Closed parks and open bars. This image – which was seen when the Madrid administration introduced a perimetral lockdown in 45 basic healthcare areas, as well as during the central government’s deescalation plan – is a good illustration of how decisions on the coronavirus pandemic are being made by politicians without scientific grounds.
Politicians have the last word on the difficult balancing act between protecting the health of the community and maintaining the economy open amid the spread of a contagious virus. But in many cases, technical criteria are left aside in favor of measures that are based less on the available evidence and more on party tactics and populist goals. On Sunday, 55 scientific associations once again called for the fight against the coronavirus to be guided by the available evidence and not by political considerations.
In a document called On Health Matters, You’re In Charge But You Lack Knowledge, the group – made up of the leading medical and scientific associations in the country and representing 170,000 health professionals – asks political leaders to let science guide the decision-making process. “Accept, once and for all, that to handle this pandemic, the main decisions must be based on the best scientific evidence available, completely disconnected from ongoing political battles,” the document states in its first point.
The declaration is likely to be a response to the feud between the Madrid administration and the central government over how to control the spread of the coronavirus in that region. The Spanish Health Ministry – with the support of the majority of Spain’s regions – issued new rules last week which indicate that a city of more than 100,000 people must be confined and subject to other social restrictions when the following criteria are met: a cumulative coronavirus infection rate over two weeks that exceeds 500 cases per 100,000 inhabitants, a positivity rate of PCR tests that is above 10%, and more than 35% of intensive care unit beds occupied by Covid-19 patients. These thresholds were agreed to by both the Madrid and Spanish government during negotiations on the basis that they would be applied to all cities in Spain. But Madrid premier Isabel Díaz Ayuso recanted on the deal after seeing that only 10 cities in the Madrid region exceeded these limits. Although the regional government applied the Health Ministry’s restrictions on Friday evening, placing 10 cities under a perimetral lockdown, it has filed an appeal against the measures with Spain’s High Court, the Audiencia Nacional.
“I understand that there might be some haggling when it comes to reaching agreements, because we are not talking about an exact science, but this must always end in a deal. If not, it is a disaster that hurts everyone and erodes the trust of citizens,” says Ignacio Rosell, a professor of public health at the University of Valladolid.
Rosell believes that not all politicians are guilty of prioritizing politics over science, arguing that many have followed the scientific advice, even if they are also guilty of grandstanding. “The problem is that a cautious region on its own cannot prevent the impact of other [regions]. There’s the impression that this has already become a fight over who gets not to be confined. Politics are being prioritized over public health,” he adds.
But the politics-versus-science debate is not that straightforward, argues Pedro Gullón, the spokesperson of the Spanish Epidemiology Society, which did not sign the document. “The economic side looks for results that are different from the health side, and there could be a contradiction,” he says. “Politicians must work to find the balance that best fits.” Gullón adds that the evidence on how to address the coronavirus pandemic is not always that solid. “Often we base [decisions] on past experience, in what is seen to be the most sensible thing to do, but there will not be studies that show what works best at each moment for years to come.”
Rafael M. Ortí Lucas, the head of the Spanish Society for Preventive Medicine, Public Health and Hygiene (Sempsph), which signed the declaration, agrees that there are no foolproof mathematical thresholds when it comes to taking action and that the scientific evidence is “complex.” But, despite this, he believes that measures “can be based on scientific criteria.” “During the deescalation process when we had an incidence rate of 40 cases per 100,000 inhabitants, we discussed whether we should reopen or not and we decided to evaluate the situation every two weeks,” he explains. Today the average 14-day cumulative incidence rate of the coronavirus is 269.49 cases on average in Spain and 647.91 in the Madrid region. “It’s not right to be sitting around since July to see what happens, and arguing about this or that. We may have our doubts but we must analyze things, see what measures we can introduce and analyze them as we go along,” he says.
Indeed, 17 Spanish medical experts warned in a letter published in the prestigious journal The Lancet that results were not being properly reviewed. José Miguel Cisneros, the head of infectious diseases at the Virgen del Rocío hospital in Seville, and the former head of the Spanish Society for Infectious Diseases and Clinical Microbiology, which signed the document, agrees with this critique. “Spain has been the leader of the first and second waves. We have not learned due to the lack of assessment, we have not done any self-review, nor used the available evidence and this is what we are calling for,” he says.
Here is a list of decisions that have been made in the past months without scientific evidence.
Since the beginning of the pandemic, for one reason or another, decisions have been made without scientific evidence, which is itself not fixed, but has changed as new discoveries have been made. One example is the use of face masks. There was no solid proof supporting their effectiveness when they were first introduced, but now the issue is no longer a matter for debate. Although this is only partly true in Spain, which has made them mandatory in all public spaces even when no one else is around. “That doesn’t make sense,” says Ortí Lucas. “If it is to ensure that [masks are worn] where they are most needed, which is mainly indoors or in crowded areas, it could be a good measure. But that needs to be explained, and they are not doing that,” he says.
Definition of a coronavirus case
Defining who is suspected of being infected with the coronavirus is the first key step in tackling the disease, as it allows doctors to narrow in on cases. The lack of tests at the beginning of the pandemic meant that the definition was initially very restrictive. According to Cisneros, during the first days of the pandemic, tests were only being done on people who had been in China. Infectious disease experts asked for tests to be done on all unknown pneumonia cases. “If that had been done from the beginning, we would have detected earlier that the virus was already in Spain and we would have been able to save lives,” he says.
Since the beginning of the health crisis, mistakes have been made with rapid tests. “First, they were bought without being proven to be effective and had to be returned. Then they were used in the mass testing of populations, such as health workers, when this is not useful,” says Cisneros. The same problems happened with the new antigen tests, which are good for detecting the virus among patients with symptoms but not for the general population. Despite this, the Madrid government rolled out fast antigen testing in areas with high transmission rates.
Cities with fewer than 100,000 inhabitants
Experts say that it is “arbitrary” to only apply the coronavirus thresholds to cities with more than 100,000 inhabitants. “What has to be seen is if the chains of transmission are known. It’s true that in a small town you can have a very high incidence rate and not need restrictions because it is much easier to find out where the outbreak started than in a big city, but we have to analyze it according to each case,” says Ortí Lucas.
Closed parks, open bars
Some Spanish cities and regions have proposed closing parks, even though the risk of contagion is 20 times lower in outdoor spaces. “If you close parks, you are encouraging indoor activities, which is counterproductive,” says Guillón, who adds that the Health Ministry’s restrictions on indoor dining should be stricter. Under the new rules, published last Friday in the Official State Gazette (BOE), hostelry establishments in confined areas must reduce capacity to 60% in outside dining areas and 50% indoors. “Maybe the proportion should have been 75% outdoors and 25% indoors. Or to completely close indoor dining,” he says. Rosell points out another contradiction: “Distance between tables must be respected, but not between chairs at the same table.”
English version by Melissa Kitson.