlovid is available, no one wants it.
  2. Case counts up now that we’re past Easter.
  3. Cases hit local peaks including in NYC, indicating BA.2 wave won’t be too bad.

Also, did you hear? Elon Musk is buying Twitter.

Let’s run the numbers.

The Numbers


Prediction from last week: 277,800 cases (+20%) and 4,100 deaths (+71%!?)

Results: 328,762 cases (+41%) and 2,485 deaths (+2%!)

Prediction for next week: 400,000 cases (+22%) and 2,720 deaths (+10%?)

On deaths this is one of the biggest misses I’ve had, and it’s not one of the ones I look back on and instantly feel was simply stupid – often it’s obvious in hindsight why I messed up, and mostly this isn’t one of those cases

There was a huge drop for Easter, and it was sustained even as cases popped back up even more than I expected. I don’t understand it, but the distributions involved look real. I can only interpret this as ‘we had inflated death numbers for a while that weren’t real, and now we have less of that’ because I can’t think of any other way to make sense of this. I guess I’m predicting a small increase next week here, but I mostly notice I am confused.

I believe a lot of this jump in cases is related to Easter, and the details suggest that we are going to be reaching another local peak soon especially in the northeast.


That is not many deaths. I don’t know how to interpret the drop being sustained in a way that makes the drop ‘real’ which is why I’m assuming this means that the death counts were previously artificially high.

This in turn makes me wonder if death counts have been artificially high at other times as well.


New York City cases have plateaued and are falling. This is a big deal because New York was ‘ahead of the curve’ on the current BA.2 wave, and there is uncertainty about how far things are likely to go before they stabilize. If NYC is stabilizing at this low level, it strongly suggests there is nothing to worry about.

The Northeast echoes this, with only a small increase. The larger increases in other areas seem like they have a lot to do with Easter, and involve being ‘farther along’ and/or different weather conditions. Yes, cases are up quite a bit, but the upside risks have diminished, which is the most important thing.

Physical World Modeling

Elizabeth finds Home Antigen tests useless in terms of keeping your gathering safe, based on them failing to find Covid cases. Cue tests were most effective although potentially overly sensitive and definitely expensive. $250 fixed cost for the reader plus $65 per test is not a reasonable additional cost to impose in most circumstances. If my job asked for such testing daily (as did the workplace in the post) and I wasn’t paid at least mid six figures, I’d be pretty upset. She did note that the antigen tests are still good at knowing if you had gotten over Covid yet and could end your isolation, which is a different use case.

Alas, public health information in many places continues to say the opposite, and even cancelling rapid test appointments for people with recent Covid.

For any ‘normal’ gathering, at this point in the pandemic, I do not think asking people for tests is reasonable. I can see an exception for exceptionally risky things like group indoor singing.

Paxlovid! Get Your Paxlovid! Anyone? Buehler?

It seems no, basically no one. It is quite the scandal that we have life saving medicine and we mostly cannot use it to save people’s lives.

So far we have administered about 500k courses of Paxlovid, which is less than 1/3rd of what was distributed or 1/10th of what was purchased.

That does not mean it is time to throw up our hands and stop buying it. If another wave comes, we will need it badly. Even if one doesn’t, over time we should presumably get at least somewhat better at getting Paxlovid to people who need it. Worst case, we can open it up to everyone and make it clear there is sufficient supply, until there isn’t sufficient supply anymore.

The White House is trying to address the situation (links to the announcement). Here are some of the things they are doing:

That all sounds like ‘tell people about the new life-saving medicine and enable them to get it’ except now we mean it and we’re going to do more of these things. Which is better than doing less, I have nothing against any of these steps. Yet given how things have gone so far, this will all presumably be inadequate to the job at hand.

The Stat News article about this pinpoints a key part of the problem quite nicely, but fails to label that it did so.

The treatments are authorized only for those with risk factors for severe illness — but as much as 60% of those who are contracting Covid may be eligible for the antivirals, because common risk factors like age and diabetes are included.

Our policy, as illustrated by this short advice video from the White House correctly advising people to try and get Paxlovid, here is the worst of both worlds. We are giving people the impression that they are not eligible and that taking Paxlovid for themselves would be selfish and unfair to those who need it more, so much so that no one uses our supply at all. Also we are not buying as many doses as we could and soon may be buying none at all.

This might be another issue.

In other White House news, the Vice President has Covid.

Which is relevant here, because she took Paxlovid (obviously) and, well…

That’s what we call ‘medical ethics.’ A call to not give the best available life-saving medicine to the literal Vice President of the United States.

If you think it’s ‘unfair’ that the VP gets the best possible medical treatments even when they are expensive or in short supply, what does one even say to that?

So yes, I have some idea how we ended up not giving out a lot of our Paxlovid.

New York City is doing an excellent job of all the things on Biden’s agenda here, other than overall communication. Communication is hard, even with no one trying to stop you.

Evusheld is also much harder to get than it needs to be.

Pandemics Are Bad and We Should Prevent Them

Maybe even spend some money towards that goal. Congress previously made a deal to take $10 billion in previously allocated funds for Covid and allow them to be used for Covid in a different way so we wouldn’t be totally out of money for things like making sure people who have Covid get tests and medical treatments, and letting us purchase things like Paxlovid.

That deal fell through. No money.

The ‘step up’ in statements like this is ‘be willing to spend any money on basic Covid things, at all.’

The op-ed has no revelations for us, all standard things that seem reasonable enough. It’s not that we should do all of the things, but it’s that we should have a sufficiently functioning government that we should be able to spend some money on some of the things. Yet we don’t. We spent trillions on “stimulus” much of which was clearly unnecessary, and always a tiny fraction of that for actual pandemic prevention, medical treatments, healthcare and research. Thus we have a lot of inflation and a high chance that future pandemics go no better than this one that cost us trillions of dollars and killed quite a lot of people.

Reasonable people can disagree on the number, and on exactly what to do with it. They can’t claim the right number is zero.

Prevention and Prevention Prevention Prevention

FDA Delenda Est, and even so, for Christ’s sake, yes this is happening no really.

The FDA is forbidding you from vaccinating your child because they worry that if they approve one vaccine, then later approve another vaccine, then that might be confusing. I have typed that sentence. It is composed of words.


Can we find anyone out there, anyone at all, who said “Well you know they approved the Pfizer vaccine, but then they also approved the Moderna vaccine, and now I’m so confused”? Are those words that have ever come out of anyone’s mouth? If they did, how would you react to this person?

The good news is Moderna has now asked for authorization so we can get both vaccines approved without any confusion over the total lack of confusion.

Bunch of people expressed confusion about why I talked about P100 and other ‘super-masks’ as an option. It is because they provide much stronger physical protection in ways that are very obvious, at the cost of mild social awkwardness (plus some actual physical awkwardness and a little bit of money), assuming you are permitted to wear one. Which before you sometimes were not, because that’s not what the mandate said and we are here to fulfill mandates rather than prevent Covid.

In other news, Philadelphia imposed a mask mandate, then lifted it four days later, claiming it was due to ‘reduced cases,’ which is not even a plausible lie. It was a scary sign when they imposed the mandate, so it’s highly reassuring to know the people refused to stand for it.

Think of the Children

Masks interfere with life in lots of small ways that add up to quite a lot, latest expression of this:

I feel it too, and I sense it in others. That’s so much more clear now that the masks are mostly gone except for the subway.

I also agree with this take in reply that this is part of a much larger, slower moving and more encompassing crisis of safetyism.

In Other News

The Atlantic suggests taking this opportunity to end security theater more broadly. As you know I strongly agree. Would be great if this becomes a cultural moment and political issue.

What is holding up Novavax’s vaccine? Manufacturing problems. We were luckier than we know to get Pfizer and Moderna ‘on time.’

Healthcare null hypothesis watch, labeling potential donors to a hospital so they’d get better care led to them dying more often edition.

Not Covid – Elon Buys Twitter Edition

Elon Musk is buying Twitter. I thought about buying some stock at various points but ultimately did not do so, which I consider at least a little bit a mistake but it is hard to know what probability I should have assigned on the deal going through at various points (including before Musk was involved at all and I simply thought someone should buy the place).

I have indeed been saying, when in conversations with those in EA who have the kind of money to at least think about such matters, that it would be an excellent idea to buy Twitter. It has long been one of my short list of clearly good uses of large amounts of money. To be fair, it was out of the relevant people’s price range, but it still feels like a lost opportunity and maybe I should have tried harder.

Then again, if Musk does what he says he is going to do and turns Twitter into a bastion of real free speech and open sources the algorithm and opens up the protocol and doesn’t care about profits and adds lots of great new features and other neat stuff like that, then Musk spent $44 billion dollars so the rest of us didn’t have to. That’s pretty sweet, even if I’m sad for the distraction in terms of electric cars and space colonization and even tunnels. Then again, can this man even be distracted?

The opposition to Musk buying Twitter is diverse, here are the opposition’s Top 10:

  1. Being rich bad. Elon Musk bad.
  2. Orange man bad.
  3. Free speech bad because kiddie porn and terrorism, ban political dissent.
  4. Free speech bad because trolls and spam, ban political dissent.
  5. Free speech bad because misinformation, ban political dissent.
  6. Free speech bad because ‘hate speech,’ ban political dissent.
  7. Free speech might be good/bad but haha good luck with those regulators.
  8. Free speech good but endangered by this man who wants free speech.
  9. Free speech good but free speech means safe spaces without political dissent.
  10. Free speech good for me but not for thee. There, I said it.

The only remotely interesting version of this is a take on #8 where people point out Tesla’s interests in China, and that Musk may thus be forced to play along with them. It is best summed up here, with so many people quoting the first Tweet and no one mentioning the other two:

If you’re looking for particular examples, the internet had a clear winner.

The whole thing made it very clear that while there is widespread support for the concept ‘free speech’ few of those people even understand the concept of what I would consider free speech, and they would not enjoy the increased commerce and cultural production thereby.

The best part is: Were you wondering who is for free speech, and who is against free speech? Real free speech? Now you know.

Also good to get this periodic reminder when it seems others are losing their minds.


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40 Responses to Covid 4/28/22: Take My Paxlovid, Please

  1. maline says:

    To be fair, the most typical response is more like “Don’t ban political dissent, only bigotry. Is it my fault that all my political opponents are bigots?”

    I do think point 8 is a real issue. Musk gets offended pretty easily and can be very vindictive and impulsive. If he’s not careful to limit his own direct control, he could easily become a petty dictator of his private “public square”.

  2. Dave B says:

    >>Elizabeth finds Home Antigen tests useless in terms of keeping your gathering safe, based on them failing to find Covid cases.

    Were they swabbing throats or just noses? (My conjecture: just noses.)

    My brother took daily rapid tests, at the height of the omicron wave while living with our parents. He was swabbing his throat. He caught a pre-symptomatic case very early and got out of the house; no one else got it from him.

  3. J says:

    I have the 3m p100 you linked. It’s definitely more socially awkward, but I find it more comfortable than disposable masks, and it doesn’t fog my glasses like those do.

    I’d still like to hear more about long term personal risk calculus in the context of potential future variants. For example, several folks have made the point that omicron is very mild and confers good cross immunity. Severity can’t go negative but it can go way more positive, so maybe this suggests being extra carefree right now.

    It’s also weird trying to navigate the world after being so careful all this time. Presumably we’ll see more serious variants coming with time to prepare, but balanced risk mitigation is more complicated than the set of very conservative measures we had in place and were used to sticking to.

    Also, it sure would be nice if we could just buy paxlovid OTC and keep it in our medicine box. Which would let us incentivize Pfizer directly to make lots of it. Central planning FTL.

    • Two reasons:

      (1) Paxlovid supply is still somewhat limited. The synthesis is complicated and involve reactions that take weeks to complete.

      (2) Paxlovid contains separate medications. One is ritonavir, which inhibits the liver enzyme CYP3A and thus slows the breakdown of the other component (nirmatrelvir). This makes paxlovid last longer in the body, and more suitable for oral availability. But… it means it inhibits the breakdown of literally hundreds of other common drugs, too!

      So you shouldn’t take paxlovid without a doctor reviewing everything else you take, including supplements. Otherwise paxlovid could harm you greatly, including killing you.

      A family member of mine had to get an antibody infusion instead of paxlovid because of a blood thinner he needed daily to prevent clotting around a medical device implant, for example. If we’d just naively given him paxlovid, he might have bled out internally. If we’d withdrawn the blood thinner, he might have gotten lethal clots. Nobody knows yet how to titrate the dose of the blood thinner during paxlovid treatment.

      So letting people buy stockpiles of paxlovid both aggravates the supply problem and gives people a shot at injuring themselves severely. Making it prescription only, and having docs check the list of prescriptions makes it safe.

  4. George H. says:

    I’m undecided on Musk and twitter. I’m pro free speech, but bringing that to twitter seems like something the congress should have done. Having a single strong man do it is a bit scary. (open to later abuse) Similar to the Caesar solution to our political divide,
    if congress is broken and can’t fix things we vote in a dictator.

    • TheZvi says:

      We definitely don’t have enough supply for private citizens to buy a reserve of Paxlovid.

      • J says:

        I think this was meant in reply to my message above. I’m getting flashbacks to “don’t buy N95s” from 2020, so if you will permit me a rant in song form (I realize I’m preaching to the choir):

        If we lived in Libertarian Utopia and the market set the prices for Paxlovid, it would have been enough

        If insurance companies had taken on Pfizer’s development risk in exchange for the first year’s production, it would have been enough

        If Pfizer set a socially-acceptable below-market price, but offered first refusal to hospitals who would prioritize vulnerable patients, it would have been enough

        If the feds had taken on the development risk and contracted for first refusal on all doses of Paxlovid this year, it would have been enough

        If the feds had merely promised to buy a sufficiency of doses subject to FDA approval, it would have been enough

        If the feds had rationed Paxlovid when it was in short supply, but continuously relaxed restrictions as supply outpaced demand, it would have been enough

        If the feds had rationed Paxlovid, then finally stopped once it was obvious that 2/3 of doses were languishing on the shelves, it would have been enough

        But the feds outlawed price gouging, made us wait for FDA approval, rationed supply, failed to budget for more as supply increased, and failed to relax restrictions as supply increased, so 300 people a day continue to die of covid in the US.

    • Ninety-Three says:

      I think it is a massive net increase for free speech if Musk lives up to even half his free speech talk while simultaneously being a petty hypocrite who bans all criticism of himself and Tesla. It is less than ideal, but that is a *much* smaller and less important set of taboos than Twitter is currently operating under.

  5. Zane says:

    Offices that are requiring Cue testing are paying for them. Workers aren’t paying out of pocket.

  6. myst_05 says:

    The funniest part about the valved masks is that there’s absolutely no reason to think that they’re any more unsafe than regular cloth or surgical masks, as air easily escapes those masks from the sides. The velocity of air escaping from my 3M respirator isn’t significantly faster than the velocity of air escaping from the sides of my surgical mask. But of course having a valved mask was seen as “selfish” so they were banned without second thought.

    Those who want to stay protected will have a much better time moving forward. I don’t know why people seriously believed that cloth or surgical masks that constantly slipped on people’s noses provided any protection to them.

  7. bbeck310 says:

    I tested positive on a home test on Friday morning. Here was my experience (in suburban Chicago):

    * Used the government site to look for test and treat locations, All the ones in my area were at CVS. I went to the CVS website to try to make an appointment, and there were no appointments available anywhere,

    * I emailed the test to my PCP and requested a prescription for Paxlovid, to be sent to the usual Walgreens I go to; the government website claimed that Walgreens carried it. My PCP immediately sent over the prescription, and checked the drug interaction lists to tell me to pause one of my medicines while taking Paxlovid. Good doctor,

    * The Walgreens that received the prescription had none in stock, and told me it would be available in 6 days. Fortunately, Walgreens has a pretty good app that let me look for another pharmacy with it in stock. After changing it over, I got a call from the pharmacist that that one also didn’t have it in stock, but he found a third that actually did. I was able to pick it up Friday evening.

    * After taking Paxlovid, my symptoms never got worse than a sore throat and cough.

  8. Basil Marte says:

    > If you think it’s ‘unfair’ that the VP gets the best possible medical treatments even when they are expensive or in short supply, what does one even say to that?

    That fair and good are two different concepts? That it is good for this case to be unfair? Or — to be more charitable to the ethicist — that, counterfactually, a state of society which both had our productivity &c. but had a very even distribution of organizational structure would be better (in terms of most people being happier to live in that kind of society, independently of their personal level of organizational centrality); alas, we don’t know how to do that, and having a hierarchy of hubs is worth the other benefits it makes available.

    Distractions: I agree with the great value on space, largely on electric vehicles, (somewhat on grid lithium batteries, in case they do manage to beat storage alternatives after all), but I don’t see the value in tunnels (nor hyperloop). Sure, if TBC both could build cheaply under the cities that currently have stupid costs (because they are able to avoid most/all of the reasons “normal” contractors can’t) and would build tunnels for things other than cars, then that would be stellar, but neither part of the conjunction seems likely to me. Even partial success as cars in relatively-speaking-cheap tunnels (i.e. still expensive compared to at-grade) is mostly uninteresting; allowing some (driverless?) taxis into bus lanes achieves the same goal of allowing people to pay through the nose for fast private travel through an area where the concentration of economic activity makes land expensive. If digging tunnels for the purpose of parking, or an additional lane — including an opposite-direction lane to a one-way surface street — of car traffic is a bad value proposition, then the same land uses aren’t earning their keep on the surface either, and form a massive amount of fruit hanging lower than tunnel-boring. On the cost side, as far as I can tell TBC, specifically as cars-in-tunnels, occupies a large fraction of societal “attention”/”mindshare” about the future of urban transportation.
    Do we disagree?

    • TheZvi says:

      We disagree in the sense that I do not think TBC is taking up non-trivial mindshare, and didn’t outside of the month or so it was the new hotness (although not the current thing). I also think that even if TBC ended up doing other tunnel things (e.g. NYC subways!) it would still be a big win, and we should be happy it’s being explored even though I also don’t expect the hyperloop concept to work out – but I’m also not 100% it won’t.

      • Basil Marte says:

        I specifically said that TBC cheaply doing “other tunnel things” is the potentially very valuable (“stellar”) thing about it, but the low probabilities to it produce a meh expected value. Whereas TBC failing at cheapness but being willing to build non-car tunnels is just as uninteresting as the cheap-car-tunnels outcome, since expensive-train-tunnels is exactly what the “normal” contractors already do. (Which is exactly why I don’t fancy TBC’s chances at cheapness. Those contractors can dig e.g. highway tunnels for in-international-comparison high but not eye-popping prices just fine in the parts of the US that are not NYC or SF, and roughly the same can be said about building construction for that matter. Thus most of the problem is not technological, but probably governmental, with some share being logistical (moving oversize equipment and megatons of rubble through a city). TBC building subway lines for NYC from municipal/state/federal funding would get bogged down in red tape and stupid requirements much like anyone else.)

        TBC trying to completely end-run around several layers of government and building yet another NYC subway system privately is also improbable. The obvious is that government still gets it. The less obvious is that urban transportation modes are close substitutes (and routes are extremely close substitutes) thus usually none of them can capture much of the surplus they create for their passengers. (Transportation creates land. A real estate developer turning farms into a suburb *can* capture a good part of the value created by a road or rail line. “Streetcar suburbs” were a thing.) This is another reason why urban transit gradually came to be funded and controlled by municipal and regional governments.

  9. atgabara says:

    I commented on the last China post, but not sure if you saw it. You said that cases weren’t going down in Shanghai, but that’s not correct. The data on Our World in Data seems lagged or just inaccurate. The 7 day average in Shanghai has been decreasing since April 14. Source:

  10. Elon Micron says:

    Zvi, what would be your best estimate of the infectiousness (basic reproduction number) of the newest variants – BA.2.12(.1), BA.4, BA.5?
    Are they easily transmitted through surfaces, so I need to return to disinfecting things?
    How dangerous are they compared to the “standard” omicron (BA.1/BA.2)?

    Also, any plans to investigate the topic of super-masks (e.g. LG PuriCare 2)? I may need one in indoor spaces – Covid did a lot of damage to young people in my circles, and these new variants are almost impossible to avoid without the highest degree of protection.

    • TheZvi says:

      My guess is they are slightly but not too substantially higher than BA.2’s base infectiousness, and no surfaces still don’t matter and they aren’t any more (or less) deadly.

      I don’t have any plans to investigate the details of different super-masks.

  11. Ninety-Three says:

    Two years ago I would have been surprised, but eighteen months ago I had updated from “we will fuck up just about everything possible” to “we will fuck up just about everything possible and I consistently underestimate the vastness of that possibility-space”, I would no longer have been surprised by your description of Paxlovid.

    I don’t think I was being overly cynical, we had the technological capacity to have a known-effective vaccine in April 2020 and it was *entirely predictable* that given that capacity it would take until the end of the year to get approval.

    • Basil Marte says:

      The next question then is: will the breadbasket degradations due to the Chinese anti-covid measures and/or the Russia/Ukraine war be severe enough that humanity tests ALLFED’s work?

  12. Dean Valentine says:

    It’s not *that* good of a flip. In post #1 he’s responding to Trump suing the company, and making fun of his legal grounds. He didn’t suggest that he can go elsewhere. I think if you asked Robert Reich he would probably say something closer to “free speech for me but not for thee”.

  13. Bobby Shen says:

    Greetings, Zvi. Am I reading this report correctly that vaccine boosters currently have efficacy X, where X is not statistically greater than 50%, against infection (and greater than 50% against hospitalization and death)?

    Click to access Vaccine-surveillance-report-week-16.pdf

    Disclosure: My personal bias is currently the following worldview. Boosters that are twice a year or more often are particularly unreasonable to recommend to the public. From this point forward, a limited segment would want them twice a year or more. However, it is reasonable to recommend a booster once a year which is simultaneous with the flu vaccine, if it is biologically feasible. (If not possible, that’s 2 virus-shots a year which is less ideal but okay).

    P.S. I admire your writing

    • Definitely >>50% for hospitalization/death, that’s overdetermined. Vs. infection is unclear, I’ve added this to my stack for next week.

      Your bias seems reasonable but doesn’t impact how effective the booster is. I’m essentially at ‘it’s fine to recommend whatever you want as long as you’re fine with people not listening.’ I don’t think asking people to get knocked on their ass once a year is going to be sustainable for that high a % of the population.

  14. Honest question: is Musk buying Twitter to create a forum where the general public can say whatever they want, or to create a forum where *he* can say whatever he wants? Like, if I post things on new Twitter that criticize Musk or Tesla or that Musk thinks are dumb or offensive, and my friends enjoy reading those tweets, will the algorithm help my tweets get distributed more widely?

    How do we know, i.e., what evidence do we have either way?

    • Depends on how you apply Bounded Distrust to Musk, and also whether you think he would possibly spend $44 billion to protect his ability to troll when Twitter wasn’t really interfering with his ability to troll. I mostly take him at his word. Even if he’d like to lash out if you criticize Musk, the backlash for doing so would now be pretty large, so he basically can’t.

  15. Yesterday Pfizer read out topline results on a Phase 2/3 clinical trial of paxlovid for prevention of transmission of COVID-19 when one member of a household is infected.

    This would have been a great way to stop the spread of COVID-19 right in its tracks. Alas, no dice. The risk ratio with respect to control was only 32% – 37% reduction, and was not statistically significant (i.e., the confidence interval included 0%, so it could have been chance).

    It was a great idea and a noble effort. I just happened not to work.

  16. Since you mentioned evusheld here, you might be interested in a short explainer I just put up about the antibody engineering, dosing, and checking the math on the efficacy results.

    Basically, there’s a triple substitution in the antibody protein that makes it have an insanely long half-life in the body. Also, high doses are well tolerated, so they dose it at 6x – 22x the levels found in convalescent patients. Starting at a high dose and having a long half-life means you can be protected for quite a while.

    Summary: sophisticated antibody engineering + brute-force dosing = working drug.

  17. M says:

    Hi Zvi, is this (being an infectious rebounder) a valid concern? And if it is, I guess that the 90% long-term reduction of Covid’s worst outcomes still holds true, so one should always take Paxlovid, correct?

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