On April 23rd 2020, Chiara Bodini (CB) interviewed Alexis Benos (AB) and Elias Kondilis (EK). They are both public health physicians and professors at the Aristotle University of Thessaloniki, where they lead the Laboratory for Primary Health Care, General Medicine and Health Services Research. They are also part of the People's Health Movement.
On the Covid-19 situation in Greece they published two reports, one of them available also in English at the this link.
CB: Can you give an overview of the current situation in Greece concerning the Covid-19 epidemic?
AB: The situation here developed with some delay compared to other countries. Italy played an important role in front of us: we were looking at what was happening in Italy, without yet seeing the problem here. The first case was a woman coming from Milan, then several cases were detected among a group of Christians who had visited Jerusalem. At the very beginning, they started to treat the cases and trace the contacts in order to contain the situation, but soon after the government and the public health services stopped intensive spotting of cases and started quickly to take lockdown measures, starting with schools. Today we can say that this had an impact in limiting the expansion of the epidemic: we are seeing a reduction of patients in intensive care units (ICUs) and the number of Covid deaths is stabilizing or even decreasing.
The underlying problem is that in Greece we had 10 years of harsh austerity politics, which meant that our health services have been dismantled. We are in front of this epidemic and know that our health services can not cope with what is happening in Italy and Spain. It is important to stick with the lockdown approach, which gave us time to reinforce the health services, including providing personal protection equipment (PPE) for healthcare workers, reinforcing human capacity of services as well as infrastructure and technology (e.g. ICU beds, as we have the lowest rate in Europe in terms of ICU beds).
We believe that we gained time with the lockdown, but this had to be used to reinforce the health system and set up and strengthen public health services and a system for epidemiological surveillance, which we do not have. It is a very critical moment now, we have controlled the epidemic up but how to open the lockdown? The only way to understand how is to have good and reliable data on what is happening in the community: epidemiological surveillance and sampling to see where the Covid is, what is the prevalence. We don't know that, so it is risky to open the lockdown. We are expecting we may have a second wave worse than the first one. Our government is made of neoliberal fundamentalists, but they had to admit that the national healthcare system (NHS) is the key in addressing this situation. On the other hand, they are not taking the measures that are needed. For instance, the new staff that has been contracted is on short-term contracts, while no new permanent posts have been created to reinforce the system.
EK: The Covid mortality rate in Greece is one of the lowest in Europe, and the number of severe cases needing ICU is relatively low and decreasing. Based on the available data and knowing their limitations, the 1st covid-19 epidemic wave seems under control. This is probably related to the early introduction of restrictive measures, which started on March 12th and escalated to complete lockdown on March 22nd. We are seeing the positive results of these measures. On the other hand, Greece is not so exposed to international trade, therefore it had a reduced exposure to the virus compared to other European countries. Finally, having witnessed the tragedy that was unfolding in Italy, the vast majority of the population was prepared and terrified, and social distancing measures were applied by the whole population.
Greece is now presented as a success story of a country with a weak healthcare system that has managed, through early lockdown, to reduce the impact and the mortality of epidemic. Is this accurate? I would say that it is misleading. The starting point is that Greece has one of the weakest healthcare systems in Europe. At the beginning of the epidemic, we had only 90 ICU beds available for Covid patients (only in Lombardy the relative figure was 720 and in whole Italy 3,000). Also, the Greek NHS has passed through 10 years of austerity, deregulation and privatization policies that weakened the system in terms of infrastructure and healthcare workforce. The situation is bad also in terms of public health services: no epidemiological surveillance, the Greek Center for Disease Contro (CDC) has been weakened, underfunded and undermined. In such a situation Greece would be unable to cope with an epidemic of such severity, and the only possible solution is a complete lockdown. In this sense, the government gained time with the lockdown, but the weaknesses of the system continue to exist. The success of Greece can not mask the structural weaknesses of public healthcare services, something very related to the management of 'the next day'. Now that we will start removing the restrictive measures, these weaknesses still exist and we are facing the risk of a second epidemic wave or multiple local outbreaks which would remain uncontrolled, undetected. Moreover, the early introduction of restrictive measures means that the population has a very low level of immunity and is therefore more vulnerable to the epidemic. Our main argument is: it is true that the restrictive measures have controlled the epidemic, unfortunately the government did not make use of the time to strengthen the healthcare system, therefore the vulnerability and the risk of a new wave and multiple outbreaks is very high.
CB: You mentioned that the available data have limitations, can you say more about data availability and reliability?
EK: Data availability is not a technical issue, but first of all and inherently a political issue. It means that you have the political willingness to collect, analyze and communicate this data in a transparent way to the public health community and the population. Availability of data has another prerequisite: you need a permanent infrastructure, in the case of an epidemic a permanent epidemiological surveillance system, in order to be able to collect in real time real data about what is going on in the population. In Greece the availability of data is extremely limited, related to both mentioned prerequisites.
The government and the Ministry of Health (MoH) are monitoring the development of the epidemic based on two data: the number of deaths from Covid and the number of Covid patients in ICUs. We do not have data on the number of hospitalized Covid patients, on the number of Covid cases in the community, on the number of healthcare workers infected, on the undertreatment of non Covid patients. We tried to push the government to release this data, at times the impression is that they have the data but choose not to communicate them in order 'not to create panic'. However, we know that transparency is key in order to have trust and, and represents a golden rule in managing a pandemic according to the World Health Organization (WHO) as well as to common logic. This lack of data makes us worry about the progressive withdrawal of the lockdown. How can they control the epidemic without real time reliable data and a system of transparent communication of these data to the scientific community and to the broader public?
AB: We also know the total number of cases, but this is of course related to the number of tests. If you do more tests, you find more cases. Now we are only testing patients with symptoms and those who are going to the hospital, but we don't know what is happening in the community. Concerning infected healthcare workers, together with the national federation of NHS doctors unions, we tried to estimate the situation. There are no other available data on the issue, which is very important also strategically because, when the staff is ill or in quarantine and out of work, the NHS capacity decreases. The healthcare personnel is not routinely tested, only if they have symptoms or had a direct contact with a positive patient. Only people working in Covid units – in Thessaloniki there is one dedicated hospital – are more controlled. In the beginning PPE was not available, now the situation has improved but it is stil unclear if it will be guaranteed also in teh future.
EK: We know that, in China, 3.8% of confirmed cases were health care workers. Based on our estimate, the relative figure in Greece is around 7%, and this in a healthcare system which was not operating under enormous stress as it was in Italy. These data are collected by trade unions, so we consider them reliable but underestimating the actual figures. The fact that the government does not collect this data is a sign of weakness and a structural vulnerability of the system.
CB: You said that the population is complying with the lockdown measures, is there any debate around this and how are the measures enforced?
AB: It is interesting, we did not expect that the people would be agreeing with the measures. Normally, and based on the general mentality and culture, we would rather expect for more negative reactions against the restrictions. We think that the Italian and then the Spanish examples produced massive fear, and that's why people were obeying. There's an interesting aspect about the church: last week was the orthodox Easter, when traditionally thousands of people go to church. There was a big match between the church and the government, and in the beginning restrictions were everywhere except in churches. There were movements opposing this, while others circulated silly arguments about God protecting people who went to pray in his house. This delayed the application of restrictive measures to churches, however in the end the government was forced to close down everything before Easter. There were small protests especially from fascist groups like Golden Dawn, they went to some churches to affirm their right to prey, but generally the population was very obeying... perhaps too much for the future we are going to see! Of course, when you go out you need to carry a document with the motivation, there are police controls on the streets and they can fine you, but controls are mild and almost not necessary.
EK: It is true that the population, under fear and threat of a disaster, has followed and supported the restrictive measures. However, this does not mean that the population is uncritically accepting these measures. There's an interesting campaign unfolding with the slogan “A covered face is not a silent face”, so I do accept to wear a mask and stay at home but this does not mean that I will remain silent. There are multiple campaigns from parties and social movements that support the measures but, at the same tiime, communicate in order to raise concerns, make critical suggestions, etc. During the epidemic, the healthcare and medical doctors movement in the public sector has launched multiple campaigns saying 'we are the heroes saving lives, but this does not mean that we will remain silent and uncritical to the vulnerabilities of the Greek NHS'. On the 7th of April, world day against the commercialization of health, there was a national campaign where small groups of medical doctors picketed outside of all public hospitals. It was very successful, and on April 28th – 1st day of removal of the lockdown – the national union of medical doctors called for a new mobilization.
CB: Can you say more about the situation outside the hospitals, at the level of primary health care (PHC)?
AB: In the beginning there was no connection, no one knew what to do in primary care. Private physicians, after a call from the medical association, closed down. GPs of the NHS also did not have any idea what to do, they had no PPE. In the first 20 days, the Greek CDC created a call center for symptomatic patients, inviting people to stay at home. The service was contracted to a private telephone company with untrained staff. We had 2 or 3 cases of people with symptoms, notified not to go to the hospita and who died in their homes without any care. This raised awareness and sparked a debate about the need to organize PHC services in order to deal with the epidemic. Now we have some health centers – very few and only in Athens and Thessaloniki – that are designated as Covid PHC centers, so that patients can go there and not in the hospital. People understood that with symptoms they should not stay at home. We are trying to organize protocols in our own PHC centers but there is no organized try by the MoH. Another issue is the fact that we are neglecting the other morbidities – both the healthcare system and the population who fears or is told not to go to the hospital . We are seeing a reduction in the rates of normal morbidity which can not be understood: e.g. less hart attacks, strokes, less problems of hypertensive crisis, etc. It is an issue that we have to see internationally because we expect to see rising mortality for these conditions.
EK: typically, in an epidemic of such a size you expect an increase in morbidity and mortality by the epidemic itself, but also from all other causes because of undertreatment. The whole healthcare system focuses on the epidemic undertreating the rest of the cases. We know it from past epidemics. We also do expect that an epidemic of such a size will have an impact on the economic and social conditions of the population, so you also have these consequences. The system has literally shut down for non Covid patients and we are focusing only on Covid patients so we are seeing significant decrease in non Covid hosphospitalized cases. Untreated hidden morbidity with no data or reliable information. Our interpretation is that Greece will be facing increased moribility and mortality for non Covid related cases.
CB: Can you tell me something about the situation of immigrants and refugees, especially in camps?
A: Even before Covid the policies of the Greek government for refugees were aimed at discouraging them from coming to the country. It was a deliberate and explicit policy with the aim to make it uneasy and unpopular for refugees to come to Greece. That's why they packed them in islands, in Lesbo there are 20.000 people in a camp made for 3.000 (Moria), with unacceptable hygienic conditions. Many weeks before the epidemic we were warning that that the risk of an epidemic in the camps was very high. The government did not do anything to monitor and diagnose cases in the camps. The same day of the first Covid cases, the Erdogan government started this policy of opening the borders and telling to refugees in Turkey to go to Greece. Our government was then speaking of two invasions: Covid and refugees, and they tried to make the link between the two. We were very afraid that the first Covid cases would be in the camps, something that was very possible and which would have fueled the fascist arguments. We were relieved when we learned that the first patient was a burgeois, as this stopped the wave of blaming the refugees. The government did not do anything for the camps up to last week, despite a big pressure from the Greek political parties and movements of the left, and not only, demanding to open the camps and put people in hotels, apartments, etc., in order to ease the situation. Even the EU, two weeks ago, made a special note to the Greek government to do something about the refugees. In the last week there were outbreaks in 4 different camps... in one camp a pregnant woman went to the hospital for a check up and was found positive. It was by chance that this diagnosis was made, which then led to the Greek CDC going to the camp: on 250 people tested they found 150 positive. There's a high risk of infection compared to the general population. They are now starting to test and to find cases but no other measures are taken for isolation, protection of those who are negative, etc. We call it an hygienic bomb. We are also really afraid that this is going to reopen the fascist propaganda that refugees are not only Muslim but also they bring Covid, and we're going to see a rise in the anti-immigrant movement.
EK: All international organizations (WHO, UN, CDC...) affirm that the impact of an epidemic is much more significant in certain population groups, including detained and enclosed people such as the elderly in nursing homes, migrants and refugees in camps, people in prison. All these population groups, based on what we know, are by definition much more vulnerable to an epidemic and specifically to Covid because of its way of transmission. Despite this knowledge, and the clear guidelines that from the beginning you should prioritize these populations, in Greece this did not happen. In the 50 day of the epidemic, only in the last week the government started collecting data through diagnostic tests in migrants and refugees detention camps. Through the very limited available data, which arrives mainly through media, we know about 4 major outbreaks in 4 refugee camps throughout Greece. All of these cases were reported accidentally, otherwise we would never know about the outbreak. Overall in Greece there are around 40 camps, with 80.000 migrants living there.
As a conclusion, from the Greek experience we can say that the early introduction of restrictive measures can delay the epidemic and save lives in the first wave, but this success can not mask the structural vulnerabilities of a healthcare system that might cause new outbreaks after the end of the first wave of the epidemic.