Spain has the dubious honour of being the country with the highest number of covid-19 cases among healthcare workers. In Spain, at the time of writing, approximately 50,000 healthcare professionals have been infected—representing 20% of all recorded cases—and 70 have died.
In a pandemic it is essential for the health system to operate at its maximum capacity, and healthcare professionals are its most valuable resource.  To help prevent infections, we must focus on addressing potentially modifiable causes, and establish appropriate screening and in-hospital pathways. 
But in Spain there are specific factors which explain why the country now holds the sad record of being the country with the highest number of covid-19 cases among healthcare professionals.
Our health system has had serious structural issues for several decades. These problems worsened following the 2008 global financial crisis and have impaired the response to this emergency. They include:
- Health system fragmentation due to division into 17 health regions;
- An inadequate Ministry structure, due to transfer responsibilities to the regions;
- Poor investment in healthcare, below the European average;
- No proactive strategy for tracing contacts/searching for potential cases; public health specialists work as advisors rather than going out into the field;
- Inadequate response from industry and insufficient investment in research and innovation limited adaptation in this highly challenging pandemic environment.
During January and February major international health agencies, including the European Centre for Disease Prevention and Control (ECDPC) and the World Health Organization (WHO), warned repeatedly of the potential severity of this infection and the need to prepare. On 28 February, the ECDPC presented several recommendations for hospitals, and the same day, the Spanish General Medical Council recommended that all medical events were suspended. 
On 2 March, the ECDPC advised countries to warn the general population about the impending threat of covid-19, to put in place covid-19 diagnostic protocols, to build stocks of protective equipment, and to implement social distancing to disrupt transmission. The Spanish Central Government Health Authority did the opposite: the population was uninformed, plans for diagnostics were inadequate for the population at large, personal protective equipment for healthcare professionals was not ordered, and a multitude of public events were ahead. The virus spread.
Despite a vast increase in the number of infected individuals during the weekend of 7-8 March, and the WHO declaring covid-19 a pandemic on 11 March, it was not until 15 March that Spain went into lockdown, wasting two essential weeks.
Planning mistakes at the health service delivery level also contributed to the high number of infected healthcare professionals:
- Failure to provide sufficient personal protective equipment for healthcare professionals;
- Infection can be transmitted by asymptomatic individuals, but the Spanish Ministry of Health did not recommend testing healthcare professionals with mild or no symptoms; 
- Contacts of positive covid-19 cases were neither systematically tested nor quarantined for at least 14 days, and testing of healthcare professionals in contact with confirmed cases was never recommended;
- Although triage outside hospitals has been shown to be effective in reducing in-hospital infection rates and infection of healthcare professionals, many Spanish hospitals did not adopt this model.
When the pandemic hit Spain, health services had little hope of containing and beating the virus. However, there is now hope, due to the responsibility demonstrated by civil society in complying with lockdown and the flexibility and adaptability shown by the health system in increasing hospital beds and intensive care facilities. Temporary hospitals, such as the Hospital IFEMA in Madrid, have been built in record time through the outstanding efforts of many professionals, including the Spanish Army.
But lessons must be learnt from the experience of the last few months. In the short term, in addition to social distancing and lockdown, immediate investment in protective equipment and use of reliable diagnostic tests to screen all healthcare professionals are critical, and health professionals treating covid-19 patients must be tested regularly. In the medium to long-term, it is essential to increase investment in our healthcare, and biotechnological sectors, as well as in improving our epidemiology fieldwork.
Mistakes should serve to inform the design of the next stage of the response in the battle against SARS-CoV-2. In our opinion, lockdown should not be completely ended until sensitive, specific tests are widely available to assess the population, and then measures should be lifted gradually. Our authorities should not make the mistake of placing economic or political interests before health. If they do, we will see a recurrent outbreak resulting in greater morbidity and mortality.
Javier Crespo is president of the Spanish Society of Gastroenterology (SEPD), head of the gastroenterology and hepatology department, University Hospital Marques de Valdecilla. Research Institute Valdecilla (IDIVAL), and a professor at the School of Medicine, University of Cantabria, Santander, Spain.
Competing interests: None declared
José Luis Calleja is vice-president of the Spanish Association for the Study of the Liver (AEEH), head of the department of gastroenterology and hepatology, University Hospital Puerta de Hierro, Majadahonda, and a professor at the School of Medicine, Universidad Autónoma Madrid, Majadahonda, Spain.
Competing interests: None declared
Antonio Zapatero is president of the Scientific and Medical Associations Federation (FACME), head of the temporary hospital IFEMA, head the department of internal medicine, Hospital Universitario de Fuenlabrada, and a professor at the School of Medicine, Rey Juan Carlos University. Fuenlabrada, Madrid, Spain.
Competing interests: AZ is the Deputy Chair of Public Health and covid-19 planning of the Health Department of the regional Government of the Community of Madrid.
Editor’s note: This article was updated on 4 June 2020 to update AZ’s competing interests.
- The Lancet Editorial. COVID-19: protecting health-care workers. Lancet 2020;395(10228):922. doi: 10.1016/S0140-6736(20)30644-9 [published Online First: 2020/03/23]
- Schwartz J, King CC, Yen MY. Protecting Health Care Workers during the COVID-19 Coronavirus Outbreak -Lessons from Taiwan’s SARS response. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2020 doi: 10.1093/cid/ciaa255 [published Online First: 2020/03/14]]
- European Centre for Disease Prevention and Control. Checklist for hospitals preparing for the reception and care of coronavirus 2019 (COVID-19) patients. ECDC, Stockholm, 2020.
- Gobierno de España, Ministerio de Sanidad Servicios Sociales e Igualdad. Guía de actuación frente a COVID-19 en los profesionales sanitarios y sociosanitarios. Centro de Coordinación de Alertas y Emergencias Sanitarias. Dirección General de Salud Pública, Calidad e Innovación. Aprobado por la Ponencia de Alertas y Planes de Preparación y Respuesta. Versión del 31 de marzo de 2020 [Available from: https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos/Protocolo_Personal_sanitario_COVID-19.pdf accessed April 7 2020.