March 3, 2021

More public health to control the pandemic and prepare for the future

The countries of the European Union are suffering the third wave of the pandemic, with tens of thousands of new infections and thousands of people dying every day with COVID-19. We must not resign ourselves to things being this way, not now, not in the future. If the first wave was difficult to prevent and avoid, perhaps the second and third waves we could have avoided or reduced significantly. Indeed, if we compare our situation with that of other countries that have followed a different strategy, it seems appropriate to ask ourselves: shouldn’t we strengthen public health much more, if we want to avoid new waves and prepare to face future pandemics?

Although each country has faced the pandemic with specific measures and the pandemic may evolve in the coming months in different ways, at this time we can differentiate between a group of countries that have opted for a “mitigation strategy“and another group that has chosen the “suppression strategyThe difference between the two lies essentially in the importance that each one gives to reinforcing resources and measures for public health surveillance and control. The impact on the results of the strategy adopted is, as can be expected, remarkable (Table 1) .

The first strategy, mitigation, focuses on avoiding health collapse, acting more intensely in those moments in which there is already a relatively high community transmission. Its main course of action, therefore, has been the application of mobility restrictions, following the logic that, if contacts are drastically reduced, infections will also fall. The main problem with this strategy, however, is that, by “doubling the contagion curve” and reducing the care pressure and the occupation of ICUs, mobility is allowed again, reducing restrictions, but without having provided sufficient resources to the services and devices of the public health and primary care systems to guarantee the location of new cases and contacts, as well as their isolation. Hence, after a few weeks, infections increase again, blocking health care again and motivating the adoption of new restrictions, more or less severe, limiting mobility and the concentration of people; measures that are sometimes confusing, inhomogeneous and difficult to apply, reducing social involvement as time passes.

The second strategy, of suppression or COVID-Zero, is distinguished by significantly reinforcing the resources of public health systems: sufficient staffing of professionals with means to ensure isolation and compliance with quarantines (the so-called “trackers”); strict public health surveillance at airports, on the streets, in the hotel industry and at the entrance to shops; conducting tests on cases, contacts, and people or groups at risk (for example, nursing home workers, caregivers, etc.), with strengthening of Primary Care to ensure quick diagnosis of new cases, etc. These resources are complemented with computer applications, powerful information systems, means of social and economic support sufficient for isolation and confinement, and penalizing people or entities that do not comply. Finally, unity of command is established and social involvement is sought in the application of the measures. As can be seen in Table 1, the suppression strategy does not go against the economy (false dilemma between health and economy), quite the contrary. The countries that have better controlled the pandemic have been able to avoid greater falls in GDP.

In Spain, “Early Response Plan in a Pandemic Control Scenario“, approved by the SNS Interterritorial Council (CISNS) in July 2020, referred to Royal Decree 463/2020, which had declared the first state of alarm in March, as” the entry into the pandemic mitigation scenario. ” In our country, after the first home confinement, it was achieved that the new cases nationwide fell to less than 500 a day (to have a current reference, in the week of January 17 to 23, 2021, they have been counted more than 35,000 new cases daily).

The new plan approved in July, on the other hand, sought to go beyond reducing the current impact of COVID-19 in Spain, setting the objective of “designing the bases for preparedness and response in the current scenario and in the face of possible future scenarios for the control of the disease “, establishing that the health authorities would guarantee this control. But it has not been that way. The location of the contacts was largely left in the hands of Primary Care doctors and nurses, without time or means to do so, in a weakened public health system after the cuts of the financial crisis. On other occasions outsourced to companies to make phone calls, fragmenting the organization. The lack of sufficient means prevents the health professional and the social worker from really knowing the conditions in which the patient and their family are, so they have significant difficulties in ensuring that the isolation measures are real.

It is true that the majority of the population abides by the indications. But sometimes this is not the case, either because the indications are not clear, because some groups of people are not convinced, or because of the impossibility of maintaining isolation. How can they take advice when they have low wages, precarious contracts, or are self-employed and doing so has a brutal economic effect on their household’s ability to pay rent, get food, or pay the most basic bills?

To stop this pandemic (and face future ones), thousands of public health officials must now be recruited (more than 30 per 100,000 inhabitants), with a structural nature. Your primary task, when the number of daily infections drops after a more than likely confinementIt will be to locate 100% of the new contacts and guarantee their isolation. In inter-pandemic periods, these professionals would work on disease prevention and health promotion. In addition, it is necessary to reinforce Social Services, managing alternative accommodation, replacement income and guarantee of job stability. The authority responsible for public health must guarantee, through the necessary administrative and judicial resolutions, the isolation of infected persons if necessary, providing families with the means for compliance. Likewise, it is essential to recover and strengthen Primary Care to speed up diagnoses and not delay care for non-COVID patients. Finally, it is necessary to pay special attention to the prevention of contagions in residences for the elderly, providing those responsible with sufficient means to do so.

At the legislative level, the Government must fully develop the General Law of Public Health of 2011, reinforcing the Ministry of Health with more resources, so that it can exercise its function of coordination, information and control. It is not reasonable that the information system is incomplete, without a comprehensive database at the state level allowing, for example, the lack of data on weekends and holidays. It is essential to ensure the binding decision-making capacity of the CISNS, to avoid contradictory decisions and inconsistent messages to the population that cause confusion.

The third wave of the pandemic will subside. The important thing is that when mobility is authorized again, the hotel industry is opened, commerce is activated, etc., we have a sufficient number of Public Health professionals, a solid Primary Care, a recovered hospital staff and strengthened public Social Services. The expense required to provide these resources is a very profitable investment. In 2020, the Spanish economy has lost more than 100,000 million euros in this health crisis. The administration of vaccines, based on their real effectiveness, and the global coverage that they reach, will help control the pandemic. But that is not enough and it will also take months. The most effective response, now and in the face of future pandemics (which may be more lethal), is to prepare ourselves to face them in better conditions, drastically strengthening public health services.


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