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  • Lack of control: de-escalation in Spain: what can be done and when in each phase

Miguel Ángel Sánchez Chillón has spent days with the word "prudence" in his mouth. Contrary to the official speech of the Community of Madrid, the president of the College of Physicians alleges that the number of new infected and ICU admissions advise against running too hard to try to pass the phase. He claims that his speech has no "political bias" and that it is based only on scientific criteria. Last Tuesday, the president, Isabel Díaz Ayuso, and her health adviser, Enrique Ruiz Escudero, summoned prominent representatives of the Madrid health sector at the Royal Post Office to talk about the de-escalation, including the presidents of the Nursing schools , Pharmacy and Dentistry. Sánchez Chillón was not invited.

What is the absence of the Madrid Medical Association from a meeting where, in theory, the entire health sector was represented? Tell me how that episode unfolded, we found out the same day, because there was no previous call, so I don't know if the call was made too urgently. What does seem clear is that it was a more institutional than technical meeting with the President of the Community of Madrid. We understand that soon we will have a technical meeting with the Ministry, because, logically, they are not going to do without the doctors in Madrid. If, as you say, it was more an institutional meeting than a technical one, does it not seem like a lack of institutional courtesy that they do not invite To the institution that represents 45,000 doctors from Madrid? I want to believe that the Community has raised these meetings in waves, in small groups, to avoid infections, because, in fact, I think that some other healthcare group was missing. The truth is that I can't think of anything else but to blame it on prudence. Can't you really think of something else? Haven't you thought for a moment that their calls for caution had anything to do with it? Well, honestly, no, because it would be too simplistic to put it down to that. In this context, I insist, Madrid Medicine cannot be dispensed with, because we are a fundamental actor in the fight against the pandemic. I want to think, as I say, that the intention of the Ministry of Health is to make these meetings in small groups. Since Tuesday, have you had any calls from the Ministry? Have you asked for or given an explanation? No, no, none. But hey, they have changed their internal structure in recent days and perhaps they are in an adjustment phase. Speaking of internal adjustments, what reading do you make of the resignation of the director of Public Health in Madrid? Another expression of the moments of tension and overflow that they have been able to experience, because we understand that the entire Administration, all the administrations, from the first to the last, are working at one hundred percent of their capacity. I understand that the departure of the principal shows that her ability to try to find a consensus, a common health policy, had reached the limit. Traditionally, the relations between the counseling and the school have been very good. Do you think they can be tarnished by this situation? No, I don't think so. As he says, our relationships have always been excellent. It must be understood that they also have political constraints, but I do not think that neither they nor any citizen can think that we doctors move for any other interest than the health of the citizenry. Both this counselor and the previous one have been very dialoguing with us and with a direct and very fruitful treatment. Do you speak regularly with the counselor? When was the last time? Throughout this crisis we have spoken long and hard several times; the last one I think about 5 days ago. At any point in those conversations have you made any observations about your calls for caution? All these conversations have been chaired by cordiality, and only once did I see you especially tense or overwhelmed, but I think it was because the health situation at that time was very complicated. There I did see his facet as a politician rather than a doctor, but the conversation ended well and, in addition, everyone who knows Enrique Ruiz Escudero knows that he is a person of excellent character. Is Madrid ready to go to phase 1 right now? I reiterate a word that you yourself have cited: prudence. The numbers and the situation of the structure and of the health professionals in Madrid do not advise going too fast. Just yesterday, in the late afternoon, the last meeting of the Scientific Council of the College of Physicians took place, an advisory body outside the structure of the college and made up of scientific societies, university teachers and experts. Well, this body again advises us to be very cautious. And this appeal, I insist, is not from the college, but from a group of 15 experts who have nothing to do with the college directive and who are governed only by scientific-technical criteria. If we were to translate that prudence on dates, perhaps Madrid Nor would she be ready on Monday to go through the phase? The numbers of new infected, new hospital admissions and new ICU admissions tell us that we are, more or less, like the beginning of March; that 80 people enter daily in Madrid hospitals or 14 people in the ICU, and that part of them die daily, would be a very clear headline in early March, right? In short, the virus is alive, active and circulating, and if we relax containment measures it is likely that we will facilitate transmission again. Does it say, then, that if we pass the phase in these conditions we are doomed to a new outbreak? No, no I say that; I only speak of numbers, and I continue to do so. The progress of the serological study put the percentage of the population of Madrid that is or has been infected at some point at 11%, so that the remaining 89% are still susceptible to becoming infected; If there were a rebound of 11% of that 89% of non-infected, we would return to a situation almost, almost, almost similar to the previous one. Why then are we not cautious until we see that the virus does not circulate as freely, especially if cities like Madrid and Barcelona have high population densities and high flows of movement and communication, which are two of the main transmission factors? The problem is that scientific discourse collides with political and economic emergencies? Yes, and it is understandable. Companies are as they are and the work and personal situation of many citizens is what it is, but if you ask me as a doctor, my speech must be scientific. If someone who is in rehabilitation wants to do without the crutches very quickly, they will probably relapse. Is Madrid health prepared to withstand a flare-up? It is better that we do not have to see it, but it is obvious that health in Madrid is very depleted, because it already started from a situation of lack of troops, especially in primary school; because there have been sick leave, because part of those who have joined after the leave have made it exempt from activities that put their health at risk, and because neither the hospitals nor the health centers are still working at their usual pace. One of the main arguments of the Ministry of Health to deny Madrid the phase step was that its primary school was not sufficiently reinforced. As a family doctor, do you agree with that diagnosis? Objective data. Madrid continues to have closed primary centers, primary emergency centers that have not yet opened; a percentage of professionals who, as I was saying, are on leave or exempt from healthcare work. In short, of a staff that was 80%, 30 or 40% is dedicated almost exclusively to the virus, so that the remaining 50% treat the pathology that previously covered 100% of the workforce, and to that we must add care for new diseases generated by Covid, home monitoring, and something that, for the time being, we are putting off, but that will have to be assumed, such as care for dependents in nursing homes. The prospects are getting complicated. In addition to waiting for the primary staff to recover their usual state, should it be reinforced to face the new phase with guarantees? Without a doubt, and we know that the counseling is making an effort in that regard, But the bulk of the reinforcements has not yet arrived and, in addition, the majority of the 650 health professionals that he has promised will be assigned to public health activities directly linked to the coronavirus, not to the assistance of other pathologies. He has promised that the 10,000 contracts made at the start of the pandemic will be renewed until the end of the year. That is an important reinforcement, isn't it? Those 10,000 do not include only doctors and nurses, but all kinds of professionals, and what we do know is that some of the reinforcements hired for primary school have already run out of contract. and they are not in the centers. The school, for example, sent a list of 1,798 doctors and volunteers willing to work and not all were hired. At the time, we asked the council to report on these hires, but they answered us, with some logic, that the overflow was such that they were not in a position to prepare a report. not just thinking about Madrid. Perhaps it has been thought late in primary school and crisis management should have been focused at this level before? Here I want to break a spear in favor of decision-makers, national or autonomous, because I don't think anyone was capable of forecast 3 or 4 months ago the dimensions that this would take. Even so, both from school and from many other sectors of the profession, we already said at the beginning that if primary was the first line of contact with the virus and that if the bulk of those infected evolved benignly, it was necessary to equip the level of human and diagnostic resources to strengthen this first containment barrier. Once the problem was overflowed, the approach is obviously different, and all you had to do was think about helping hospitals.

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