Madrid’s Minister of Health, Enrique Ruiz Escudero, explains in detail how the Autonomous Community executed a different COVID-19 strategy from other Spanish regions, following a “basic health zones” model, why it might be too soon to speak about “flu-isation”, and their plan to boost home hospitalisation and telemedicine.
Enrique, you have been serving in Madrid’s MoH for over four years and had the difficult task of guiding the region during the COVID-19 pandemic. Can you begin by speaking about your experience during COVID?
I have served in this position for over four years, almost a record, and recently received a vote of confidence from Isabel Díaz Ayuso, the president of the Community of Madrid, to continue. In fact, the latest electoral victory of our party (People’s Party) could be attributed to the adequate management of the COVID-19 crisis by taking a dual approach, linking health and economy. Madrid opted for a different approach than most of the Spanish regions and the national government, choosing to create secure environments, providing tools to citizens such as masks and diagnostic tests, betting on their individual responsibility instead of hard restrictions.
Reflecting on the epidemiological and healthcare provision data obtained in the following months, Madrid has obtained positive results, allowing the region to lead the country’s economic recovery.
Was the strategy following any particular model from another country? Can you go into the details behind the strategy and compare it to other regions in Spain?
Madrid’s model was the result of the internal work from the Community’s Ministry of Health [Consejería de Sanidad]; there was great coordination between the public policy and healthcare provision teams.
From a health policy perspective, we needed to implement a daily monitoring system to detect where each contagion occurred, to whom, in which setting, and so on, in order to make decisions targeted to those hotspots. We analysed how infected people behaved – whether they went to primary care or hospitals – and created a “basic health zones” model. Each zone consisted of a health centre that covered approximately 30,000 people, 247 zones in total, and each of them applied restrictions whose magnitude reflected the indigence rate of the virus.
In such a highly populated area as Madrid, there was a need to take selective measures, thus allowing people in so-called “safer” zones to continue their economic and social activities.
To measure the effectiveness of the model, we analysed what happened in the 15 days after measures were implemented; if the total incidence decreased significantly, the strategy worked.
From our perspective, Madrid’s public health strategy was successful because healthcare practitioners (HCPs) rose to the challenge, and because of a great use of data, always measuring scenarios with quality data in a transparent manner. The model empowered Madrid’s Ministry of Health to take less restrictive measures.
Our prediction models – done in collaboration with technology partners – were ahead of those of the central government. We understood exactly when an outbreak reached its peak, that the peak of hospitalisations came seven days after, and that it took ICUs three weeks to reach maximum levels.
Another important model we used was the Sistema Vigía (Monitoring System) – done in collaboration with Canal de Isabel II, the company in charge of managing Madrid’s water – to detect the virus in the community’s wastewater. The system gave us three extra days, getting ahead of what we knew was going to happen in terms of positives and hospitalisations.
Overall, we fed the system with data from our own hospital network, the city’s wastewater and individual positive results – when the central government allowed us to do antigen tests.
As the health authority of a region with 6.7 million people, which includes one of the most visited cities in the world, how would you describe the balance between keeping people from being infected and the economic implications of lockdowns and restrictions?
We utilised a conceptual decision-making framework; economy and health are not opposing terms, they are complimentary. Our goal was to boost economic activity as long as people’s health was preserved.
How to achieve that? You must know exactly how the virus behaves in your particular region. The first wave caught the world unprepared but left many learnings: it revealed that the elasticity of Madrid’s health system was good, that we had to improve the detection system, the importance of acting fast, and that extreme measures did not work.
Naturally, as a regional authority, there were many things beyond our control such as measures at Adolfo Suárez Madrid-Barajas Airport – under the responsibility of the national government. When the country passed through the first wave of infections, in May 2020, we were very outspoken in saying that the airport had to be controlled during a global health crisis, asking for COVID-19 testing for arriving international travelers. It took the government a long time to listen.
You have publicly stated your opposition to the central government’s new strategy to manage the pandemic, which aims to treat it as the flu. Why do you believe it is not the best decision at the moment?
We understand that the overall strategy should change in favour of lighter measures if certain conditions are met, but there are many unknowns beyond our control such as further mutations of the virus. Let’s not forget that the two most recent large-scale outbreaks came from outside countries.
The “flu-isation” of the COVID virus would entail two things: changing the criteria for restrictions and changing the epidemiological surveillance system. In my opinion, it is not the right time because of the high incidence brought by the Omicron variant; it would be a serious mistake. Before speaking about significant changes to the current strategy, incidence must be low and public pronouncements should come with a caveat, leaving the door open for possible mutations of the virus. After so many years, we more or less know how the flu virus behaves, but the novel coronavirus is unpredictable at this moment.
Public authorities must speak with caution because “flu-isation” could translate into a generalised relaxation; we must remember that better outcomes are the result of vaccines and masks in crowded spaces. Big changes should be made once effective treatments for mild cases are widely available; at the moment, monoclonal antibodies and the new antiviral pill treatments are designed for moderate to severe illness.
Our current stockpile of approved medicines is not large enough to sustain a big wave of infections and hospitalisations.
There appears to be a substantial difference between the national government and Madrid’s health authorities regarding the next stage of the pandemic. How can both levels of government align their strategies and collaborate when politics stand in the way?
Unfortunately, we have not seen collaboration from the national government, they have opted for political confrontation. I could name at least 20 measures proposed by the Community of Madrid to the Interterritorial Council of the Spanish National Health System that were initially dismissed by the government and later implemented. For example, we were the first to speak about mask mandates – conducting a program to deliver 14 million masks to the population which was criticised because they were “overly protective” –, Madrid was the first region to include antigen tests in its detection network, and we asked for rapid tests to be available in pharmacies, but it took the government eight months to approve that initiative.
The current central administration understands co-governance as every region doing what they ask. For us, co-governance is about putting the interests of citizens at the centre, always basing decisions on science and not politics.
Madrid was heavily criticised for ending strict lockdowns as soon as possible, but, over time, we have proved that lockdowns are not a magic tool; if you compare Madrid and Catalonia, they have had worse results in terms of cases and hospitalisations with more restrictions.
You have also spoken recently about a new model of care for Madrid, one where services are provided at home. Can you explain the plan?
For the Community of Madrid, the next step relates to the concept of “liquid health,” which is providing health services wherever patients are. Even before the pandemic, we had several projects for home hospitalisation which have only accelerated. Today, we believe that the best place to be hospitalised and treated there by nurses and doctors are the homes of the people of Madrid whenever it is possible; as we speak, HCPs are caring for 4,600 patients at home. It is a system that educates patients, practitioners and frees hospitals from unnecessary visitors.
While it is a win-win proposition, we must implement that model all across the region and set clear guidelines as to which patients can be included. In addition, there is a big effort to increase the use of telemedicine and make the most out of the virtual health card, which allows patients to receive and use electronic prescriptions, among other things.
In terms of human resources, just as every other region in the country, we are foreseeing HCP shortages, particularly in primary care, which is why this model is more necessary than ever. In addition, we have a very proactive attitude towards mental health, especially after what the population has gone through during the pandemic.
There is plenty of talk about a fresh wave of EU funds coming to Spain’s healthcare system and industry. Can you speak about current investment in the region and what do you expect from the upcoming funds?
At the moment we have two ambitious investments underway, the transformation of two important hospitals: the Hospital Universitario 12 de Octubre with an investment of EUR 257 million to renovate the entire main building, and the Hospital Universitario La Paz which has been voted as Europe’s best hospital for six straight years and will receive a total investment of nearly EUR 500 million.
In relation to the European Union funds, we welcome all funds coming from the EU and appreciate the effort made by Spain’s national government to renovate medical equipment.
Since Madrid has a very active research ecosystem, we are looking forward to new opportunities to invest in advanced therapies.
What message would you send to international life sciences companies that already see Spain as an attractive investment destination?
Madrid is positioning itself as an attractive investment destination by offering freedom, great public services and lower tax rates. The region has experienced an influx of new health companies that have continued to populate two centres: Tres Cantos-Colmenar, which has a strong presence of pharmaceutical and biotech companies, and Alcobendas. We are looking forward to supporting more companies install themselves in the Community; the life sciences industry is a priority for Madrid because they bring quality jobs and innovation.
The life sciences ecosystem of Madrid is living through a very exciting moment since it was announced last year that the Puerta de Hierro Hospital began administering the first-ever drug to have been completely developed in a public Spanish hospital, a cell therapy for partial medullary lesions called NC1.
