A bulletin from Greece: a health system under the pressure of the second COVID-19 wave

ABSTRACT

In this article, we analyze the cascade of events since the beginning of the coronavirus disease 2019 (COVID-19) pandemic in Greece, with emphasis on the crisis' management so as to preserve the functionality of the national health system, which remains vulnerable due to the financial recession of the previous decade and chronic shortcomings . We compare and contrast the situation during the first and second epidemic wave. Understanding what possibly went wrong and when, is crucial . Such knowledge provides valuable guidance for the confrontation of the strong second wave that we are currently facing in Europe and other regions around the globe, as well as for the future waves that may follow.

KEYWORDS:

• SARS-CoV-2
• coronavirus
• epidemic wave
• public health
• Europe
• Greece

Sensing the imminent danger following the devastation caused by the coronavirus disease 2019 (COVID-19) epidemic in neighboring Italy, the Greek government progressively implemented social distancing measures, starting with the closure of schools and universities and culminating in a national lockdown, just 12 days after the country’s first confirmed case, on 26 February 2020 [1]. Greece was internationally praised for its proactive approach in those early phases of the pandemic. The swift implementation of the non-pharmaceutical interventions, before the first wave reached its full potential, averted an estimated 4,360 deaths and protected the National Healthcare System (NHS) that remained particularly vulnerable due to the financial recession of the previous decade and chronic shortcomings [2].

Following the 42-day lockdown, public acceptance and compliance were nonetheless largely replaced by relaxation toward proposed control measures as people were eager to return to the pre-virus status quo. Under a false sense of security and the intense public pressure to resume business activities, the economy and Greece’s tourist industry, opened on 4^th May and 15^th June, respectively. Screening of perceived high-risk passengers was implemented to drastically reduced traveler flows. Meanwhile, visitors and workers from neighboring Balkan countries, where much less frequent testing led to falsely low reported incidence and perceived relative importation risk, entered Greece freely for several weeks during the summer. Nevertheless, although the virus continued to spread in the community despite the hot weather, the situation seemed to be under control until the season changed.

As autumn came, Greece has started facing a much stronger second wave, with a lag phase of a few weeks compared to other European countries, evidently due to its geographic location and Mediterranean climate. Because of the second national lockdown that has been in effect since 7^th November, a deceleration started to become evident toward the end of November, while currently the total number of cases is 142,267, the death toll spiked to 5,099 and 399 intensive care unit (ICU) beds are occupied by COVID-19 patients, as of 6 January 2021 [1]. Notably, over 35% of infected cases (41.6%) and of critically ill hospitalized patients (36.1%), are between the ages of 40 and 64 [1].

The fragile NHS was close to collapse as a consequence of years of financial cuts during the economic crisis that begun in 2007. Over the period 2009–2015, the NHS suffered cuts of more than €7 billion, while under 5% of GDP (EUR 9.1 billion) was allocated to health in 2019 as public spending is still bound by fiscal constraints [3,4]. The reduction in medical doctors from 2010 to 2013 was 35%, while today public hospitals lack 6,000 doctors and at least 25,000 paramedics. The number of public hospitals has dropped from 142 in 2009 to 125 in 2017. Two infectious diseases hospitals were included in those cuts; one of them has been urgently opened in response to the current health crisis. Hospital beds were reduced from 38,115 to 29,495 in the same period [4]. In 2017, 4.2 hospital beds per 1,000 population were available, while the EU average was 5.0 [3]. Greece had only 565 ICU beds in February 2020 before the pandemic outbreak [5]. By March 31, that number increased to 870, with 703, 137, and 30 ICU beds in public, private, and military hospitals, respectively [5]. Primary care, which could be particularly useful at present to identify patients truly at risk and avoid flooding hospitals with mild COVID-19 cases, is underdeveloped and fragmented as NHS's services are disproportionately located in urban areas.

Testing increased from a total of 1,335 in August to 1,968 tests per million people in Greece (including both molecular and rapid antigen tests) in December 2020 [6]. However, given that silent transmission from a combination of pre-symptomatic stage and asymptomatic infections constitutes the primary driver of COVID-19 outbreaks [7], testing has to be intensified in order to: (i) isolate those currently infected to prevent further viral spread, hospitalizations and straining of the health system, and deaths, and (ii) assess the epidemiologic situation of the evolving infection dynamics and adopt appropriate control measures. Ensuring sufficient and specialized workforce capacity in addition to physical infrastructure of the NHS is crucial for dealing with the COVID-19 outbreak, without neglecting, nevertheless, other medical conditions. Long-term strategic measures should target the strengthening of the public health system, with emphasis on the enhancement of the prevention and primary care facilities network. However, firstly we have to get through a very harsh winter, hopefully with as few casualties as possible. This is not a drill. It is the ultimate test.

Authors’ contributions

CS and AT conceived the study. CS, CA, CT, and GV searched the literature. CS and CA wrote the manuscript. All authors collaborated on content development, revised the manuscript and, approved the final version of the manuscript.

Disclosure statement

We declare no conflicts of interest.

Additional information

Funding

No specific funding was obtained for this study.