During the months of March, April and May, Spain was one of the countries with the highest number of COVID-19 cases and deaths, in proportion to the number of inhabitants. At this moment, Spain leads the number of infected and deaths registered in Europe during the last two weeks. There is no longer any doubt that we are in the midst of a second wave of the pandemic. The situation is very worrying.

In recent months, two articles have been published in The Lancet and The Lancet Public Health on the need to independently evaluate Spain's response to the COVID-19 crisis. Why is Spain in such a bad situation? What has been done wrong to lead the ranking of countries with the worst data? Where have we failed?

Pandemics are very difficult to control; otherwise they would not be pandemics. The level of uncertainty has been very high and, therefore, it has not been easy to make decisions. For this reason, and although there have been and there are those responsible for what has happened, we do not want to make here an incisive criticism a posteriori to look for culprits, but rather to assess what has happened in order to prepare ourselves for future waves and prevent it from happening again.

Lack of leadership
In times of crisis, leadership is a key element. Leaders must build bridges, foster consensus, integrate different people and groups in pursuit of a common goal. Acting with flexibility, the leader must surround himself with the best, regardless of ideology, because the objective is the health, safety and welfare of all. Spain has lacked such leadership throughout this crisis.

2. Lack of coordination
There has been an evident lack of coordination between the central government and the Autonomous Communities. From the total centralization of the state of alarm, we have moved on to "every man for himself". Viruses know no borders, so, in a decentralized state like ours, the principle of subsidiarity must be intelligently reconciled with the necessary coordination between the different administrations: state, autonomous and municipal.

3. Misleading role of science
Informed decision making requires the best available knowledge. Therefore, effective leadership requires that all decisions be informed by a multidisciplinary scientific committee. This does not mean that only scientific elements are taken into account; others must also be considered.

But the ultimate responsibility must lie with the decision-maker, i.e., with the competent authorities. Many policy makers at different levels have self-interestedly confused the supposed scientific support for their decisions with considerations of a political and economic nature. This confusion must disappear; the best guarantee for this is that the reports on which decisions are based are public and available to all.

4. Lack of data
The best available knowledge requires, of course, having the data that give an account of the situation at any given moment. But during these months, data management has been chaotic. Without having clear metrics, indicators and thresholds in time, a crisis like this one cannot be managed. Coordination on this point has also been very poor.

It is essential to know the number of deaths, cases with symptoms, asymptomatic cases, percentages of PCRs performed with positive results, other tests, types of infection, number of tracers, primary care data, hospitalizations, severity, by age, sex, origin, mobility, etc. And all these data must be public, because public scrutiny is the best guarantee that they are being put to good use.

5. The political controversy
The pandemic is not a political problem, but a community problem. But since its inception it has been used as a weapon in the partisan confrontation. And from this confrontation, the only beneficiary has been the virus. Political tension feeds polarization, which leads citizens to align themselves with their own and renounce to evaluate their actions critically.

Moreover, it increases confusion regarding the appropriateness of the proposed measures or their possible alternatives, which ends up undermining the credibility of those to whom their paternity is attributed (the experts) and, of course, also of the political decision-makers. The seriousness of the situation calls for a broad-based state pact on health, research, education and economics.

6. Lack of education and transparency
In order for the population to accept certain measures, especially if they entail limitation of freedoms or a high cost, it is essential that the reasons why they are taken are understood. And for this, they must be clearly explained, specifying their scientific basis, on the one hand, and the assets to be preserved, on the other.

Although numerous and extensive press conferences have been held, the explanations have been confusing and, on more than one occasion, have given rise to the belief that the truth was not being told. Especially when there have been contradictions between messages delivered at different times. Let us not forget that truth inspires confidence and helps to persevere. Communication must take into account people's fears and concerns, in order to be able to respond to those emotions. Otherwise, the infodemia that feeds hoaxes and denialism is fed.

7. Rapid de-escalation
Confinement had a devastating effect, not only on the economy but also on the mood and mental health of the population. It was necessary not only to save lives but also livelihoods. However, the de-escalation process was very rapid. The proximity of the summer season led to the prioritization of leisure, vacations and tourism, without taking due precautions (border control and quarantines, for example).

The restrictions should have been lifted in their entirety only after a robust and safe health system had been ensured, when effective diagnostic systems were in place and widely deployed, and when an effective system of detection, tracing and isolation of potential outbreaks was in place.

8. Slow response and lack of forcefulness
Every time there have been outbreaks or a dangerous increase in the incidence of COVID-19, the response has been slow and, when it has been taken, it has been timid. The reason for the delay has surely been the desire not to damage the economic fabric but, paradoxically, this course of action has aggravated the economic situation itself.

On the other hand, bureaucracy and the regulatory framework have contributed to delaying the implementation of measures that were to be implemented too late. The necessary legal and administrative tools must be made available to enable urgent decisions to be taken in the common interest.

9. Weakened healthcare system
Cuts after the 2008 crisis weakened the healthcare system. During the state of alarm, the focus was on hospital beds and ICUs. But the deficits in healthcare personnel have been glaring. It is therefore necessary to reinforce the number of healthcare personnel. It is essential to focus and act now on public health and primary care in order to reduce the number of people who have to be hospitalized.

Special attention should also be paid to pediatric and geriatric services. All this implies the need to incorporate more personnel and to do so as soon as possible. A healthcare system stretched to the limit has consequences that go far beyond the COVID-19 itself: delays in other diagnoses and treatments, altered child vaccination schedules, etc., with the consequent loss of health and lives.

10. Lack of trackers
The diagnostic, tracing and isolation system has been and still is, by all accounts, insufficient. In proportion to the number of inhabitants, we have had far fewer trackers than other European countries. We are facing one of the most insidious and difficult dangers to control: a new virus for which the population has no previous immunity, which is very easily transmitted by the respiratory route, which can be transmitted before the onset of symptoms and even by asymptomatic people. The pandemic cannot be controlled without knowing where the virus is. Under these conditions, diagnosis, detection of those infected, contact tracing and isolation of possible outbreaks is essential to contain the spread of the pandemic.

However, there has been indolence when it comes to assembling diagnostic and tracking teams of the required capacity. Some Autonomous Communities have even asked for volunteers for this activity, and others have ended up resorting to the Army. The Radar COVID mobile contagion alert application, which can help in this task, has arrived late and is not yet fully implemented throughout the state.

Time to correct the course
None of the above is intended to diminish the responsibility of individuals. But personal behaviors, although they may deserve reproach, are difficult to regulate through administrative decisions. What happened in Spain during the summer of 2020 was a great collective failure. There is still time to correct the course and flatten the curve again, without incurring unbearable costs in economic and social terms. It depends on everyone, but especially on those with political responsibility.