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It feels like a flashback. Pneumonia, a common acute manifestation of the COVID-19 disease, is keeping Spanish intensive care wards busy again. And it's also leaving medical workers who are still recovering from the pandemic's peak with an anxious sense of deja vu.

Foreseeable as it was, the second wave has arrived in Europe earlier than expected, hitting countries with different intensity. In Madrid, for the second time the capital worst hit by coronavirus outbreaks on the continent, doctors and nurses say that authorities are responding, again, too erratically and too late.

"In a way, it’s like the situation in March but in slow motion," said Dr. Carlos Velayos, who works as an intensive care unit physician at the public hospital in suburban Fuenlabrada. The hospital is expanding its ICU capacity from 12 to 24 beds by the end of September, as all of them are currently filling up with coronavirus patients.

With 1,273 patients in ICUs, Spain has as many beds devoted to treat grave patients of COVID-19 as France, the United Kingdom, Germany and Italy together. And 359 of them are in the Madrid region, which for the past week has accounted for roughly one-third of a national average of 8,200 new infections per day.

Spain has a virus caseload above 600,000, one of the world's highest, and more than 30,000 confirmed deaths for the new virus.

Velayos said that prediction models were telling hospital administrators in Madrid that some ICU wards could reach peak capacity in the second half of September. But little or nothing has been done to avoid a return to extended shifts among many health professionals that are still recovering from the stress of the pandemic's first wave.

"In March, it was like a nuclear bomb that brought the health system as a whole to a collapse in a matter of weeks," Velayos said. "We might not be there yet, but that’s not a reason not to be worried. We have allowed the outbreaks to reach a level of being uncontrollable.”

Medical workers are this time better prepared, with lessons learned on how to treat incoming patients more effectively and they have means to better protect themselves against contagion. But operating rooms in the Madrid region, which has a population of 6.6 million, are already being turned into ICUs and surgeries have been postponed, while hospitals compete to hire professionals for the expanded capacity.

Regional authorities say that the health system still has room to manage the incoming flow of patients, but following warnings by medical personnel like Velayos, officials are now reacting with stricter measures that could include selective lockdowns as early as next week.

The restrictions, if finally adopted, will center on urban areas where the coronavirus is spreading faster, officials said Wednesday. That's suburban towns like Fuenlabrada, but also working-class neighborhoods in southern Madrid where contagion rates have been steadily soaring since August.

They also happen to be areas where less affluent residents and mostly migrant families cram into small apartments and commute on public transportation to manual work in other quarters of the Spanish capital.

Ángela Cantos, who lives in the Vallecas neighborhood, one of the hot spots in the recent wave of outbreaks, said that if her neighborhood is locked down, "then Madrid will be paralyzed.”

"Who is going to cook and clean in other districts if they close down here?" she said.

The regional deputy health chief, Dr. Antonio Zapatero, said Wednesday that "Madrid wants to flatten the curve before the arrival of autumn and the complications that cold weather could bring,” adding that the "drastic measures” to be taken will be decided by the weekend.

Zapatero also said that people have relaxed protection measures by holding large gatherings, often forgetting about social distancing or masks. He also announced that police will monitor compliance of mandatory self-isolation since at least 90 people have been found to be skipping quarantines after testing positive for the new virus.

Madrid will introduce selective lockdowns in urban areas where the coronavirus is spreading faster, regional health authorities announced on Tuesday.  | AP
Madrid will introduce selective lockdowns in urban areas where the coronavirus is spreading faster, regional health authorities announced on Tuesday. | AP

The country flattened the curve of contagion earlier this year with a three-month lockdown, one of the strictest anywhere, but since it relaxed measures in mid-June, outbreaks have spread throughout the country.

Authorities say they are now doing more tests and that more than half of the newly infected show no symptoms, but health centers are starting to struggle to cope with the number of virus tests required and responding to patients. In hospitals, 8.5 percent of the country’s beds are now treating COVID-19 patients, but in Madrid at least one-fifth of hospital capacity is devoted to coronavirus-related complications.

In terms of ICUs, official data shows that 38 percent of the region's beds have coronavirus patients, but some hospitals are already at 90 percent of their capacity before rolling out emergency plans for new beds, like they did in spring.

"Madrid is maintaining a steady level of infections, but we have to take into account the impact of the pandemic in primary care, in hospitals, which is totally sustainable at the moment, but we have to make that line of infections decrease,” said Zapatero, who back in March was tasked with Madrid's makeshift hospital of 1,500 temporary beds in an exhibition center.

This time officials are saying that they hope they don't have to reach that point. The regional government is spending €50 million ($59 million) to build a massive new "epidemics hospital” with more than 1,000 beds by the end of October, and it's promising more resources for primary care, since health centers have now become the new bottleneck of citizens concerned that they may have contracted the virus.

In addition to performing most of the testing, primary care in Spain has now taken the burden of contact tracing.

"The problems in primary care are not from the past six months," said Dr. Olaya Munoz, who works in a health center in the heart of the city. "COVID has just been more stress for a system that was malfunctioning for at least a decade.”

Munoz finds time to talk, while catching her breath, as she walks uphill to visit two elderly patients at home. After that, more than 40 appointments await her back at her community health center. Although these days they do most of them by phone, she can't devote more than an average of six minutes per patient.

"The workload is just unbearable,” she said.

Nursing home workers hold a minute of silence in Madrid on Tuesday.  | AP
Nursing home workers hold a minute of silence in Madrid on Tuesday. | AP

Dr. Maria Cruz Martin Delgado, spokeswoman for Spain's intensive care specialists' association known as Semicyuc, says that a collapse in primary care couldn't only lead to more asymptomatic cases to go undetected but also poorer service of other illnesses that eventually could lead to more patients downstream, in hospitals and ICUs.

What Martin wants is a clear protocol from authorities at the national and regional levels on how to proceed.

"We need to know what is the point when we need to turn down other patients, because we doctors can't take all responsibility again having to respond to an emergency when we are not given the resources to do so.”

"The work overload in March and April was acknowledged as part of an exceptional situation that needed to be met with all the world's generosity,” said Velayos, the intensive care specialist from Fuenlabrada. "But right now we are talking about a situation becoming chronic, where stress is going to be the norm and routine.”

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