Spain, at the time of publication on 1 June, had recorded around 50,000 cases of coronavirus infections among healthcare professionals – representing a fifth of all recorded cases – with 70 deaths.

Authored by Javier Crespo, president of the Spanish Society of Gastroenterology, José Luis Calleja, vice-president of the Spanish Association for the Study of the Liver, and Antonio Zapatero, president of the Scientific and Medical Associations Federation, the analysis of the Spanish experience outlines several factors that explain why the country has the dubious record of the highest number of COVID-19 cases among healthcare professionals.

“Our health system has had serious structural issues for several decades,” he writes. “These problems worsened following the 2008 global financial crisis and have impaired the response to this emergency.” 

He cites these problems as: 

1. health system fragmentation due to division into 17 health regions; 
2. an inadequate Ministry structure, due to transfer responsibilities to the regions;
3. poor investment in healthcare, below the European average; 
4. no proactive strategy for tracing contacts or searching for potential cases, and public health specialists working as advisors rather than out in the field; and
5. an inadequate response from industry and insufficient investment in research and innovation limiting adaptation during the pandemic. 

The article explains how the European Centre for Disease Prevention and Control (ECDPC) advised countries on 2 March to warn the general population about the impending threat of COVID-19, to put in place COVID-19 diagnostic protocols, to build stocks of protective equipment, and to implement social distancing to disrupt transmission. According to the analysis, the Spanish Central Government Health Authority did the opposite: the population was uninformed; plans for diagnostics were inadequate for the population at large; personal protective equipment for healthcare professionals was not ordered; and many public events went ahead. Consequently, the virus was allowed to spread.

The weekend of 7-8 March saw a huge increase in the number of infected individuals in Spain, with the World Health Organization (WHO) declaring COVID-19 a pandemic few days later. However, the country did not go into lockdown until 15 March. 

Planning mistakes at the health service delivery level were also made, says the article, including: 

1. failure to provide sufficient personal protective equipment for healthcare professionals;
2. no government recommendation to test healthcare professionals with mild or no symptoms;
3. contacts of positive COVID-19 cases were neither systematically tested nor quarantined, and testing of healthcare professionals in contact with confirmed cases was never recommended; and
4. many Spanish hospitals did not set up triage outside hospitals, which has been shown to be effective in reducing in-hospital infection rates and infection of healthcare professionals.

Health services had little chance of containing the virus, says the article. However, there is now hope thanks to the population’s compliance with lockdown rules and the flexibility shown by the health system in increasing hospital beds and intensive care facilities. The rapid construction of temporary hospitals, such as the Hospital IFEMA in Madrid, is also applauded.

Short-term lessons include immediate investment in protective equipment and use of reliable diagnostic tests to screen all healthcare professionals, with regular testing for those workers treating COVID-19 patients. Medium- to long-term lessons include increasing investment in the healthcare and biotech sectors, as well as in improving epidemiology fieldwork. 

The commentary argues that lockdown should not end until specific tests are widely available to assess the population, and even then, measures should be lifted gradually. 

“Our authorities should not make the mistake of placing economic or political interests before health,” Crespo concludes. “If they do, we will see a recurrent outbreak resulting in greater morbidity and mortality.”