30 March 2020

English

Coronavirus: Why are deaths rising so quickly in Spain?

KONFRONTASI-Every night in Spain since the coronavirus state of alert was decreed on March 14, citizens take a moment to applaud the country's beleaguered medical workers.

But this hopeful image does little to dim the pain of the pandemic; Spain's daily death toll reached a harrowing new high of 769 on Friday, bringing the total number of fatalities to almost 5,000.

Fresh cases of coronavirus-related infections did drop, from a record total on Thursday of 8,578 to 7,871 on Friday.

But both numbers are far worse than a week ago, when new cases stood at 2,833.

Another unnerving fact is that compared with Italy, where eight percent of health workers are affected, in Spain by Friday that tally stood at 16.5 percent.

What has caused such a rapid spread of coronavirus in Spain?

Multiple factors

The most high-profile reason touted by the media in Spain is the public health service's uneven and reportedly depleted resources for tackling this, or indeed any, kind of virus-related pandemic.

Academics in Spain partly confirm this as one possible reason, but underline multiple other factors.

"As recently as Wednesday, the Centre for Disease Prevention and Control in Europe pointed out that the impact of COVID-19 depended on a country's level of preparation and its ability to implement rapid countermeasures," Silvia Carlos Chilleron, a professor in the department of Public Health and Preventive Medicine at the University of Navarra, told Al Jazeera.

"If the increase in cases has been fast, as it has been in Spain, and the human and material resources to fight it are not guaranteed, then the impact is more serious. That probably causes a greater number of deaths among the most vulnerable sectors of society, particularly when medical professionals are among those affected."

Also on Wednesday, Spain's State Confederation of Medical Unions (CESM) lodged a case with the country's Supreme Court, asking the health ministry to provide sufficient protective equipment as soon as possible.

CESM alleged in their case, which was rejected, that the ministry had so far failed to provide professional health workers with sufficient protection to carry out their work in a manner that reduces the risk of catching coronavirus.

"People are generally respecting the lockdown and trying not to come into hospitals for minor illnesses and that's helping reduce the risk of contagion," one hospital doctor in southern Spain, who did not wish to be named for fear of reprisals, told Al Jazeera.

"But there is a lack of sanitary material in the hospitals for this kind of crisis, which multiplies the possibilities of health staff getting contagious infections, and that's going to be a huge factor."

Underlying reasons for the coronavirus spread before the state of alert could have been "the low level of perception among the population at large that coronavirus represented a risk", Jose Hernandez, a researcher and assistant professor of sociology at Cordoba University, whose specialties include social health policies, told Al Jazeera.

At that point and "until relatively recently, there wasn't enough information on what coronavirus was", he said.

Spanish population distribution may also have an effect, observed Alberto Mataran, a professor of Environmental Sciences at the University of Granada

"There's a huge density of people in cities like Madrid or on the Mediterranean coast in particular, and a lot of blocks of flats in cities' outlying suburbs.

"Add in a lot of communal spaces, a very affectionate kind of social behaviour compared to some countries - we always shake hands, or hug, or kiss each other, when we meet, for example - and the opportunities for propagation surely could increase, too."

As for the much-cited dearth of resources, Hernandez argued it explains the "relatively rapid saturation" of the health services.

"Also, Spain has a large elderly population, who are very vulnerable, and retirement homes do not, generally, have massive medical resources.

"On top of that, the fact that Spain's hospitals and medical services are run by different autonomous regions creates some very important underlying inequalities."

Hernandez added that while regional governments can demand assistance from Madrid, this does raise the risk of poorly judged medical strategy decisions in the central government.

In 2014, medical staff in Madrid protested against the lack of effective protective equipment and safety precautions amid the Ebola epidemic.

"We could see that the public health system had some big gaps in the early detection of infections. And these are structural weaknesses," he said.

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Why is Italy's coronavirus fatality rate so high?

KONFRONTASI-The numbers are dizzying and horrifying. Four hundred and thirty-three dead. Six hundred twenty-seven dead. Seven hundred ninety-three dead.

For weeks now, the daily briefings by Italy's civil protection agency have been providing grim updates on the number of people killed by COVID-19, the highly infectious respiratory disease caused by the new coronavirus, deepening a sense of gloom in a country that has become the deadliest centre of the pandemic.

Despite a series of near-draconian measures gradually rolled out to halt the spread of the virus, including a nationwide lockdown and the shutdown of all non-essential businesses, Italy has been unable to "flatten the curve" - slowing the spread of the contagion in a bid to prevent an already overburdened healthcare system from being overrun.

The country's latest tally reported a total of 6,078 deaths from 63,928 infections, with a world-leading fatality rate of more than 9 percent.

In contrast, in China, where the outbreak originated, the mortality rate stands at 3.8 percent. In Germany, which has reported more than 24,000 cases and 94 deaths, it is at 0.3 percent.

But there may be several reasons for Italy's alarming mortality rate.

"The numbers we have are not representative of the entire infected population," said Massimo Galli, head of the infectious disease unit at Sacco Hospital in Milan, the main city in the worst-hit region of Lombardy where 68 percent of the total national fatalities have been reported.

Galli explained that as the emergency situation rapidly deteriorated over the past month, Italy focused its testing only on people showing severe symptoms in areas with high epidemic intensity - the result, experts say, is that the currently available numbers produce a statistical artefact, a distortion.

"This causes an increase in the fatality rate because it is based on the most severe cases and not on the totality of those infected," Galli said.

The coronavirus may take up to 14 days before an infection flares into symptoms, such as fever and dry cough, and during that incubation period, asymptomatic patients may potentially transmit it. Experts believe it is this so-called "stealth transmission" that has driven the rapid spread of the outbreak, infecting communities that remain unaware until they develop symptoms and get tested.

As of March 15, Italy had carried out about 125,000 tests. In contrast, South Korea - which implemented a strategy of widespread testing - has conducted some 340,000 tests, including for those showing mild or no symptoms at all. It has recorded almost 9,000 infections to date, with a mortality rate of 0.6 percent.

Italy's 'social contact matrix'

While the new coronavirus can infect people of all ages, older adults, whose immune systems have declined with age, appear to be more vulnerable to becoming severely ill after contracting the virus.

In Italy, 85.6 percent of those who have died were over 70, according to the National Institute of Health's (ISS) latest report. 

With 23 percent of Italians over 65 years old, the Mediterannean country has the second-oldest population in the world after Japan - and observers believe age distribution could also have played a role in raising the fatality rate.

Another possible factor is Italy's healthcare system itself, which provides universal coverage and is largely free of charge.

"We have many elderly people with numerous illnesses who were able to live longer thanks to extensive care, but these people were more fragile than others," Galli said, adding that many patients at Sacco Hospital - one of Italy's largest medical centres - who died due to coronavirus were already suffering from other serious diseases.

According to the ISS's latest report tracing the profile of COVID-19 victims, 48 percent of the deceased had an average of three pre-existing illnesses.

Experts also pointed to Italy's "social contact matrix" as another possible reason, although indirect, behind the wider spread of the coronavirus among older people.

"Elderly Italian people, while most of them live by themselves, are not isolated, and their life is characterised by a much more intense interaction with their children and younger population compared to other countries," said Linda Laura Sabbadini, central director of the Italian National Institute of Statistics.

"When such an external shock [such as the coronavirus outbreak] takes place, it's important that these interactions decrease, hence isolating elderly people should have immediately been a priority."

'Forever unprepared'

However, such explanations arising from the peculiarities of the Italian experience - ranging from strong familial ties in a geriatric society to issues surrounding testing practices - should not make other nations complacent, experts warned.

"Other countries should watch closely," said Pierluigi Lopalco, epidemiologist and professor of hygiene at the University of Pisa.

"What we are watching in Italy is the same movie we have already seen in China, where Italy is Hubei and Lombardy is Wuhan," he said, referring respectively to the Chinese province that was sealed off by the authorities, and its capital where the new coronavirus was first detected late last year.

"I am afraid we will be re-watching the same film again in other countries in the coming weeks," warned Lopalco, who is part of a taskforce leading the epidemiological response in Puglia, in southern Italy.

Citing the epidemic curve of other countries, Lopalco suggested that the difference between them and Italy is timing: they are simply at an earlier stage.

"After China, Italy is the first country where the epidemic erupted; hence, we are dealing with the effects of an advanced-stage epidemic."

While many countries are gradually adopting stricter measures to implement social distancing, they have so far resisted taking the same drastic steps as Italy due to significant worries about the economic effects of such moves.

Italian doctors at the centre of the country's battle with the pandemic have warned that the reluctance to act quickly and decisively could have important consequences.

"If I were the head of any country's health ministry I would be terrified, and I would move extremely fast to adopt strict measures to contain it," Galli said, stressing that "in these situations, we all are forever unprepared: it is impossible to be fully ready to handle such events".

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