From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Chile’s response to the coronavirus pandemic – The August Update (2020)

Maria Soledad Martínez-Gutierrez, School of Public Health, University of Chile, Chile
Cristóbal Cuadrado, School of Public Health, University of Chile, Chile
Sebastián Peña, Department of Public Health Solutions, Finnish Institute for Health and Welfare, Finland

Since our last report, the COVID-19 epidemic in Chile has continued to unfold, with a peak in the number of daily cases (over 7,000) and deaths (over 200) in mid-June. By August 9, the Chilean government had reported 373,056 cases and 10,077 deaths (confirmed by a COVID-19 positive PCR test). After the peak, the daily number of cases and deaths steadily decreased until mid-July and since then it has stabilized with approximately 2,000 cases per day and around 10% of positive PCR tests. The number of patients in critical care reached a maximum at the end of July (~2,500 patients) and since then it has continuously declined to less than 2,000 patients by August 8. The number of patients hospitalized in operation theaters, pediatric ICUs and emergency rooms has, likewise, declined from ~300 patients to 27 patients by August 8. However, the current number of patients in ICU exceeds three times the normal ICU capacity in the country.

The healthcare system response has experienced changes since our last report. The government’s communication strategy remained controversial until Jaime Mañalich stepped down as Minister of Health on June 13. He resigned amidst controversy about the correct number of deaths being reported every day by the Public Health Undersecretary and a worsening of pandemic indicators which was interpreted as a failure of the dynamic lockdown strategy. During the peak, the occupancy rate of critical beds was exceedingly high in the Santiago Metropolitan area and patients had to be transported to other regions in the country to be hospitalized. Patients also began to wait in primary care centers to be hospitalized, often for days. The focus, up until late May, was on expanding the health system capacity, but the Chilean press raised attention to the fact that the public health authority was not able to reach a large number of cases and contacts and ensure their isolation and quarantine. Contact-tracing became a salient issue in the public agenda at that point and only on June 3 (three months since the first case), did the Ministry of Health announce that primary care would be included in contact-tracing efforts, although a high number of municipalities were already doing some kind of contact tracing on their own. A national contact-tracing strategy was formally announced one month later and additional funds destined for this labor reached municipalities only a couple of weeks ago.

The new Health Minister, Dr. Enrique Paris, has adopted a less confrontational communication strategy and included in the government’s daily report scientists, experts and Mayors. The Chilean government has begun to ease the lockdowns in several municipalities, but it is not entirely transparent which indicators will be used to decide which municipalities remain or enter in lockdowns. The scientific community has expressed concerns about the early release of the lockdown, considering that there are still a large number of cases and the quality of contact-tracing (and the data available) is still deficient, as the Undersecretary herself admitted a few days ago.

Broad social and economic policies to respond to the pandemic have been a matter of intense debate in Chile. While direct cash transfers to households have been demanded to cover wide portions of the population, the government was reluctant and insisted on narrowly focussed programs for the poorest segments of society. Moreover, instead of direct cash transfers, the government started transfers of in-kind food benefits, requiring several weeks of logistical arrangements to finally reach some households around the country. In this context, discontent due to hunger and poverty increased the perception of a government that was not reacting timely and adequately enough to population needs. Congress took the initiative and negotiated with the Executive to increase the population covered by cash transfers including the middle-class and recently approved a controversial law allowing the population to use up to 10% of their pension funds for living expenses for one year. After more than 5 months of the pandemic, at the beginning of August, a large proportion of Chilean households are receiving effective relief to cope with basic expenditures in the context of growing unemployment and economic instability.

Chile’s response to the coronavirus pandemic – Update (May 2020)

Maria Soledad Martínez-Gutierrez, School of Public Health, University of Chile, Chile
Cristóbal Cuadrado, School of Public Health, University of Chile, Chile
Sebastián Peña, Department of Public Health Solutions, Finnish Institute for Health and Welfare, Finland

Since our last report, the communication strategy from the Government has continued with a confrontational style causing several controversies. Moreover, the decision-making process kept the relevant actors off the table and a reluctance by the Government to data-share has worsened the opacity perceptions of their actions. As of May 7, 2020, Chile has 24,581 confirmed cases and 285 deaths related to COVID-19. The epidemic curve is on the rise as well as the number of patients in critical care and connected to mechanical ventilators. The effective reproductive number has increased from 1.06 to 1.4 over the last week, with a clear breakpoint on April 29 when cases doubled on the previous day. Critical care capacity might collapse in the short-term if this pace of viral transmission continues.

The Government discourse has clearly focused on the availability of mechanical ventilators and ICU beds. Consequently, the Ministry of Health increased the critical care beds capacity substantially (from 726 ICU beds on April 2 to 1,615 on May 6) through transitory hospitals and a reconversion of beds.

Unlike other countries, Chile disregarded the use of large-scale lockdowns as part of its containment strategy. Instead, the government proposed “dynamic lockdowns”. These small-area lockdowns were implemented at the municipal level (or parts of a municipality) and were re-evaluated every week based on certain criteria such as the number of new cases in a territory, the propagation velocity, the number of cases per km2, the proportion of vulnerable population and factors related to social determinants of health. The first of these lockdowns started on March 14 in the small and isolated town of Caleta Tortel in Patagonia. By March 26th, a lockdown in the Metropolitan Area covering more than one million citizens was implemented and followed by several cities in the following weeks.

A recent development has been the start of an active testing strategy on asymptomatic cases in high-risk groups (i.e. prisons and elderly residencies). This policy started in late April following the recommendation of the Scientific Advisory Committee and, since April 29, the Ministry of Health has reported separately asymptomatic and symptomatic cases. The first day that COVID-19 cases were reported separately (symptomatic and asymptomatic), a controversy ignited. The Ministry of Health presented first that only the symptomatic COVID+ persons were counted as cases and reported to WHO concordantly. Nevertheless, it was unclear if in the previous days the authority was strictly reporting symptomatic cases to make the statistics comparable over time. After a formal request from the Chilean Epidemiology Society, the report was corrected and all COVID confirmed patients, independently of their symptomatic status, were informed to the WHO surveillance system.

On April 9 the government announced the implementation of an immunity card, which would allow recovered patients to return to work and move in the city without lockdown restrictions. This policy was criticized both in Chile and internationally. One critique was the unclear criteria for issuing the card, as the Ministry of Health inconsistently suggested that people would be considered immune if they had a SARS-COV2 positive test, were symptomatic and recovered, or if they had a positive rapid antibody test. A minor impasse with the WHO ensued after a Chilean journalist asked a WHO spokesperson about the measure, to which he replied that it was not advisable to use passports since there were no reliable tests to date or strong evidence about the length of immunity acquired (if at all). WHO further established its position on this warning that “the use of such certificates may, therefore, increase the risks of continued transmission” (April 24th). Chile recently ratified a plan to dispense release cards to recovered Covid-19 patients but rowed back from an earlier idea they would effectively be used as an “immunity passport”.

On April 20, the Government announced that some measures would be relaxed in the near future (such as opening schools and returning the majority of public workers back to work) and the country would go back to “the new normal”. Undersecretary of Public Health Paula Daza explained that people could get together for a coffee in small groups with social distancing. The announcement was not well received by the public and was widely criticized. The Scientific Advisory Committee issued a declaration saying that they were not consulted on the decision; however, they later stated that they supported the government’s decision of a “gradual return” to activities and the need for an adequate plan. Dynamic lockdowns started to be lifted and the government focused its agenda on recovering the economic activity.  These policies received different names; “New Normality” and “Safe Return”.

Less than two weeks after this call to a “New Normality”, the new-case counts sky-rocketed, from a median of 500 cases per day to more than 1,000 and increasing. This change in viral spread suggests the idea of an early return to normal activities was a misstep. This new situation forced the Government to issue new containment efforts in twelve municipalities in the Metropolitan Region, resulting in that on May 8th nearly 4.5 million persons in Santiago (55.2% of the Metropolitan Area population) will be in lockdown. However, a decision was made to gradually phase out lockdowns on 15 municipalities. Now, the epidemic outbreak is growing at a higher pace and is far from being under control.

Chile’s response to the coronavirus pandemic – Original post (April 2020)

Maria Soledad Martínez-Gutierrez, School of Public Health, University of Chile, Chile
Cristóbal Cuadrado, School of Public Health, University of Chile, Chile
Sebastián Peña, Department of Public Health Solutions, Finnish Institute for Health and Welfare, Finland

Chile erupted in social unrest on October 18, 2019. Subway stations were burned, supermarkets looted and millions gathered every week on the streets and protested for a variety of demands such as pensions, healthcare, education, feminism, working conditions, and wages. The neoliberal system imposed by the dictatorship 30 years ago was truly challenged for the first time. Conservative president, Sebastián Piñera, took a hit in his approval rates which reached 6% in December 2019. The Constitution was deemed illegitimate and a referendum to decide if Chileans would have a new constitution was set for April 26 in an unprecedented agreement of almost all political parties.

In January -in the middle of the summer break- the Ministry of Health issued alerts about COVID-19 to customs and immigration departments instructing them to detect incoming cases using a voluntary questionnaire. On March 2, the Ministry decided to demand a mandatory sworn statement to every person entering the country to detect passengers that had been to affected countries. Once identified, travelers were tested for COVID-19 and put in optional quarantine. However, checks at the airport were weak and unsystematic.

Chile reported its first imported case of COVID-19 on March 3. On the 11th, the President formed an expert advisory committee composed of public health officials and scholars. The public was kept from the committee’s deliberations and since the government stance vis-a-vis the population was precarious, many believed that the committee’s recommendations were overlooked in favor of the economy and big business interests. On March 14, phase 3 was declared. By that time, the public, the Chilean Medical Association (CHMA) and the mayors’ association (ACHM) were demanding a more drastic course of action including a nationwide school closure.

Sunday, March 15 was a key date. At 1 PM, a number of measures were announced including a bill to allow some prison inmates to serve their sentences under house arrest, a ban on events with 200 or more attendants, and quarantine of long term care facilities and children’s homes. A spokesperson of the advisory committee announced that schools were not being closed since students were “safer at school than in their own homes”.  During the day the pressure mounted and nongovernmental organizations were demanding to know what was being discussed with the advisory committee; especially the reasoning for not closing schools. The CHMA demanded more strict measures like banning mass events and making the SARS-CoV-2 test free at the point-of-care; they also reported that the quarantine of cases and their contacts was not being enforced properly. One by one, the main universities in the country announced they were closing and would start using online tools for instruction. Some municipalities and private schools followed suit. In the evening, after meeting with ACHM representatives, the President declared schools would be closed from March 16. The public had access to the Committee’s minutes for that day in the evening, where it was explained that there was a disagreement about school closures with some members advocating to focus on case and contact management. The role of the expert committee was jeopardized and questioned publicly after that.

Chile reached 100 confirmed cases on March 16 and phase 4 of the pandemic was declared. The influenza vaccination campaign started that day and agglomerations of vulnerable populations were reported in multiple locations. The third week of March was marked by weak leadership by the Central Government. Local municipal authorities took the lead and decided to cancel events, close shopping centers, and parks, even against Central Government’s recommendations. The CHMA gathered political actors across the spectrum to discuss the need to reconsider the date of the referendum for a new constitution and led a call for the population to stay at home and avoid new public demonstrations. Both the public and local government representatives started pushing for a mandatory quarantine and lockdown for the city of Santiago. The Ministry of Health engaged in a communicational battle with all these actors and was unable to find substantial support from the public.On March 18, the Central Government finally responded to the pressure, declared a state of emergency and the borders were closed. An intense debate about the convenience of a national lockdown ensued. The Government insisted on a “stepwise approach” and the Minister of Health discarded the idea of a national lockdown considering it “senseless”, since he estimated the measure would last at least three months. The Vice President consequently took the lead and convened a High-Level Committee with representatives from the Government, Municipalities, Universities and the CHMA on March 22. The same day a national curfew was imposed from 10 PM to 5 AM. Since then, some districts of the Metropolitan Area have been quarantined, as well as a few cities with a significant number of cases. It is interesting to note that only on March 26 did the Ministry of Science and Technology call public health and mathematical modeling national experts to analyze different scenarios in order to inform decision making at the national level.

Regarding testing, there have been some controversial issues such as the lack of information in terms of how many tests were available and being performed daily and what the waiting times for results were. The number of cases has been rising at a constant rate; however, it is not clear if this is due to effective control of contagion or limited testing capacity. The price of the PCR test was capped at 30 dollars, although it was determined that it would be free at the point-of-care for publicly insured people seeking care in the public system. There have been reports of rationing of tests in the public system and lack of critical medical supplies for testing.

Actions to increase the health system’s capacity to deal with a surge in demand for inpatient/critical care were announced in the second week of March. They included the early opening of 5 hospitals and repurposing of facilities for basic acute inpatient care.  Transitory hospitals are expected to be available in early June. The government reported having purchased ventilators in January; however, the purchase of 872 machines was materialized only on March 13 and they will arrive in late May. For now, Chile has not reached its critical care capacity, although in some places like Temuco the maximum patient capacity in Intensive Care Units has been reached.

Overall, the main shortcoming in the government’s response to the crisis has been its communication strategy which has been perceived as confrontational and opaque by many key actors in the epidemic containment effort, such as healthcare professionals, the academic community and local governments.

As of April 5th, the epidemic outbreak is still in an early phase in Chile and the results of the strategy adopted by the government have yet to come to light. The COVID-19 pandemic and the unfolding of social unrest will pose an interesting challenge in the post-pandemic period and can shape a very different path for Chile in the future.

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