Archive for April 2020

Covid-19 Pandemic

The coronavirus disease (COVID-19) pandemic has created a mass casualty disaster of staggering proportions. By April 2020, the novel coronavirus responsible for COVID-19 had forced many parts of the United States into crisis mode, while others race to prepare for the inevitable. In regions where the case numbers have not yet begun to climb, disaster planning teams have time to prepare for a crisis response and implement lessons learned from those who were impacted earlier. The goal is the greatest good for the greatest number of people, so hospitals and health care systems are turning the focus from individual health to population health in their disaster surge response to save as many lives as possible.    

Mass casualty incidents (MCIs) can be man-made acts of violence, such as mass shootings, bioterrorism, or exploding bridges, or natural disasters in the form of earthquakes, tornados, tsunamis, and pandemics. Tragedies of intentional violence or infrastructure disasters create a sudden surge, demanding a rapid shift in a hospital’s daily routine, and are usually limited geographically—for example, the site of an active shooter or a train derailment. Natural disasters, however, cover much larger regions (i.e., the path of a tornado), whereas, by definition, pandemics know no boundaries.

One key variable in these disasters is time. Time, in most cases, determines our ability to prepare for and maintain a disaster response. In trauma MCIs, there is a window of time when patients arrive to local hospitals, which is often measured in minutes to hours. In the case of bioterrorism or pandemics, timelines are prolonged, measured in days to weeks. Regarding the ongoing COVID-19 pandemic, the window of time is indefinite and unknown. The disruption of a hospital’s daily routine for prolonged periods of time and the need for resources beyond those available, or worse, outstrips the supply chain, placing severe strain on the health care system. Our best tools to manage these challenges are preparation, planning, and practice.  

Preparation and planning take place from the federal and state levels to the community and local health care facility levels. Community planning should be coordinated with local governmental agencies, in accordance with state and federal disaster planning efforts, and integrated with local public health and emergency medical services. With respect to pandemics, community strategies must make every effort to “flatten the curve” in order to break the chain of transmission and slow the spread of infections. At the same time, hospital system strategies “raise the roof” of surge response by increasing health care system capacity (Fig. 1) through predesigned efforts focused on three factors: space, staff, and supplies. The hospital system is the backbone of these three elements.  

Figure 1

Community efforts to “flatten the curve” of coronavirus infections often intersect with health care system strategies to “raise the roof” for patient capacity (modified from Disaster Med Public Health Prep with permission from the Society for Disaster Medicine and Public Health).

Strategies for increasing health care system capacity will include conservation and substitution during a conventional response, adaptation and recycling during a contingency response, and, finally, reallocation of resources during a crisis response—essentially, withholding resources from one patient population to use them more effectively on another patient population. These “raise the roof” strategies involve nuanced ethical and legal considerations that must be addressed in advance, authorized by hospital leadership, and communicated clearly to frontline health care workers.


Ultimately, the hospital system component directs the response that determines the allocation of the three critical resources of space, staff, and stuff, which are based on supply and demand.

A robust hospital incident command system provides broad management for a multitude of issues, including: hospital controls (facility access, ventilation), communication (internal and external), community coordination (health care facilities, state and federal agencies, as well as utilities and supply chains), and continuity of emergency health care operation (vis-à-vis utility or other system failures). The hospital incident command should also determine and communicate which disaster response is being utilized. Disaster response can be described, in escalating intensity, as conventional, contingency, and crisis, dependent on surge severity and resource availability. The more severe the surge, the fewer the resources; the lower the hospital’s capacity to take care of victims, the more quickly the disaster response must shift into a higher mode (Fig. 2). 

Figure 2

As the hospital incident command system escalates the intensity of disaster response—from conventional to contingency to MCI—the minimum acceptable standard of care for patients is diminished (modified from Disaster Med Public Health Prep with permission from the Society for Disaster Medicine and Public Health).


Upon declaration of an MCI, efforts must be made to free up physical space for patients. The size and nature of the disaster will dictate the scope and speed necessary. 

The conventional response is for surges causing a 20% increase in patients beyond normal capacity. In this situation, all staffed beds are made available and filled. Elective procedures are postponed or cancelled, and patient discharge plans are activated to dedicate more space and empty beds to the surge.

A contingency response is used for surges that are twice a hospital’s capacity and demands more aggressive actions. As the numbers of patients greatly exceed the available hospital and critical care beds, hospital spaces designed for other purposes, including step-down units, observation units, and procedure suites, can be repurposed to recruit more space to bed patients. Transferring patients to other available facilities for ongoing, nonemergent care can be initiated.

A crisis situation completely overwhelms a health care facility. Patients fill hallways, and makeshift spaces, such as tents and offices, need to be devised. Erecting tent hospitals with intensive care units in city parks, converting convention centers into field hospitals, and docking of the United States Naval Ship (USNS) Comfort in Manhattan and USNS Mercy in Los Angeles are evidence that our nation is in crisis because of the COVID-19 pandemic.


As more space becomes available, achieving appropriate staffing and obtaining adequate supplies for the surge of patients is vital. The hospital incident command system should be convened for action as soon as a disaster is declared to urgently alert and mobilize necessary staff. The type of injuries that are expected (e.g., blunt trauma, penetrating trauma, or biological agent) will determine the type of staff best suited to respond. If staffing levels are insufficient, measures to increase staffing may be warranted, including expanding the scope of responsibilities, lengthening shifts, and enlarging patient-to-nurse ratios.  

In a conventional response, trained and credentialed staff are able to care for patients with minor modifications, while maintaining usual standards of care.

The standard of care is challenged in a contingency response, as adequately trained staff must train and supervise off-service staff to safely provide care. Bringing in additional staff should be considered, and outside staff need to be given emergency privileges and credentialing.     

A crisis response demands staff to perform clinical functions outside their usual domain. Aggressive staff recruitment and rapid training are necessary to meet the patient care demands and volume. During crisis mode, triage becomes necessary to ensure that acceptable care is provided for the largest number of people. Over- and under-triage can result in higher mortality rates. 

Supplies (“Stuff”)

Supplies include medications, medical equipment, and personal protective equipment (PPE). Considerations must also be made for laboratory reagents, diagnostic testing, as well as for food, water, and linens.

The hospital system must be aware of onsite and offsite supply storage and availability through supply chains. The ability to adapt, reuse, and reallocate becomes necessary in both contingency and crisis situations.

In the current COVID-19 pandemic, we are witnessing contingency and crisis responses. Hospitals are experiencing severe shortages of ventilators and PPE, meaning patients may be deprived of life-saving care and health care providers are likely to be infected with dire, cascading ramifications.

Radiology Department Response

A departmental incident command team should be in place to implement a disaster management plan and engage in clear and consistent communication. The radiology department must have containment and mitigation strategies that ensure the safety of all staff and patients being imaged. For COVID-19, these measures include ensuring adequate PPE, especially for frontline technicians performing imaging studies, enforcing physical distancing, and limiting in-person interactions. Remote reading should be instituted, where possible. Decontamination protocols must be defined and executed. Nonemergent studies should be halted, including interventional procedures, to preserve PPE and limit exposure.

All real-time changes to address incident-specific issues should be frequently updated and communicated. Implementing these types of measures allows radiology departments to provide safe and appropriate care during surges and helps to ensure sustainable operations.

The lessons we learn from responses nationally and internationally should be incorporated into our hospital and departmental MCI and disaster planning process. Our ability to plan and prepare by focusing on system, space, staff, and stuff will make all the difference in the number of lives saved.

Public use of surgical masks to slow COVID-19

In laboratory experiments, the masks significantly reduced the amounts of various airborne viruses coming from infected patients, measured using the breath-capturing “Gesundheit II machine” developed by Dr Don Milton, a professor of applied environmental health at the University of Maryland and a senior author of the study. Milton has already conferred with federal and White House health officials on the findings, which closely follow statements from the head of the US Centres for Disease Control and Prevention saying the agency was reconsidering oft-stated advice that surgical masks aren’t a useful precaution outside of medical settings. (The debate takes place at a time when clinicians themselves face dangerously inadequate supplies of masks – a shortfall other UMD researchers are scrambling to help solve.)

The question of masks has roiled society as well, with some retailers refusing to let employees wear them for fear of sending negative signals to customers, and cases of slurs and even physical attacks in the US and elsewhere against Asians or Asian Americans who were wearing masks, a measure some consider a necessity during a disease outbreak.

The study, conducted prior to the current pandemic with a student of Milton’s colleagues on the faculty of medicine at the University of Hong Kong, does not address the question of whether surgical masks protect wearers from infection. It does suggest that masks may limit how much the infected – who in the case of the novel coronavirus often don’t have symptoms – spread diseases including influenza, rhinoviruses and coronaviruses. Milton, who runs the Public Health Aerobiology, Virology, and Exhaled Biomarker Laboratory in the School of Public Health, demonstrated in a 2013 study that surgical masks could help limit flu transmission. However, he cautions that the effect may not be as great outside of controlled settings.

Nevertheless, he said, the chance they could help justifies taking a new look at whether all people should be encouraged to wear them when they venture out of their houses to stores or other populated locations during the current COVID-19 lockdown.

“In normal times we’d say that if it wasn’t shown statistically significant or the effective in real-world studies, we don’t recommend it,” he said. “But in the middle of a pandemic, we’re desperate. The thinking is that even if it cuts down transmission a little bit, it’s worth trying.”

Previous studies have shown that coronavirus and other respiratory infections are mostly spread during close contact, which has been interpreted by some infectious disease specialists to mean that the disease could spread only through contact and large droplets, such as from a cough or sneeze – a message that has often been shared with the public.

“What they don’t understand is that is merely a hypothesis,” Milton said. The current study (along with earlier ones) shows, by contrast, that tiny, aerosolized droplets can indeed diffuse through the air. That means it may be possible to contract COVID-19 not only by being coughed on, but by simply inhaling the breath of someone nearby who has it, whether they have symptoms or not. Surgical masks, however, catch a lot of the aerosolized virus as it’s exhaled, he said.

The study was conducted at the University of Hong Kong as part of the dissertation research of the lead author, Dr Nancy Leung, who, under the supervision of the co-senior authors Drs Cowling and Milton, recruited 246 people with suspected respiratory viral infections. Milton’s Gesundheit machine compared how much virus they exhaled with and without a surgical mask.

“In 111 people infected by either coronavirus, influenza virus or rhinovirus, masks reduced detectable virus in respiratory droplets and aerosols for seasonal coronaviruses, and in respiratory droplets for influenza virus,” Leung said. “In contrast, masks did not reduce the emission of rhinoviruses.”

Although the experiment took place before the current pandemic, COVID-19 and seasonal coronaviruses are closely related and may be of similar particle size. The report’s other senior author, Professor Benjamin Cowling, division head of epidemiology and biostatistics, School of Public Health, HKUMed, and co-director of the World Health Organisation Collaborating Centre for Infectious Disease Epidemiology and Control, said, “The ability of surgical masks to reduce seasonal coronavirus in respiratory droplets and aerosols implies that such masks can contribute to slowing the spread of (COVID-19) when worn by infected people.”

Milton pointed to other measures his research has found is even more effective than masks, such as improving ventilation in public places like grocery stores, or installing UV-C lights near the ceiling that works in conjunction with ceiling fans to pull air upwards and destroy viruses and bacteria.

“Personal protective equipment like N95 masks are not our first line of defence,” Milton said. “They are our last desperate thing that we do.” Hong Kong University contributed to this report.

Coronaviruses and Acute Respiratory Syndromes (COVID-19, MERS, and SARS)

Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. 

Numerous coronaviruses, first discovered in domestic poultry in the 1930s, cause respiratory, gastrointestinal, liver, and neurologic diseases in animals. Only 7 coronaviruses are known to cause disease in humans. 

Four of the 7 coronaviruses most frequently cause symptoms of the common cold

Coronaviruses 229E and OC43 cause the common cold; the serotypes NL63 and HUK1 have also been associated with the common cold. 

Rarely, severe lower respiratory tract infections, including pneumonia, can occur, primarily in infants, older people, and the immunocompromised.

Three of the 7 coronaviruses cause much more severe, and sometimes fatal, respiratory infections in humans than other coronaviruses and have caused major outbreaks of deadly pneumonia in the 21st century:

  • SARS-CoV2 is a novel coronavirus identified as the cause of coronavirus disease 2019 (COVID-19) that began in Wuhan, China in late 2019 and spread worldwide.

  • MERS-CoV was identified in 2012 as the cause of Middle East respiratory syndrome (MERS).

  • SARS-CoV was identified in 2002 as the cause of an outbreak of severe acute respiratory syndrome (SARS).

These coronaviruses that cause severe respiratory infections are zoonotic pathogens, which begin in infected animals and are transmitted from animals to people.

COVID-19 is an acute, sometimes severe, respiratory illness caused by a novel coronavirus SARS-CoV2.

COVID-19 was first reported in late 2019 in Wuhan, China and has since spread extensively in China and worldwide. 

Transmission of COVID-19

Early COVID-19 cases were linked to a live animal market in Wuhan, China, suggesting that the virus was initially transmitted from animals to humans. 

Person-to-person spread occurs through contact with infected secretions, mainly via contact with large respiratory droplets, but it could also occur via contact with a surface contaminated by respiratory droplets. 

Researchers are still learning how readily this virus spreads from person to person or how sustainable infection will be in a population, although it appears more transmissible than SARS and spread is probably more similar to that of influenza.

Super-spreaders played an extraordinary role in driving the 2003 SARS outbreak and may also play a significant role in the current COVID-19 outbreak. 

A super-spreader is an individual who transmits an infection to a significantly greater number of other people than the average infected person. 

Quarantine and isolation measures are being applied in an attempt to limit the local, regional, and global spread of this outbreak.

Symptoms and Signs

People with COVID-19 may have few to no symptoms, although some become severely ill and die. Symptoms can include fever, cough, and shortness of breath. 

Those with more severe disease may have lymphopenia and chest imaging findings consistent with pneumonia. 

The exact incubation time is not certain; estimates range from 1 to 14 days. The risk of serious disease and death in COVID-19 cases increases with age.

Symptoms and signs reference

1. Centers for Disease Control and Prevention: Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep 69:343-346, 2020. doi: 10.15585/mmwr.mm6912e2external icon.


Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) testing of upper and lower respiratory secretions.

Diagnostic testing for COVID-19 is being made available to select laboratories authorized by the Federal Drug Administration under an Emergency Use Authorization (EUA). 

Clinicians can also access laboratory testing through public health laboratories in their jurisdictions.

For initial diagnostic testing for COVID-19, the CDC recommends collecting and testing a single upper respiratory nasopharyngeal swab. 

Collection of only oropharyngeal swabs is acceptable if other swabs are not available. 

The CDC also recommends testing lower respiratory tract specimens, if available. 

For patients for whom it is clinically indicated (eg, those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. 

Collection of oropharyngeal swabs is a lower priority and if collected should be combined in the same tube as the nasopharyngeal swab. 

Collection of sputum should be done only for those patients with productive coughs. Induction of sputum is not recommended. 

Specimens should be collected as soon as possible, regardless of the time of symptom onset. 

Maintain proper infection control when collecting specimens. 

For biosafety reasons, the CDC recommends local institutions do not attempt to isolate the virus in cell culture or do initial characterization of viral agents in patients suspected of having COVID-19 infection.

Because of the increasing availability of test kits in the US, previous restrictions on patient selection for testing are being relaxed, and testing is expanded to a wider group of symptomatic patients. 

Clinicians should use their judgment as to whether a patient’s symptoms and signs are compatible with COVID-19 and whether they should be tested. 

Decision to test should also take into account the local epidemiology of COVID-19, the course of illness, and the patient’s epidemiologic factors such as close contact with a confirmed COVID-19 case within 14 days of symptom onset or history of travel to an affected geographic area within 14 days of symptom onset. 

Clinicians are also strongly encouraged to test for other causes of similar respiratory illness (eg, influenza). 

Areas of sustained transmission will vary as the outbreak proceeds. For areas inside the US, clinicians should consult state or local health departments. 

For countries outside the US, affected areas as of March 5, 2020 include China, Iran, Italy, Japan, and South Korea.

If any of these criteria are present, infection control personnel at the healthcare facility and the local or state health department should be notified immediately.


Supportive Treatment of COVID-19 is supportive. No vaccine, antiviral drug, or other specific treatment is available.

To help prevent spread from suspected cases, health care practitioners should use standard, contact, and airborne precautions with eye protection.

Why Greece Succeeded as Italy, Spain Failed to Tackle Coronavirus

When the covid-19 pandemic broke out in Europe, no government had any experience of how to face it and each tried to weather the storm in its own ways. Some governments fared better, some less so.

By and large, there are three major factors that have determined, and still do, how governments cope with the virus.

These are, first, the resoluteness and efficiency of their leadership; second, the capacity of states and public health systems in particular to deal with such an extraordinary health crisis situation; and, third, the cooperation of national publics in following emergency rules.

At a more specific level, as shown by an even cursory comparison of the Spanish and Greek experiences with the pandemic, it seems that a well-integrated and liberal government performs significantly better than one which is disunited and, moreover, diluted with populists. Let’s have a closer look at the two cases.

At the time of this writing (5 April 2020), Spain has close to 130,000 confirmed cases of coronavirus victims and about 12,000 deaths. At the same time, Greece has about 1,700 confirmed cases and 68 deaths.

So, the question is: Why these two Mediterranean countries, whose people are equally sun-loving, bar-hopping, and intensely social, and which should have drawn the same lessons from Italy’s preceding experience, have had such different fates during the early phase of the coronavirus crisis? The answer is simple, almost mundane: Different governments!

The little comparison table below shows the reaction of Italy, Spain, and Greece to the coronavirus outbreak. It reveals three things.

First of all, Italy, the first country in Europe to be hit by the virus with catastrophic results, offered valuable lessons that shouldn’t be missed by other governments.

Secondly, Spain’s government failed to learn and, in fact, performed even worse than Italy.

And, finally, among these countries, Greece is by far the best performer in confronting the pandemic, at least so far.

It certainly helped, of course, that Greece has a centralized state administration system which, unlike in Spain or Italy, facilitates the fast implementation at regional and local levels of decisions taken at top state level. But this explains only part of the different reactions to the pandemic in Spain and Greece. Let’s have a closer look beginning with the case of Italy, which served as a backdrop against which the Spanish and Greek governments made their decisions.


Italy, indeed, offered early valuable lessons to any government that was willing to learn. Coronavirus was confirmed there on 31 January, when a traveling Chinese couple, originally from Wuhan, China, tested positive in Rome. In the next three weeks, more cases of infection were confirmed in the northern regions of Lombardy and Veneto and, on 22 February, the first death from the coronavirus was reported.

From there on, the number of deaths in Italy went into an upward spiral. By 5 March, as the number of the deceased had reached one hundred, the government shut down all schools and universities nationwide.

On 8 March, with confirmed cases approaching 6,000, Prime Minister Giuseppe Conte extended the quarantine lockout to all of Lombardy and other northern provinces, which, at the time, was the most radical measure to combat the virus taken anywhere outside China. On 10 March, the government expanded the quarantine to all of Italy and ordered Italians to stay at home.

From the first confirmed case, it took the Italian government 38 days (and 16 days since the first death) before it imposed a first nationwide lockdown. It was, unfortunately, too late. A few days later, on 19 March, Italy became the country with the highest number of confirmed deaths in the world.

Clearly, then, the chief lesson from Italy was that governments elsewhere would need to react early and take most aggressive measures in order to check the pandemic. But the reactions of the governments in Spain and Greece couldn’t differ more than they actually did. And that had very different consequences in each of these two countries.

Spain, first, was reluctant to learn from Italy. “We are going to have only a handful of cases,” asserted on 9 February Dr. Fernando Simón, an epidemiologist serving as the head of medical emergencies in Madrid. Even as the number of confirmed cases of coronavirus continued to increase, the Spanish government still resisted to take mitigating steps so as to combat the virus spread; in fact, it initially defended the decision to let mass gatherings go on.

On 8 March, about 120,000 people were allowed to march through the center of Madrid to celebrate the international Women’s Day and some 60,000 soccer fans filled one of the city’s stadiums. During that same weekend, 9,000 supporters of Vox, an upcoming right-wing party, gathered inside a former bullring.

By Friday, 13 March , Spain already had the second highest number of coronavirus infections of any European country after Italy, now facing the fastest spreading contagion on the continent and an already overwhelmed health care system. Two ministers of Sánchez’s cabinet, including Irene Montero, the partner of Deputy Premier Pablo Iglesias and one who had participated in the women’s march, tested positive. Another prominent victim of the virus was Santiago Abascal, the leader of Vox.

It was only then, on 13 March, one full month after the first death from the virus was reported (13 February) and with the tally of deaths at 189, that the government decided to close all schools and declare a state of emergency across the country. Why all this was let to happen?

For one thing, it didn’t help that Prime Minister Pedro Sánchez leads a leftist minority government that only formed with difficulty after the inconclusive elections in November 2019.

In the aftermath of that contest, Sánchez, leader of the center-left PSOE, and Pablo Iglesias, leader of left populist Unidas Podemos, formed an alliance which subsequently produced Spain’s first coalition government since its transition to democracy. The new government, consisting of the prime minister, four deputy prime ministers and 22 ministers, formed on 13 January 2020.

Nor did it help that Podemos as a populist party has thrived on political polarization, often militated against the legality of Spain’s institutions for allegedly failing to serve the people’s interests, and typically opposes technocracy and the expert knowledge stemming from it. All that played at the level of micro-politics with disastrous consequences.

Friday, 13 March, was a critical moment. Sánchez announced his intention to enact emergency measures and decree a state of alarm across all the country on the following day. But things went awfully wrong.

The coalition government’s Council of Ministers, which was meant to include only ministers considered essential for responding to the crisis, was marred by intense infighting . Pablo Iglesias, who was supposed to be in quarantine after his partner had tested positive for the virus, appeared unexpectedly to the Council objecting the concentration of powers under the ministries of interior, defense, transport, and health, all headed by PSOE politicians, and demanding that his party be given prominent roles in the national emergency situation.

He also insisted that the government takes social measures for helping poor families, such as paying rents and mortgages. According to El País , the minister of finance rejected the proposal for the high cost it involved amid a developing economic crisis.

The Council of Ministers meeting lasted eight hours and ended with acrimony on both sides with dire consequences for the country. It first of all delayed the implementation of lockdown and other emergency measures, and also led to cancelling a teleconference planned for the same day between Sánchez and the leaders of Spain’s regional governments.

Even worse, since all that happened on a sunny Saturday, several people from Madrid and other big cities left for the regions, bringing the virus with them. One such case was José María Aznar, Spain’s former conservative prime minister, who moved to his holiday villa in the rich resort of Marbella, fueling public anger against him and the government alike.

Meantime, as the death toll keeps rising, Spain’s fissured coalition government utterly failed to rally the opposition parties on its side for creating a unified front against the pandemic. Pablo Casado, the leader of the center-right People’s Party, accused prime minister Sánchez for spreading lies and misinformation, while ultra-right Vox called for Sánchez’s resignation and replacement by a government of national unity.

To make things even worse, most of the regional governments, especially in separatist Catalonia, miss no chance to show their displeasure with the incompetence of, and health crisis mismanagement by, the central state administration.

How different from Spain was the reaction to the coronavirus pandemic in the other Mediterranean country, Greece!

For starters, the effect of the virus in Greece was a particularly big setback since the country was just coming out of years of recession and recent projections for its economic future were quite optimistic.

But Greece’s government was quick to learn from Italy and Spain, and act decisively and swiftly, despite having to simultaneously face additional difficulties.

In February, Turkey ignited a refugee crisis by opening its border with Greece to Europe and aiding thousands of displaced persons to cross it. Greece responded by strengthening the border with soldiers and armed police, soliciting the support of her EU partners, and by refusing to accept asylum applications for a period of one month. The situation at the border remained tense during most of March, which diverted part of the Greek government’s attention to that crucial front.

Another problem was the cramped living conditions in refugee camps in both Greece’s islands and the mainland. And yet, the government’s response to the coronavirus outbreak was nearly outstanding as it determined to reduce the spread of the virus within the country and flatten the curve as early as possible in the hope that the long-term effects on both the society and the economy could be minimized. Here’s what happened in Greece, in brief.

The first case in Greece of a person to test positive – a woman who had recently traveled to Milan – was reported on 26 February and, on the following day, two more cases were confirmed.

That same day, Greece’s minister of health cancelled all planned carnival events throughout the country and the government banned all educational trips abroad.

Only thirteen days later, on 10 March, with the number of confirmed cases totaling 89 and no deaths, the government closed all daycare centers, schools, and universities nationwide.

On 11 March, Prime Minister Kyriakos Mitsotakis, in a nationally televised address, urged the public to follow the instructions of doctors and other experts, and admonished the Church to refrain from delivering the “holy communion” and instead cooperate with the state authorities in enforcing the public health regulations.

On 12 March, the first death from coronavirus was reported in Greece. In the few days to follow, the government shut down theaters, cinemas, restaurants, bars, shopping centers, playgrounds, museums, courthouses, parks, recreational areas, marinas, organized beaches and ski resorts; it only excluded supermarkets, pharmacies and food outlets.

Eventually, the government suspended all religious services, including the Sunday masses of the Greek Orthodox church, and also announced the closure of most hotels in the country and subjected all Greek citizens returning from abroad to mandatory 14-day quarantine.

During March, the Geek prime minister gave five nationally televised addresses (on 11, 17, 19, 22 and 25 March), every time explaining to the Greek people the development of the situation and asking them to comply to the new rules.

The government’s infectious disease spokesman, epidemiologist Sotiris Tsiodras, goes on TV every afternoon to both brief journalists and offer advise to the citizens. As of Greece’s significant opposition parties, they all showed an admirable sense of social responsibility, political moderation, and even readiness to support the government in its difficult decisions during crisis.

The major moral from the different stories of pandemic prevention in Spain and Greece is that governments matter a lot.

More specifically, they need to set aside their political compulsion and listen to experts and other technocrats; they must act early and swiftly; and they should be efficient in making working trade-offs with the society at large, various economic interest groups, and, perhaps more importantly, the political opposition.

So far, Spain’s government has unfortunately failed in all these areas with enormous cost for the Spanish society. And the Greek government gets all credit due for its success in preventing the wild spread of the virus and minimizing the suffering Greek society would otherwise have to endure.