After the holding of general elections, a new opportunity presents itself to review the challenges that lie ahead for our National Health System and how to address them. From the General Council of Physicians and in collaboration with scientific societies and the IMAS Foundation, we recently carried out a complete diagnosis of the public health system and measures to improve it.

I want to start with the structural problems, such as the separation between public health and healthcare, which has led to a predominantly curative rather than preventive approach.. This paradigm must change and for this it is necessary to reorient the system towards health promotion and disease prevention through the implementation of structures that integrate public health and health care.

Another structural aspect is the health education of the population. Undoubtedly, working in this direction will be essential for proper use of health services.. We must raise awareness throughout society about the health system and respect for health professionals, as well as promote the therapeutic alliance between doctors and patients, and the participation of patient associations and scientific-medical entities in the reorientation of public health.

Another challenge that has a direct impact on the structure and approach of the SNS is the increase in the population of elderly people and patients with complex chronic diseases, as well as unwanted loneliness.. To solve this immense challenge, we must develop comprehensive care that incorporates the necessary social and professional resources to provide quality care, including multidisciplinary teams, prevention of frailty, and palliative care..

In this sense, we cannot forget that greater integration between primary and specialized care, as well as the creation of care networks that guarantee continuity of care, represent a giant step forward in this regard.. But we must also face in the coming years the expansion of the portfolio of services of the public health system, especially in mental health and oral health, to close the existing gaps compared to other developed countries.

The crisis generated by the pandemic has highlighted the need for an effective governance structure in the health system that provides it with transparent, participatory governance based on scientific evidence.. In this sense, steps have been taken such as the creation of the State Public Health Agency, but it still needs to be put into operation to, among other actions, order and assess the results of the health system and establish a shared information system.

And if we talk about major changes, we cannot ignore the patients. It is essential to incorporate patients in the government structures and in the decision-making process of the health system, guaranteeing their active participation and promoting shared decision-making.. But if patients are 50% of the SNS, the other 50% is made up of health professionals, authentic bastions of the SNS. Therefore, involving the medical profession in the planning and management of the health system and improving the doctor's experience in the National Health System through their participation in the management of the system, promoting their autonomy and responsibility is, simply, a large part of the solution.. But this implication will not be total without improvements in the working and motivational conditions of doctors that allow increasing the quality and efficiency of the system.

The organization and management of health systems are another key to take into account. This will make it possible to establish quality standards, make the results public and encourage the participation of scientific-professional entities in health policy.

All these changes and movements must go in rhythm because the transformation of our system cannot be done in sections and patches or it will fail.. It is necessary to have a holistic vision, and this implies developing assistance models adapted to the needs of citizens. Along these lines, it would be positive to organize care based on groups of patients with similar needs, develop multidisciplinary teams, measure results and costs by subgroup of patients, and strengthen community care.

If we talk about transformation in the year 2023, we cannot ignore the “digital” concept. Promoting a digital transformation of the SNS that includes, among many other aspects, the use of technologies such as artificial intelligence and the citizen's digital health history, is absolutely basic.. To do this, it is necessary to establish a digital health strategy, promote the automation of processes and foster the digital education of professionals and citizens.

In short, these are the ten great challenges that the medical profession consider crucial when it comes to rebuilding a health system that is in danger. A system that allows sustaining the universal, public and free healthcare model that for more than 40 years has helped build and unite our country. A State pact for health is urgently needed to consolidate and strengthen this pillar of our welfare state, a consensus that perhaps now has a new opportunity to start its journey.

Tomás Cobo Castro is president of the General Council of Physicians of Spain

People with HIV, especially men who have sex with men, are at increased risk of developing anal cancer.. In these patients, early detection of precancerous lesions is essential to prevent the tumor from developing. However, the techniques that are commonly used for this purpose can be greatly improved..

An international team, led by Spanish researchers, has identified two new biomarkers that could significantly improve this detection of precursor lesions of cancer (called high-grade squamous intraepithelial lesions) and, therefore, prevent the development of tumors..

Specifically, these researchers have discovered that in the anal microbiome there are two metabolites produced by bacteria that directly correlate with the aforementioned intraepithelial lesions..

As they were able to verify, the production of succinyl-coA and cobalamin is increased in the microbiome of patients with precancerous lesions.. Therefore, these metabolites may serve as useful biomarkers in clinical practice..

“Our goal is to create a diagnostic kit that allows self-sampling to measure these markers. This would mean a great saving of resources and would increase the accessibility of the diagnosis.. The ultimate goal is to improve our ability to diagnose and, therefore, treat high-grade anal dysplasia more efficiently and effectively”, explains Sergio Serrano, a researcher at the Ramón y Cajal Health Research Institute (IRYCIS), member of the Infectious Diseases service of the Ramón y Cajal University Hospital in Madrid and first signatory of the paper..

Researchers from the CIBER of Infectious Diseases, the CSIC, Hospital La Paz and the Jiménez Díaz Foundation, as well as the Universities of Hohenheim (Germany), Oslo (Norway), Bangor (United Kingdom) and Milan (Italy) have also participated in the research.

To carry out the research, the scientists have studied 213 patients, who were already undergoing follow-up with anoscopies and anal biopsies as they presented an increased risk of anal cancer, a type of cancer that is linked to papillomavirus infection..

“Our previous investigations led us to believe that we could identify a specific group of bacteria that would indicate the presence of lesions,” Serrano said via email.. This was not the case and the team came to think that it would have to end the investigation without significant results.. “However, by looking at the proteins expressed by the bacteria we discovered something fascinating.. We found a powerful statistical signal in certain proteins. In addition, these proteins were linked to two metabolic pathways previously described in bacteria that adapt to cause infections and in tumor cells that invade tissues.. In other words, there was a strong biological basis for our findings.. These proteins guided us to study two metabolites derived from these metabolic pathways: cobalamin or vitamin B12, which only bacteria can produce; and succinyl CoA, a key compound in the reactions that generate energy in cells,” says Serrano, who remembers that moment as a true “eureka” moment..

The research indicates that the combination of biomarkers is superior in diagnostic capacity to conventional anal cytology, since it improves sensitivity, specificity, and predictive values..

In addition to trying to develop a diagnostic kit, the researchers want to replicate the results in other populations, study whether these biochemical pathways represent possible treatment targets, and analyze the levels of these metabolites in other cancers originating from epithelia..

“Because of the parallels with that of the cervix, this will be the first one that we investigate,” says Serrano..

Regarding the mechanisms involved in the relationship between metabolites and precancerous lesions, the researcher clarifies that “due to the design of the study that we have already carried out, we cannot establish the causes that lead to the induction of these biochemical pathways. But given the functions of the proteins associated with the presence of precancerous lesions, we believe that they are involved in the development of these lesions.”.

Heat waves are (and will be) increasingly frequent, long and intense. And virtually all experts agree that the main cause is climate change, combined with warming caused by the natural El Niño event in the Pacific, and exacerbated by changes in atmospheric circulation in Europe, parched soils and rising sea temperatures.

“What is happening can be explained in two words: climate change,” says Isabel Moreno, a meteorologist for the RTVE program Aquí la Tierra. “Heat waves are surely the weather phenomenon that can be most easily attributed to climate change.. And that without forgetting the episode of extreme heat that caused Córdoba to reach 38.8 degrees at the end of April, up to a hundred times more likely due to the effect of climate change, according to a report by the World Weather Attribution (WWA).

“Behind extreme heat there may always be an element of natural climate variability,” warns German climatologist Friederike Otto, WWA co-founder.. “But the longer, more intense and more frequent heat waves that we are seeing in Europe are mainly caused by human-induced climate change.”

From the observatory at the Grantham Institute for Climate Change in London, Otto no longer considers it necessary to wait for a new attribution study on this summer's heat waves to take action: “The role of climate change in what is happening is already sufficiently proven.”

“We are experiencing unprecedented heat for humans,” adds Otto. “And as long as we keep burning fossil fuels, temperatures are going to keep rising.. But we are not facing the collapse of the climate, we still have time to act and reach the goal of zero emissions.”

“The possibility of sequential and longer heat waves like the one we are seeing is increasing,” says Clement Albergel, climate applications scientist at the European Space Agency (ESA).. “The link to human-induced climate change is very clear.. Although this year there is an element that is adding fuel to the fire: the El Niño weather pattern that is taking shape in the tropical Pacific.”

The impacts of El Niño reach the entire planet. The year 2016, the hottest ever recorded, was precisely the penultimate year in which the natural warming effect of the Eastern Pacific was experienced.. “Every time El Niño occurs, global temperatures rise,” warns Albergel. “2023 may ultimately be the hottest year on record.”

A person cycles past a fountain in Rome. MASSIMO PERCOSSI EFE

June 2023 already was, and on July 3 the record for the hottest day in recent history was broken (17.18 degrees). The successive heat waves have caused temperatures above 44 degrees in Spain and around 47 degrees in Italy (the European maximum continues to be in Sicily with 48.8 degrees in 2021).. In Greece, temperatures above 43 degrees forced the temporary closure of the Acropolis and caused a chain of forest fires.

The dangers to health still persist, and the meteorologist Isabel Moreno emphasizes the difference in criteria between Health and AEMET in the face of heat waves, defined as “an episode of at least three consecutive days, in which at least 10% of the stations register maximums among the 5% of the highest temperatures of their series between 1970-2000”.

The last two heat waves experienced this summer have had their origin “by the rise of a mass of very warm, dry and stable air originating in North Africa”, according to the AEMET, which also warns how “this type of spells of extreme heat that has become more frequent in recent decades as the jet stream that dominates the western hemisphere has become unstable”.

The increased frequency of heat waves in Europe may in fact be related to fluctuations in the jet stream that flies over the Eurasian region, according to the results of a study sponsored by the Potsdam Institute for Climate Impact and published in Nature.

Based on statistical data from the last 42 years, it has been proven that heat waves in the European continent increased between three and four times faster than in the rest of the northern mid-latitudes, such as the United States or Canada.. The researchers have verified how the “double jet states” – when the current divides into two branches – last longer and cause the upward trend of heat waves in 30% of the continent.

Another factor that comes together this year is the prolonged drought, which may be feeding back on the situation. Moist soils serve to absorb extreme heat, but when they dry, evapotranspiration decreases: less water evaporates from plants or directly from the soil, and that energy goes on to heat the air.

The slowdown in ocean circulation and the increase in sea temperatures may also be contributing to the situation. The British Met warned at the beginning of the summer that the temperatures to the east of the North Atlantic between April and May were the highest recorded in those months in a series that began in 1850, with temperatures up to four or five degrees above average (the first heat wave in June reached the United Kingdom, which has, however, been “protected” from the last two by the “double jet”).

The phenomenon of heat islands has also worsened this summer, with lows of 25 degrees at night in some of our cities. The lack of vegetation, pollution, the layer of asphalt, glazed surfaces, human crowds or refrigeration systems are some of the factors that contribute to temperatures in the city being higher (one to three degrees) than in rural areas. They know it well in Phoenix, the Arizona city that this summer has broken its own record with 19 consecutive days above 43 degrees.