GP in Spain in times of corona
What’s the situation like in Spain in these times of corona? Dr Jan Otto Landman (Medicine, Leiden, 1979) has a GP practice in Torremolinos and Fuengirola, Southern Spain, and since 16 March he has been writing blogs about corona on the Facebook page of his practice. He has covered issues such as the restrictive measures, the possible finding of a vaccine, medication to combat corona and the different strategies that countries are using in the fight against corona. You can read some extracts from his blogs below.
State of emergency
Spain has been hit very hard by coronavirus, particularly the highly organised regions of Madrid and Catalonia. Andalucia (with 8 million inhabitants) is one of the less affected regions. On Saturday 14 March, Prime Minister Sanchez declared a state of emergency.
16 March: Start of lockdown
Monday morning, a new day, a new week. And possibly a new era. Lockdown. Unprecedented measures have been taken to contain coronavirus. Guidelines received this weekend from the College of Physicians for private practices to prevent the spread of coronavirus. Most of the measures related to general hygiene at a practice. We already regularly disinfected door handles and asked patients to disinfect their hands when they came into the surgery. As with earlier flu epidemics, we made separate waiting rooms for ‘coughers’. The main changes now are that I will start wearing a facemask and gloves when I’m at work.
As well as spending time at the surgery, every day I visit patients who are in hospital. One of my patients has been admitted to hospital with corona. The visit is a real performance: gloves, facemask, protective glasses, operating gown, second pair of gloves all have to be donned before you can enter the room. My patient is happy that the words emerging from the being in its mask, safety glasses and green gown are Dutch. She is being given oxygen via a mouthpiece but apart from that her condition is reasonable. I don’t really add anything to her medical treatment, but an explanation in your own language can be very reassuring.
18 March: Road block
On my way to the practice, there’s another road block. It’s the Policia Local, the most agreeable branch of the police force. The queue moves very slowly; just about everyone has to answer some questions, and for some people it takes a long time. Then it’s my turn. The police officer is wearing a facemask and a bulletproof vest. If I were a virus, my courage would sink to my boots. He asks me pleasantly and politely where I’m going and then gestures to me to continue on my way.
20 March: 14% of hospital staff have the infection
On my way to the practice, I feel very privileged. I’m not likely to suffer corona exhaustion in my work as most of the foreign winter guests and tourists have returned to their home countries. In principle, the role of a GP in this crisis is fairly limited, although it’s still important. Making sure that the right people go into hospital, giving information about the infection, isolating suspected corona patients and definitely not forgetting that besides corona all the other illnesses are still continuing as normal. This is also the season when the elderly are more likely to find themselves in hospital with pneumonia. I wouldn’t be at all surprised if many of them were overlooked, which would be most unfortunate.
The situation in Madrid is very dark, with a new death every 15 minutes. The Spanish media are reporting extensively about the lack of protective equipment, particularly facemasks. In Madrid, some doctors are even working without them and are trying to keep a distance of two metres between them and their patients. Hospital staff, 14% of them are already infected, need to be well protected because they are so vital. And hospital staff who pass on the infection to patients is obviously a nightmare scenario.
One of the world’s richest men is Amancio Ortega, a Spanish textile king and owner of Zara. Ortega is now going to produce, distribute and donate 300,000 masks every month. That’s fantastic, I hear you say. But there is criticism too, just a fraction of Ortega’s wealth could have prevented the depletion of state hospitals over the past ten years and fewer people would have died. It’s food for thought, but in the present situation, all contributions are welcome.
26 March: International criticism of Spain
The thirteenth day of lockdown. Yesterday there were images on internet from two hospitals in Madrid where patients were lying on sheets in the corridors because there were no beds available.
It’s relatively calm at the hospital today as most of the out-patient clinics are closed. The third floor is the lung department where the corona patients are. Outside these rooms there are tables with disinfectants and personal protection equipment, and on the door there’s a warning telling people not to enter. There are around 15 of these rooms in the long corridor and the number has remained the same over the past week. The IC isn’t full either; the situation here in any event seems stable.
The nationwide state of emergency implemented by the Spanish government was probably a saving grace for Andalucia. The seriousness of the outbreak in Madrid meant that Andalucia, at that time in an early stage of the epidemic, also went into lockdown. Spain is very transparent with its figures; there’s a detailed update every day, specified by region and even by hospital. Here are some interesting figures: Andalucia has 8.5 million inhabitants, half the population of the Netherlands, and on Saturday morning (28 March) there were 144 deaths as a result of the virus, ten of them in the last 24 hours. That’s an increase of 7.5%. As of yesterday, the Netherlands had 546 deaths, 112 of them in the past 24 hours, an increase of over 20%. Based on these figures, corrected for the number of inhabitants, Andalucia has half the number of deaths compared to the Netherlands and the death rate is increasing less rapidly.
There has been a lot of international criticism of countries, such as Spain, that were late in taking effective measures. But Spain, with its population three times that of the Netherlands, already went into lockdown when it had 120 deaths as a result of coronavirus. When the Netherlands had that number of deaths, people were still flocking to the beach to get some fresh air and an infected throat.
29 March: What happened to European solidarity?
It’s a bright, sunny Sunday. The restrictive measures have just been tightened in Spain to deal with the peak in intensive care beds that are expected to be needed in the coming weeks. From Monday, only people who work in essential jobs may go to work. There’s still wide support for these measures in Spain.
There’s now increasing criticism in the Spanish press of the Netherlands for blocking financial support to Southern European countries hit by the corona crisis. The Netherlands is critical of the financial policies in these countries and also believes that they are treating patients in IC units who are too old, which is overburdening the healthcare systems. According to the Spanish media, in the US, the UK and the Netherlands Neoliberalism and age discrimination are undermining the right to life. One of the articles, under the headline: ‘Dutch doctors refuse to treat elderly patients suffering from corona in IC units, and let them die at home’ defends the relatively high number of deaths in Spain. Different countries have different ways of counting their deaths. What happened to European solidarity?
31 March: Peak in number of deaths
The situation in Spain is still at its worst, with Madrid reporting 849 new deaths in a single day, the highest number so far. The situation in the IC units in the city is chaotic, and the same situation is threatening Barcelona. Political groups on both the right and left in Spain – even in these difficult times – are mainly preoccupied with blaming and maligning one another.
1 April: Madrid
On the Costa del Sol there are enough IC beds and the situation there seems under control. In Madrid there have been signs in recent days that the number of new deaths is stabilising. However, the situation in the IC units remains dramatic. A coronavirus patient spends on average two to three weeks in the IC unit. With that length of stay, there is very little movement of patients out of the unit, which means that even with fewer admissions, the shortage of IC beds will be a problem for some time to come.
5 April: Cautious optimism
The state of emergency and the lockdown are being extended to 26 April. After three weeks of lockdown, Spain is now seeing a reduction in the number of new deaths in the last few days; the same happened in Italy. There seems to be some basis for cautious optimism.
Another explanation for the more extreme course of the epidemic in Italy and Spain could be that people live closer together in smaller spaces and that they hug and kiss one another more often. Research has shown that in Italy in comparison with Germany there is much more frequent contact between the elderly and young people, so that symptom-free young people have been able to transmit the virus to the elderly.
10 April: Sirens, clapping and music from people’s balconies
The 28th day of lockdown. Yesterday and today are holidays, important festivals in Holy Week. Under normal circumstances, this is when the towns and villages hold their most important religious processions, celebrations that they work on together for a whole year. In 2020, Holy Week is a week of silence, with everyone staying indoors. At eight o’clock in the evening the silence is broken by sirens, clapping and music from people’s balconies and windows. This, too, is community spirit, but 2020 style.
The Holy Week brought some good news for Spain: the number of deaths from coronavirus is clearly lower than previous weeks and seems to be set to reduce further. This new trend is still very much at an early stage and the figures aren’t always reliable, but there is reason for hope.
12 April: Easter weekend
Good weather on Friday and Saturday, days when the Costa would normally be crowded. But now: empty boulevards, empty cafés, empty beaches and no tourist trains. Instead, there’s a big tractor driving through Benalmáden, towing a large tank behind it, and two men in white suits are liberally spraying the streets with disinfectant. We almost think it’s normal. It’s amazing just how much life has changed in such a short time, and who would ever have expected that people would have been so willing to accept the changes
16 - 20 April: Postponing appointments with the doctor
It is quiet at the practice this morning, with no suspected corona cases. But the phone rings incessantly. People seem to be wary of coming to the practice with their health complaints. Too often in recent weeks we’ve seen patients become ill unnecessarily because they’ve put off a visit to the doctor. It’s understandable that people are concerned about becoming infected, but the practice is very clean and it’s not busy. Either that, or they’re worried about getting into trouble with the police on their way to the surgery, even though in all circumstances people have the right to visit a doctor. If necessary, we send a mail or app in advance to confirm the appointment.
Taking your chicken for a walk
In Marbella, a man was detained by the Civil Guard when he was taking his sheep for a walk. Apparently he didn’t have the documents for the sheep with him, so he was fined for breaking the rules of the state of emergency. Actually, he should have known better: on 25 March someone was fined for taking his chicken for a walk.
The next pandemic
The expectation is that the next pandemic will be another virus that is transmitted from animals to humans. Just as governments were poorly prepared for this pandemic, even though warnings have been issued about it for years, the fear is that nothing will be done about the most obvious causes: intensive livestock farming, and the consumption of (wild) animals. Livestock farming is, certainly in the Netherlands, an important sector of the economy. Animal cruelty, environmental damage – none of that makes any difference. It’s all about the economy. The only thing we can do as consumers is to stop our excessive meat consumption and put an end to this business sector. The Chinese, too, like to eat wild animals, but nobody takes them to task about it. It’s all about trade relations.
When is the crisis really over?
The answer is simple: when there is an effective and inexpensive medicine or vaccine. Otherwise it’s a matter of waiting for herd immunity. To demonstrate a high level of herd immunity, antibody tests will have to be carried out on a large scale as many people experience the virus without any significant symptoms. At the moment, hardly anyone is counting on herd immunity. Recent figures from the Dutch blood bank indicate that around three per cent of the Dutch population may be immune, while over 50% is needed for herd immunity.
The successful strategy applied by South Korea at the start of the pandemic is generally taken as an example of the first stage of easing the measures. Tests, tests and more tests, isolating those who have the infection and making detailed studies of social contacts. And there’s also ‘social distancing’, although it’s questionable whether we in the West will be as disciplined as the South Koreans. One thing is sure: the virus will change the way we interact with one another and will result in a new normality.
Apps that know whether we are sick and that can track where we are physically well will also be part of the exit strategies. These apps are currently still under development, and each country will make its own decision about how far they are prepared to go with compromising the privacy of its inhabitants.
And finally
In recent weeks two patients at my practice have died of coronavirus. They were both people who already had existing medical conditions and they only contacted the practice when they were having serious breathing difficulties. Sadly, they died shortly afterwards in hospital. Corona can very suddenly take a turn for the worse. The lady with corona whom I visited in hospital is still there. She had serious breathing difficulties for several days more and was on the verge of being transferred to the IC unit. Now she’s doing well; she’s feeling fit, but is still waiting for two negative virus tests before she can be repatriated. Most of the people who wanted to return to their home country have now been repatriated. It’s relatively quiet on the Costa del Sol and it will stay that way for some time.
In Spain the number of new deaths is gradually reducing. There is talk of easing the measures and having different measures for different regions. For Andalucia, where the effect of corona has been relatively mild, that could be news.
Wherever you may live, I wish you the very best – and stay healthy!
Dr Jan Otto Landman
1990 Medical exam (Leiden)
1996 PhD (Leiden): "Long term effects of bisphosphonate (pamidronate) therapy in osteoporosis."
You can follow his blog on his Facebook page.
More information about Spain and coronavirus is available here.
(In Dutch)