Medical experts call for independent review of Spain’s coronavirus response

In a letter published in 'The Lancet,' 20 Spanish professionals stress the need to identify why the country is faring worse than its neighbors in order to better prepare for future pandemics

A health worker in the Basque Country testing residents of San Sebastián.
A health worker in the Basque Country testing residents of San Sebastián.Javier Etxezarreta (EFE)
Javier Salas

A group of 20 Spanish epidemiologists and public health experts have published a letter in the scientific journal The Lancet asking for an independent review of the Covid-19 response in Spain, where coronavirus cases are soaring again in one of the world’s hardest-hit countries.

The letter notes that Spain had more than 300,000 cases, 28,498 confirmed deaths and around 44,000 excess deaths as of August 4. More than 50,000 healthcare workers have been infected, and nearly 20,000 deaths were in care homes.

“With a population of 47 million, these data place Spain among the worst affected countries. Spain is also reported to have one of the best performing health systems in the world and ranks 15th in the Global Health Security index. So how is it possible that Spain now finds itself in this position?,” ask these experts, some of whom work abroad at institutions such as Oxford University, Toronto University and Johns Hopkins University.

We encourage the Spanish government to consider this evaluation as an opportunity that could lead to better pandemic preparedness, preventing premature deaths and building a resilient health system, with scientific evidence at its core

It is a question that many Spaniards are asking themselves these days. On Thursday, the Health Ministry reported 580 active outbreaks across the country, and the Basque government admitted that it is already experiencing a second wave of the coronavirus epidemic.

Spain ranks eighth in the world for Covid-19 fatalities, taking into account the official figure of around 28,000 deaths. But the 45,000 calculated by EL PAÍS based on regional and other records would put Spain in fifth place, with similar figures as the United Kingdom.

And the numbers get worse relative to the population: Spain has 61 deaths for every 100,000 people, higher than Italy (58), France (45) or Portugal (16). Within Spain, there have been huge differences between regions like Madrid, Castilla-La Mancha and Cataluña, with over 30,000 fatalities, and other parts of the country with a much lower death count.

“Potential explanations point to a lack of pandemic preparedness (weak surveillance systems, low capacity for PCR tests, and scarcity of personal protective equipment and critical care equipment), a delayed reaction by central and regional authorities, slow decision-making processes, high levels of population mobility and migration, poor coordination among central and regional authorities, low reliance on scientific advice, an ageing population, vulnerable groups experiencing health and social inequalities, and a lack of preparedness in nursing homes,” posit the authors of the letter. “These problems were exacerbated by the effects of a decade of austerity that had depleted the health workforce and reduced public health and health system capacities.”

The experts who signed the letter include leading researchers such as Margarita del Val, a virologist at the Severo Ochoa Cell Biology Center; Manuel Franco, a researcher at Johns Hopkins University in the United States; Daniel Prieto-Alhambra, a pharmacoepidemiologist at Oxford University in the United Kingdom; Rafael Bengoa, who served as an advisor for Barack Obama’ health reform; Carme Borrell, a manager at the Barcelona Public Health Agency, and Carles Muntaner, a professor of public health at Toronto University in Canada.

“A comprehensive evaluation of the health and social care systems is now needed to prepare the country for further waves of Covid-19 or future pandemics, identifying weaknesses and strengths, and lessons learnt,” says the letter. “We are calling for an independent and impartial evaluation by a panel of international and national experts, focusing on the activities of the central government and of the governments of the 17 autonomous communities.”

The authors underscore that the goal of this independent evaluation they are requesting is not “to apportion blame.”

You cannot conduct your own evaluation of your own actions
Helena Legido-Quigley, London School of Hygiene & Tropical Medicine

“Rather, it should identify areas where public health and the health and social care system need to be improved. Although this type of evaluation is not usual in Spain, several institutions and countries, such as WHO [World Health Organization] and Sweden, have accepted the need for such a review as a means towards learning from the past and preparing for the future,” they write.

The initiative was started by Helena Legido-Quigley, an expert in public health who is affiliated with the London School of Hygiene & Tropical Medicine. “It is important to know what happened, now that the situation is not as difficult as it was at first, especially so we can be ready for a potential second wave in the fall,” she says.

“It would be very good for Spain to do it, because right now things are still being done so-so by some administrations, and we need to be better prepared for the future,” adds Legido-Quigley, who began contacting colleagues about her idea when she heard that the World Health Organization wanted to conduct its own evaluation.

This expert also stresses the importance of not politicizing the initiative. To bring home the point, the letter was signed by 20 people of varying political affinities, said Legido-Quigley. Some of these experts have worked for governments from across the political spectrum, both in Spain and abroad.

Ideally, the evaluation committee would be able to conduct anonymous and confidential interviews of individuals working at all levels of the pandemic management, in central and regional governments, says Legido-Quigley, who is also affiliated with the National University of Singapore.

“This kind of evaluation has more negative overtones here, but it is customary at centers and institutions – you cannot conduct your own evaluation of your own actions,” she notes.

The review of Spain’s response should analyze “governance and decision-making, scientific and technical advice, and operational capacity. Moreover, the social and economic circumstances that have contributed to making Spain more vulnerable, including rising inequalities, must be considered.”

The letter ends with a call to the executive of Prime Minister Pedro Sánchez: “We encourage the Spanish government to consider this evaluation as an opportunity that could lead to better pandemic preparedness, preventing premature deaths and building a resilient health system, with scientific evidence at its core.”

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