On the front lines of the response to covid-19 in Spain: a nation under a state of emergency

I work as a paediatrician in a primary care centre in Madrid. It is the area in Spain that has been hardest-hit by the covid-19 pandemic. Spain is currently the second worst affected country in Europe after Italy. Following the Spanish cabinet’s decision to declare a state of emergency on 14 March, the entire country remains in lockdown.

The number of diagnosed cases, deaths with coronavirus, and patients that are now in or have required admission to the intensive care unit (ICU) at some point are still escalating at a high rate. On the 31 March 2020 they numbered 94,417, 8,189, and 5,607, respectively. One third of the ICU admissions and almost half of the deaths have occurred in the Community of Madrid, the metropolitan area of the nation´s capital (population: 6,6 million). Catalonia (population: 7,5 million) follows with 20% of the total cases.

Nevertheless, under detection remains a problem given the many asymptomatic cases and our shortage of diagnostic tests. Since at least mid-March, and following our Ministry of Health protocols, we have been testing only those with acute respiratory infection admitted in hospitals or expecting admission, and essential personnel, such as healthcare workers. 

Our healthcare facilities are being pushed to the brink of collapse in the most affected areas. There is a concerning lack of personal protection equipment for healthcare workers and rates of exhaustion are high. Over 12,000 nurses, doctors, and other healthcare workers have already been infected (12,7% of the total of diagnosed cases). Many remain on sick leave or quarantined and many are probably undiagnosed, which is further exacerbating the situation. A 52 year old nurse was the first one to die. It happened in China, it´s happening in Italy, and it will happen elsewhere.

The issue is not only that large hospitals in the hardest-hit areas are overwhelmed and many patients are not receiving proper care, but that regular healthcare is being affected the consequences of which we will only be able to account once this whole crisis is over.

In Madrid, thanks to the collaboration between national, regional and local authorities, the whole regional healthcare system is undergoing a massive scale emergency reconfiguration. It´s worth noting that Spanish public healthcare has suffered important austerity “reforms” following the 2008 financial crisis. Madrid has been particularly affected by budgetary cuts and privatization policies implemented by conservative Governments that, although strongly contested by health workers, may now be taking a toll.

There currently a lack of protective equipment among staff in residential care homes. They come in and out regularly and thus can transmit the disease unintentionally. Some of those premises have become very dangerous for the most vulnerable populations. In some of them the Military Emergencies Unit (UME) has found death bodies left abandoned. Some staff report wearing robes made from plastic bags and self-made masks.

If you still have the common misperception that covid-19 is just “like flu”, consider also that in Madrid a large skating rink has just been set as a temporary new morgue, given current overwhelming situation of our local funerary services.

The limited availability of ventilators and intensive care beds and the dramatic consequences it’s involving for some of our largest hospitals means that the large amount of patients with mild symptoms goes unnoticed. They remain at home thanks to the ongoing telephone follow-up we are undertaking from the public primary care network, where all scheduled appointments have been cancelled. This policy aims to prevent people from leaving their homes and hospitals to collapse.

At a time of widespread community transmission and lack of diagnostic tests, we are considering all new cases of people presenting with acute respiratory infection such as cough, fever, or difficulty breathing, including children, as a “possible covid-19 case.” Therefore, we take all possible precautions if people with any such symptoms seek attention, and we try to make all possible diagnosis through phone calls to our primary health centre. This means that what two months ago could be considered “a cold”, is now considered a “possible covid-19 case.” Covid-19 specific hotlines have been established in most regions countrywide.

Even without confirmation—which is usually the case—we quarantine all patients with mild symptoms at home, we do home visits if their condition worsens, and do regular follow-up calls until they remain symptom-free for two weeks—the period it is consider patients may remain contagious although clinically fully recovered. Advice on how to conduct remote assessments can be found in recent literature. [1]

Widespread community transmission probably applies now worldwide, particularly in urban areas. If in some countries the number of diagnosis remains strikingly low, this may be due to an incapacity of healthcare systems to test, a lack of transparency, or both. Consider this policy to prevent health workers from contagion if you lack enough diagnostic tests and make all efforts to provide them with proper protective equipment.

Physical distancing, hygiene, and staying at home seems the only way to flatten this widespread outbreak and allow healthcare systems to cope with it. From Madrid, let me tell you—prepare for it, prepare right away. We keep on.

Aser García Rada @AserGRada is a paediatrician and MD, PhD who works at a primary care center in Madrid. He is also an actor and a freelance journalist.


  1. Greenhalgh T, Koh GC,  Car J. Covid-19: a remote assessment in primary care.  BMJ 2020;368:m1182. Available at: https://www.bmj.com/content/368/bmj.m1182