Article In Brief
Greece has very few cases of COVID-19. Neurologists in the country discuss the steps that were taken to prevent the spread of the coronavirus and why they were so effective.
Five years ago, Neurology Today told the story of a bankrupt health care system in Greece, ravaged by a series of economic austerity measures. Overcrowded and understaffed public hospitals, profound prescription shortages, severe limitations on testing and treatments, and long waits for neurology residency training slots had crippled neurologic care. Additionally, the percentage of elderly in the country is second only to Italy and it had the fewest intensive care beds in Europe. So when we checked back to see how the global health crisis had impacted the country, we were surprised to see that in fact Greece has become noteworthy for defying the odds.
In a population of 10.72 million, Greece has had a total of 2,716 COVID-19 cases and 151 deaths to date. What's more, at press time, relatively few people required intensive care, not a single physician on the front line has died, and there have been no COVID-related nursing home deaths.
Neurology Today asked neurologists practicing in Greece to describe the actions taken to stave off the spread of coronavirus and to speculate as to why they worked so successfully.
Early, Decisive Action by Governmental and Health Authorities
The first known COVID-19 patient was diagnosed in Thessaloniki, Greece on February 26. One day later, the government cancelled the annual Carnival celebration, its version of Mardi Gras. Schools and universities were closed on March 10, and on March 13, cafes, restaurants, libraries, and museums were shuttered.
“Within three weeks of the first documented case, all cultural and commercial enterprises were shut down as were sports facilities and areas of religious worship; cities or villages with gradually increasing numbers of COVID-19 cases were strictly quarantined,” Antonios Kerasnoudis, MD, PhD, senior consultant neurologist in the outpatient department for multiple sclerosis and neuroimmunological disorders at St. Luke's Hospital in Thessaloniki, told Neurology Today.
“Greece has a centralized state administration system, which unlike Italy, facilitates the decisions taken at the top state level with expeditious implementation at regional and local levels,” explained Paraskevi Sakka, MD, PhD, chair of the Athens Alzheimer Association, and director of Hygeia Hospital Memory Clinic in Athens. “Before the first case was even diagnosed, we had already begun examining people and isolating them,” she added.
Full Compliance by the Public
“Visits to supermarkets, pharmacies, physicians or banks were allowed only once a day, and the vast majority of citizens showed remarkable discipline and stayed home,” Dr. Kerasnoudis said. People needed to send an SMS text to 13033 requesting permission to leave the house, the reason, name and home address, and had to wait for a reply before venturing out, otherwise risking a fine.
“The compliance with the plan was driven by many factors including strict implementation from the government, witnessing the frightening experience from Italy and other European countries, and by the realization that no matter how well-prepared the health care system is, our ability to tackle the virus is, in reality, quite limited,” said Nikolaos Scarmeas, MD, MS, PhD, associate professor of neurology at Columbia University, and professor of neurology, National and Kapodistrian University of Athens, located in the city with most of the cases.
Trained Experts Are Primary Sources on Science
“An unprecedented media campaign was launched by the Ministry of Health in Greece,” Konstantinos Charalampopoulos MD, consultant neurologist at 216 Military Hospital of Alexandroupolis, said. “The public was well-informed and thus persuaded to implement preventive measures enduring not only social distancing and isolation but new financial hardships from an economy that came to a standstill,” he explained.
The government designated an infectious disease specialist, Sotirios Tsiodras, MD, MSc, PhD, FIDSA, as its communications liaison for the health crisis, and he gave daily press conferences to inform and update the nation about the course of the pandemic. Described as a soft-spoken, Harvard-trained professor by Dr. Sakka and others, he led a committee of 25 infectious diseases specialists. “Greeks appreciated Prof. Tsiodras' calm manner, his knowledge of the matter, his dedication to the nation's nursing staff, and his deep respect for victims,” Dr. Kerasnoudis said.
Konstantinos Vadikolias, MD, professor of neurology at Democritus University of Thrace, and general secretary of the board of directors of the Hellenic Neurologic Society, agreed that the daily official press conference about COVID-19 on the national television channel (ERT.gr) were instrumental in gaining public acceptance.
“The director of the Scientific Committee of the Ministry of Health informed the public about the number of new cases, deaths and ICU patients and answered questions from journalists, while the ministry of civil protection announced the governmental measures,” he said. Almost all television stations in the country broadcast these 30-minute presentations, he added.
“Personally, I believe that this type of information was a crucial step; it came directly from the scientists who have gained considerable credibility with the public, and as a result, it was easier for people to understand the severity of the situation and to follow the strict regulations such as the lockdown, school closure and sudden pause of most of the commercial activity,” Dr. Vadikolias continued.
Protection of Hospitalized Patients
“Guidelines for hospital visits were sent by the government in order to ensure the protection of hospitalized patients belonging to vulnerable groups and doctors and nurses on the front lines,” said Dr. Kerasnoudis, “and external visits were not allowed, except by special permission.”
“Although initially many health care professionals had to purchase their own personal protective equipment (PPE), later, masks, eye goggles, and face shields were provided to the front line from universities, institutions and private donors, free-of-charge, thanks to 3D printing technology,” Dr. Kerasnoudis added.
Specific hospitals were designated as COVID hospitals and affected patients were sent there. “Greece managed to almost double the number of its ICU beds,” said Dr. Sakka, adding, “Doctors, nurses and other health care professionals had the time and means to act in an organized and safe way.”
“The health care system never reached its capacity nor even came close to it; only about a quarter of the available ICU beds were used, and medical visits at all settings decreased substantially,” said Dr. Scarmeas.
“The impact of lessons learned during the ten-year economic crisis helped increase efficiency and decrease misuse of available resources,” Dr. Charalampopoulos said.
The decade of hardship also primed the medical community for meticulous supply chain management. “There was strict central organization of practice and supply flow, and PPE proved to be in adequate supply,” said Dr. Sakka. “Greece had only recently exited a prolonged period of economic crisis, and coronavirus will no doubt make things difficult again,” predicted Dr. Sakka, adding that the costs to an economy so dependent on tourism have already been high.
Certainly, Greece's economy this year is expected to be severely damaged by the COVID-19 pandemic and the counter measures taken to limit its spread, according to the European Commission's Spring 2020 Economic Forecast released on May 6. The forecast provided a dismal economic picture for Greece in 2020, as it says the nation's GDP is expected to contract by 9.7 percent this year – the highest out of all EU countries – and its unemployment rate may reach 19.9 percent, up from 17.3 percent in 2019.
“The Greek state announced a package of measures to support the economy, businesses and employees, including a suspension of tax and social security obligations by corporations ordered to close, as long as they did not dismiss any workers; an 800 Euro stipend and four-month suspension of March tax payment for employees of suspended businesses and freelance professional affected; and the reduction of the value-added tax (VAT) from 24 percent to 6 percent on pharmaceutical products such as PPE and antiseptics,” said Dr. Kerasnoudis. “Unfortunately, these measures are still under discussion.”
Homonoia and Empathy Reigned
Traditional Greek concepts, based on ancient mythology, include Homonoia (Greek Оμóνоια), representing concord, unanimity, and oneness of mind, and Empathy (Ancient Greek εμπάθεια), the ability to understand and share the feelings of another.
“These traits have always been the ideological cornerstones of the Greek nation, especially during historically difficult times,” Dr. Kerasnoudis remarked. The Ancient Greek philosopher, Aristotle, once taught his student, Alexander the Great, that Homonoia resembles friendship, and this kind of solidarity always leads to a successful common achievement. The Ancient Greek teacher of rhetoric, Isocrates, referred often to Homonoia and Empathy as the basis for pan-Hellenic unity, and I think we did our best to keep our longstanding tradition of these concepts alive,” Dr. Kerasnoudis said.
Similarly, the televised pandemic update reports by Dr. Tsiodras have often been followed by remarks of unity and compassion from the infectious diseases doctor. The Washington Post recently likened them to sermons and reported that the humanity struck a chord with many Greek citizens.
“Guidelines for hospital visits were sent by the government in order to ensure the protection of hospitalized patients belonging to vulnerable groups and doctors and nurses on the front lines, and external visits were not allowed, except by special permission.”
—DR. ANTONIOS KERASNOUDIS
“The key to success, if any—because we don't know the end yet—was the fact that for this difficult period, human life comes first, no matter how great the cost might be,” Dr. Vadikolias said.