What a year of pandemic tells us about European healthcare systems

Mainly three things: the number of doctors and nurses and the population density of a region are more important indicators than the number of ICUs in predicting Covid-19 deaths, there does not appear to be a causal association between per-capita numbers of ICUs and deaths from Covid, and excess mortality showed a correlation with the "pandemic waves".

On April 1, 2021, Greece was the sixth “best-performing” country in Europe in terms of the total number of confirmed deaths from Covid-19, counting 783 deaths per million inhabitants since the beginning of the pandemic (according to ourworldindata.org ). The safest places to survive the coronavirus in the year of the pandemic in Europe seem to have been at the two extremes: in the North (Iceland, Norway, Finland, Denmark, although not Sweden, which followed a different model) and in the South (Cyprus and initially Greece). This is not a snapshot, but rather a general picture that applies to the average death rates in all three phases of the pandemic so far. In reality, the situation is much more complex, as the phenomenon is evolving dynamically.

The number of coronavirus deaths per capita in a country is a function of variables that are too difficult to define and accurately quantify to give safe conclusions. These variables include virus spread, degree of initial preparedness and subsequent strengthening of national health systems, response measures, population and geographical data (e.g. population distribution), behavioural trends, and evolution of the vaccination programme. 

An overview of Covid-19 deaths is not sufficient to draw firm conclusions. Other epidemiological indicators are needed. "Excess mortality", i.e. deaths from all causes in the coronavirus era which exceeded the average over a five-year reference period (2015-2019), skyrocketed in the majority of European countries. According to Eurostat data, in total, by November 2020, 450,000 more deaths were recorded in the EU than in the same reference period previously . The European platform EUROMOMO , which monitors mortality from any cause in the 27 EU member states, has recorded a relatively small increase in excess mortality in Greece in recent weeks.

Not all countries have been affected in the same way by non-Covid-19 deaths. In Greece, in the first ten months of 2020 excess mortality was close to or below the average of the last five years. But the situation started to change dramatically in November and December (when the second wave peaked). Then, in the first two months of 2021, there was an initial decline in "excess deaths" from all causes. 

In Greece, 8,802 more deaths were recorded in 2020 compared to 2019. Deaths from Covid-19, however, were 4,881 , and the difference of 4,921 deaths was not evenly distributed over the year.  

A one-disease system

This difference is not easy to attribute to specific causes. Despite the reasonable conclusion that it may be linked to undiagnosed Covid-19 cases, the forced conversion of the National Health System into a one-disease, coronavirus-focused system played a decisive role. 

In order to document the initial preparedness and response of the Greek National Health System in the face of the pandemic, MIIR collected from various sources and analysed one year's data on the number of deaths from Covid-19, the number of available ICUs, the number of intubated, the number of deaths and cases among nursing staff.  

The deaths of the "heroes" in white shirts 

When healthcare workers get sick during a disease epidemic, overall case numbers and mortality rates may increase significantly, according to recent research from the University of Pennsylvania . The researchers investigated the direct impact of the loss of health workers. They calculated that a reduction in the quality of care in an epidemic potentially leads to up to a 15% increase in cases and up to a 1,716% (!) increase in deaths.  

During the first wave of the pandemic, according to another global study published in BMJ Global Health, Europe had the highest number of confirmed cases (119,628) and the highest number of deaths (712) among healthcare workers. The Eastern Mediterranean region in the first wave recorded the highest number of healthcare-worker deaths per 100 infections globally (5.7). In Greece, the competent body, the National Organisation of Public Health (EODY), does not provide detailed data on deaths and infections of doctors and nurses.

"Drowning is a great torture. Don't let it happen to anyone. I flirt with death every moment. Don't call me. Say a prayer", wrote a 53-year-old nurse from inside a hospital in early December. He had been diagnosed positive on November 24 and was hospitalized for a week at the hospital where he worked in Kilkis. To relieve the hospital of coronavirus cases he was transferred to the Serres hospital and was hospitalized there for many days and intubated in an ICU. On January 9, 2021, he died. It was then the 20th death of a healthcare worker in Greece. By the end of March, 26 healthcare workers died in Greece, 25 of them in the second and third waves of the pandemic. Their median age was 48 years, while the median age of deaths in the rest of the population from Covid-19 is 68 years. The total toll of the pandemic after one year in the Greek NHS is more than 4,000 cases and 26 deaths. At the end of April, 700 doctors and nurses were ill and 50 of them were hospitalized. Workers regularly protest about the need to recruit doctors and especially nurses. Other demands include tenure for contract workers and the strengthening of primary healthcare in terms of staff, infrastructure and equipment.

Deaths and ICUs 

The number of available multi-purpose ICUs for Covid-19 patients is one of the crucial indicators that determine the resilience of healthcare systems. Reliable, transparent, up-to-date data on the ICU numbers within the period of the pandemic do not exist in many European countries. By isolating other otherwise-important parameters (viral load, response measures, number of workers, vaccination status, etc.) we cross-referenced the number of confirmed Covid-19 deaths per capita with the number of multi-purpose ICU beds per capita at the beginning of the pandemic for a number of countries (source: OECD , Eurostat ).

Before the pandemic, Germany was the country in Europe with the highest ratio of ICUs per capita (it remains so). In contrast, Greece has generally had one of the lowest ratios of ICU beds and nurses. Nonetheless, in the first wave of the pandemic the weakness of the Greek system did not lead to its collapse. The system held up, mainly due to reduced virus circulation, timely measures and citizen compliance. The situation changed dramatically in 2021, and as a result by mid-March there were no more ICU beds available, while hospitals had lists of patients waiting to be admitted to ICUs.

The data processing shows there does not seem to be a causal relationship between deaths and available ICUs. However, the graph shows that countries with a lower proportion of available ICUs (Italy, Spain, the Netherlands, Greece) are under more pressure and some have recorded disproportionate deaths (Italy). The interpretation of the phenomenon is more complex, as in several regions (Northern Italy) the system broke down. This was due partly to increased virus circulation, which in turn affects admissions, intubations and consequently deaths. Another exception is the northern countries (again, except Sweden). Indicative of the complexity of the problem is the fact that although Hungary and Switzerland had roughly similar ICU capacity, Hungary recorded almost double the number of deaths.  

According to a survey by the UK-based independent Health Foundation, in the first six months of the pandemic countries with a higher ratio of ICU beds and surgeons per capita actually recorded fewer deaths from Covid-19. However, the researchers point out that it is unlikely that the particulars of healthcare systems are the sole determinant of differences in deaths around the world. They also found something remarkable: countries with higher bed capacity decided to impose lockdown measures earlier than those with lower capacity. This was interesting in social and economic terms, but also in terms of secondary healthcare issues. But it was not the case in Greece.  

Another global survey of 183 countries , based on reliable data from the World Health Organization (WHO), the World Bank and other official national organisations on the availability of ICUs and hospital beds in each country, showed that there is indeed some correlation between per-capita ICUs and deaths from coronavirus. The paradox was at the global level: countries with much lower GDP and capacity in ICUs and beds had a lower death rate. The interpretation of this contradictory phenomenon, according to the researchers, was that areas with high population density are likely to have a greater number of ICU beds to meet the needs of the population. However, densely populated areas are also the ones that promote the spread of the coronavirus and ultimately yield a higher death toll. The positive correlation is likely to be influenced by population size as a modifying variable. The higher mortality rate observed in high-income countries may also be due to the increased ability of patients to travel, cancelling out high-quality care. 

However, the same study shows that there is no significant association between either the per-capita number of hospital beds or ICUs and deaths from Covid-19. This, the researchers point out, suggests that there are other factors that influence coronavirus mortality, such as available supplies (e.g. ventilators) and the number of nursing staff. In addition, a relative shortage of protective material can exacerbate the effects of a shortage of healthcare personnel and can have a dramatic impact on the survival of patients with Covid-19.

Lockdowns proved to be beneficial at reducing viral spread in Greece, especially during the first wave. However, in the third wave of the pandemic, after 5 months of restrictive measures in February and March 2021, the pandemic reached its worst stage in early April. As it prepares to open up its economy and tourism, Greece looks nothing like the country it was a year ago, with record numbers of cases, intubations and deaths. 

Information blackout in Greece

On 19 November 2020, MIIR  submitted an official request for documents submission to the Ministry of Health, the National Public Health Organization (NPHO), the Deputy Minister of Civil Protection and the General Secretariat of Civil Protection, on the basis of Greek and European legal and constitutional provisions regarding access to information and transparency (the equivalent of a FOIA request, which is a very rare request by journalists in Greece). MIIR requested, among other things, to be provided with detailed data on the total number of available intensive care units (ICU) in the National Health System throughout the country since the beginning of the pandemic. We made a new written request on 9 December. 

On 12 December 2020, we contacted the EODY by telephone. They verbally assured us that we would receive a written response within the next month. After two months and after the implicit rejection of our request we made a third written request to the relevant bodies. No response was given.  

For over a year there has been no official posting on the EODY's website of the number of available ICUs. Only the coverage rate of the existing ICUs dedicated to Covid-19 is announced, without specifying the available total. All data obtained from media surveys and from individual citizens are secondary. The government, while regularly announcing the alleged increase in available ICU beds, constantly mixes up general ICU beds with Covid-19 ICUs. What exactly is happening? 

The actual ICUs and deaths 

As of 14 September 2020, according to POEDIN , the ICU beds in Greek hospitals then amounted to 930. Of these, 701 were available for patients with diseases other than Covid-19 and 229 were available exclusively for the treatment of patients with Covid-19.

"Currently we have 1,305 ICU beds in the country, 748 Covid-19 beds and 557 non-Covid-19 beds, and we continue to open new beds. We received 557 ICUs in 2019," Health Minister V. Kikilias said verbally (as always) on 7 December. But the reality is different. According to MIIR's information, and as confirmed by the government and the opposition, the government received 568 ICU beds in 2019. But it also received 510 specialist ICU beds (180 in the NHS involve burn units, cardiac and coronary surgery units, plastic surgery units; 260 were in private clinics and 70 in military hospitals). The number of specialist ICUs taken over by the government is not mentioned and it claims to have increased the number of available ICUs to 1,400.

"It is a lie what the government says about 1,300 and 1,400 ICUs in Greece. That number does not exist. The multi-purpose ICUs available in the health system were about 650 in the second wave of the pandemic. Based on the data we collect, more than 80% of deaths from Covid-19 have taken place outside the ICU," Michalis Giannakos, president of the Panhellenic Federation of Public Hospital Employees (POEDIN), tells MIIR. 

"The primary data with which we can evaluate the work of the state and the scientific committee is lacking. In fact, they are carefully hidden. How many patients can't find beds? How many are dying outside the ICU? Are patients being screened? Who was vaccinated as a priority? The answers to these questions are the criteria for citizens to assess whether the state did its job properly. These data exist. They are just not made public," explains Vassilis Tsaousidis, professor in the Department of Electrical Engineering at Democritus University of Thrace . "In any case, if the recovery rate (of those discharged) in ICUs is between 35-50%, then the rate of deaths outside ICUs, so far, ranges between 61-79%," the professor states. 

Conclusions

By European standards Greece still has a relatively low per-capita death toll. But it has been severely affected in the second and third waves, and the data have changed dramatically in recent weeks. The NHS in Greece is weak compared to most European countries, having a very low number of nurses per capita and one of the lowest per-capita ICU ratios in Europe since the beginning of the pandemic. The same is still the case a year later despite government efforts to muddy the waters.

Given the above, Greece had a low capacity before the collapse of the health system, which led it to adopt a prolonged five-month lockdown which did not work. The country is opening up the economy and tourism with the epidemiological data in the red. With more ICUs, doctors and nursing staff, the country would have been better able to shield itself without having to lock down for so many months, which risks a new economic crisis after the painful decade of the Memorandum. 

The number of patients who have ended up in Covid ICUs, and the rate of recovery in them, are being concealed. It is therefore not possible to accurately calculate the number of those who have died outside of ICUs. This fact alone warrants a public outcry.

Available translations
Wednesday 28 April 2021

Source/s:

MIIR

Translation by:

VoxEurop
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