The thinning ranks of doctors and nurses, particularly in Spain, are hampering the ability to fight the epidemic, straining hospitals and raising fears that health workers are spreading the coronavirus.
Across Western Europe, health care professionals have used the language of war to describe the struggle against the coronavirus, which has left some hospitals on the brink of collapse.
And health care workers are the soldiers on the front lines.
Out of Spain's 40,000 confirmed coronavirus cases, 5,400 — nearly 14 per cent — are medical professionals, the health ministry said Tuesday. No other country has reported health care staff accounting for a double-digit percentage of total infections.
• Covid 19 coronavirus: New Zealanders make last minute scramble for supplies before Covid-19 lockdown
• Covid-19 coronavirus: Perspex screens and pack-your-own, Countdown's lockdown safety measures
• Covid 19 coronavirus: Couple say 'I do' as lockdown looms
• Covid-19 coronavirus: What the lockdown means for you and how it will be enforced
But the problem is widespread throughout Europe. In Italy, France and Spain, more than 30 health care professionals have died of the coronavirus, and thousands of others have had to self-isolate.
In Brescia province, the center of Italy's outbreak, 10 to 15 per cent of doctors and nurses have been infected and put out of commission, according to a doctor there. In France, the public hospital system in Paris has tallied 490 infected staff members, a small but growing proportion of the system's 100,000 or so employees.
The same dynamics are starting to take hold in countries like Britain and the United States, where the contagion is bearing down but has yet to fully bite.
At the La Paz hospital in Madrid, one of the largest in Spain's capital, 426 employees — 6 per cent of the medical staff — are isolated at home, after testing positive or showing possible symptoms of the coronavirus, according to internal numbers provided by a labor union that represents doctors in Madrid. At the smaller Igualada hospital in Catalonia, a third of the 1,000 hospital staff has been sent home.
"The virus was already among us when we were really only testing those who came from Wuhan and then from Italy," said Ángela Hernández Puente, a doctor who is the deputy secretary general of the doctors' union. "Some of our doctors unfortunately worked without adequate protection and acted as vectors."
As doctors, nurses and other practitioners fall sick, the burdens increase on health care systems already groaning under the strain of an expanding epidemic. And infected workers and their hospitals are increasingly being recognised as vectors for the spread of the virus.
The number of cases in Spain has been doubling every four days, and the country is fast shaping up as Europe's next epicentre of the contagion. On Tuesday, Spain's coronavirus toll reached 2,700 dead, the second-highest in Europe after Italy.
In Madrid, the focus of Spain's outbreak, so many are dying that bodies are being placed in an Olympic-sized ice skating rink that has been converted into an emergency morgue.
In some retirement homes, soldiers deployed to disinfect the premises found elderly people abandoned, or dead in their beds, prompting Spain's public prosecutors to open an investigation.
It has not helped that Spain's population, on average, is among the world's oldest. But the government was also late to impose restrictions on the movement of people. Even as a tragedy unfolded in northern Italy, mass events went ahead earlier this month in Madrid, and the government waited until March 14 to declare a state of emergency that has since forced people to stay indoors, barring exceptional circumstances.
Spain also did not shore up its stock of medical equipment early on. Doctors and nurses have had to work with a dangerous shortage of masks, gloves and other essential gear that has proved disastrous for them.
The grim situation has left many of Spain's health care professionals overwhelmed and pleading for more equipment, doctors, nurses and ambulance crews have told The New York Times. For those who have been infected, a feeling of powerlessness has sunk in.
"You are used to taking care of others and now you're being asked to stay home and take care of yourself," said Marc Arnaiz, a doctor in the internal medicine unit of the Igualada hospital, who tested positive earlier this month. "For most of us this job is a vocation, so it's shocking and frustrating."
Arnaiz, 31, said he had likely been infected by a patient. He noticed the first symptoms on March 9, the day his patient was confirmed positive, among the first in the hospital, which has since become one of the worst infection clusters in northeastern Spain.
While it's impossible to know how many patients infected doctors and vice versa, the alarming spread within hospitals has forced the government to struggle with a shortage of both professionals and equipment. Last week, the government launched an emergency recruitment plan to add 50,000 health care workers, ranging from medical students to retired doctors.
After employees began complaining openly about the stresses on the system, some Madrid hospitals told their staff not to speak out. Many of those interviewed by The New York Times were not authorized to comment publicly and asked that their full names not be used for fear of retribution.
One, Yolanda, has been a nurse for 30 years, working in a public hospital in Madrid. But earlier this month, as the outbreak worsened in Spain, she said she was moved instead to a makeshift emergency ward, where she had to learn new skills on the job while working without decent protective gear.
"We've been put on the front line not only without enough protection, but also sometimes with the stress of a very different work environment," she said, noting that she had never before handled intubated patients. The nurses in her unit wore face masks and gowns, but they had to reuse them because of a shortage.
"Putting on a face mask again and again is as useless as sticking a piece of paper on your face," she said.
Last Thursday, Yolanda went home feeling feverish. On Sunday, she tested positive for coronavirus, along with about 30 colleagues. "We have done our best, but some of us sadly became part of the contamination chain," she said.
Hospital workers' unions were less hesitant to point fingers. "When we already knew that the virus was circulating in hospitals, we were still being told that the usage of protective gear should be limited to specific circumstances," said Juanjo Menéndez, the communications director of SATSE Madrid, a nurses' union. "It's the kind of basic error that a student learns to avoid in the first year of medical school."
In Spain, France and Italy, officials and health care professionals said they were shocked by the equipment shortages.
Giorgio Gori, the mayor of Bergamo, one of the hardest hit towns in Italy, said "the doctors weren't protected," and lacked "the sufficient defences," adding that he was still receiving requests for masks and gloves from doctors making home visits.
Jean-Paul Hamon, the president of one of France's biggest doctor unions, told the LCI television broadcaster on Tuesday that he was particularly worried about workers who are not in hospitals but are still in close contact with patients, like general practitioners or retirement home employees.
Three of the five doctors who have died of COVID-19 so far in France were general practitioners, and one was a gynaecologist. "The state is absolutely unprepared," said Hamon, who is himself infected. "The state is going to owe an explanation."
In Spain, doctors warned that hospitals were now paying the price of the loose measures announced in the early days of the outbreak.
"The lack of protection is everywhere, the improvisation seems to be widespread," said Antonio Antela, a doctor who coordinates the infectious disease unit at the university hospital of Santiago de Compostela, in northwestern Spain. He has been hospitalised for a week after developing pneumonia and testing positive.
"The lesson is: take care of your public health care system, because there will be other epidemics and we ought to be better prepared," he added in a telephone interview from his hospital bed.
At a medical center in the heart of Madrid, María, another nurse who is now isolated at home with coronavirus, said that she spent several days working without a face mask and gloves, handing out masks only to visitors who reported breathing problems or had recently been in Italy.
On March 11, the day she first felt fever, her medical center finally ordered all staff to wear masks. "We probably didn't have enough face masks, but we also acted for far too long as if this was a limited problem, mostly imported from Italy," she said.
The Spanish government is now stepping up efforts to buy medical equipment, as well as distributing about 650,000 new test kits across the country. Two Chinese cargo planes filled with face masks and other gear landed in Madrid and Zaragoza on Tuesday.
"We are a target like everybody else, but we are also a threat to other co-workers," said Juan, a 37-year-old doctor in a Madrid public hospital. "Also, if you test everyone and there's no health care workers left in the hospitals, what can you do?"
Written by: Raphael Minder and Elian Peltier
Photographs by: Samuel Aranda, Gianfranco Tripodo, Nadia Shira Cohen
© 2020 THE NEW YORK TIMES