The Spanish Constitution recognizes the right to public health and divides such matters between the state and the autonomous communities. Based on this constitutional framework Spain has created an integrated and coordinated network of agencies and institutions to address public health crises and also closely follows World Health Organization standards, alerts, and directives. In cases of public health emergencies, the Ministry of Public Health, Social Services and Equality is the authority in charge of maintaining health and hygiene control over the international transit of people and goods at Spanish ports of entry. The state has the authority to monitor and coordinate public health services with all other local authorities when there is a risk to public health with domestic or international consequences. The National Network of Epidemiological Surveillance and the Carlos III Health Institute are the entities in charge of epidemiological planning, coordination, and research. Information of a personal nature in cases of the declaration of an epidemic remains mainly confidential.
The most recent case of a health crisis impacting Spain was caused by the Ebola outbreak in West Africa. In spite of all the preventive measures taken by the health care authorities, Spain had the first confirmed case of Ebola virus contracted outside Africa after a Spanish nurse came into contact with two Spanish nationals who were infected in Africa. The nurse has now fully recovered.
I. Government Structure
Spain is a parliamentary monarchy with a bicameral Parliament (Cortes Generales) composed of the Senate and the Congress of Deputies. The Constitution recognizes and guarantees the right to autonomy of the regions that comprise the state. Bordering provinces with common historical, cultural, and economic characteristics may accede to self-government and form autonomous communities (comunidades autónomas). The country’s fifty-two provinces have been grouped into autonomous communities since adoption of the 1978 Constitution.
II. Structure of Public Health Crisis Management System
Spain’s Constitution expressly recognizes the right to the protection of public health, stating that it is incumbent upon the authorities to safeguard public health through preventive measures and necessary care and services, which are regulated by law.
The Constitution determines which health matters are reserved for the state and which are to be delegated. The autonomous communities are responsible for regulating social assistance matters and health and hygiene, while the state reserves the exclusive right to regulate matters pertaining to the structure and coordination of the public health system, and to enact legislation on pharmaceuticals. The state is also responsible for regulating matters pertaining to the basic legislation and economic structure of the social security system, even when the services are rendered through the autonomous communities.
Based on the constitutional mandate, Law 14/1986 on General Public Health created a National Health System (NHS) that integrates and coordinates all health services of the autonomous communities, including those rendered at centers and hospitals managed by the municipalities. The Law expressly provides that the state is the exclusive authority over international health relations and agreements and over external health. It further states that matters of external health are those related to vigilance over and control of potential health risks imported and/or exported through the international transit of people or goods.
The Ministry of Public Health, Social Services and Equality (MPH) was recently reorganized under Royal Decree 200/2012, under which the central administration is given the authority to uphold the powers assigned to the state in health matters and to guarantee the population’s constitutional right to health protection. The MPH cooperates with other government departments to ensure that the inspection and control of external health matters is coordinated within the government in order to simplify and expedite international transit, in compliance with international agreements. The regulatory directive of Law 14/1986 has been implemented by Royal Decree 1418/1986, which provides that the MPH has the power to manage relations with other international health and consumer affairs entities through the Ministry of Foreign Affairs; adopt all necessary measures under international agreements on health and consumer affairs to which Spain is a party; and maintain health and hygiene control over, and surveillance of, international traffic at Spanish ports, airports, customs ports, and terminals. The MPH also works in conjunction with the Ministry of Agriculture to oversee the transportation of people, corpses, and human remains, and of animals and animal derivatives. Together with the Ministry of Economy, it oversees the transportation of goods and of any other merchandise that could pose a potential risk to public health.
In the event of an emergency, the MPH has the authority to coordinate international transit that could affect the health of people or their legitimate interests when they may be affected by the international traffic of goods or services.
The Law on General Public Health provides that the state, without prejudice to the authorities assigned to the autonomous communities, is responsible for monitoring and analyzing epidemics and for coordinating the services of the different public health administrations in situations that may create public health risks with domestic or international consequences. It also provides that the state is in charge of setting up a health information system and preparing statistics of general interest to the autonomous communities. The state is also responsible for establishing a network of information and communication between the state and the autonomous communities in health matters.
III. Powers of Public Health Authorities
Health emergencies are declared by the state through the MPH, or by the autonomous communities when such power has been delegated by the state.
Organic Law 3/86 on Special Measures in Matters of Public Health lists the conditions under which the Spanish health authorities may, within their jurisdiction, adopt urgent and necessary public health measures in times of emergencies. The government has the authority to declare a state of alert in extraordinary circumstances that make it impossible to keep public order by normal means, and in public health crises, such as an epidemic or situation of serious contamination. Measures taken under a state of alert must be temporary, restricted to a specific area, and limited to those measures necessary to contain the emergency. If the emergency is limited to a specific autonomous community, the community’s president may request that the government declare a state of alert in that community. The state or the president of the affected autonomous community serves as the competent authority for purposes of the state of alert. The declaration of a state of alert is enacted through a decree issued by the Council of Ministries.
Under a state of alert, the Minister of Public Health and Consumer Affairs may temporarily order the restriction of the movement of people or motor vehicles; search and seizure procedures; the occupation of facilities or industries (but not private dwellings); the limited consumption or use of necessary food items; and any other measure to fight infectious diseases, protect water and the environment, and protect against forest fires. In these cases, the state may also order the participation of companies and services and the mobilization of their personnel.
The MPH is in charge of the study and management of epidemics, the promotion of health, preventive measures against epidemics, and the surveillance and control of possible health risks derived from the import or export of goods and the international movement of people. The Underdirectorate for the Promotion of Public Health and Epidemiology (Sudireccion General de Promocion de la Salud y Epidemiologia) is in charge of planning, coordinating, and developing strategies for the National Network of Epidemiological Surveillance (NNES) (Red Nacional de Vigilancia Epidemiologica), in conjunction with the Carlos III Health Institute (Instituto de Salud Carlos III), a public research institute created in 1986 to provide scientific and technical support to the MPH and the health services of the autonomous communities. One of the Carlos III Health Institute’s specific functions is conducting research and studies in epidemiology that are carried out by the Underdirectorate for the Promotion of Public Health and Epidemiology.
The NNES was created by Royal Decree 2210/1995 within the NHS to collect and analyze information on epidemics, contribute to the application of individual and collective control measures in cases where a health risk may have national or international consequences, and inform all operational levels about health risks. The National Directorate of Public Health (Dirección General de Sanidad Pública) of the MPH has been established as the Spanish health authority liaison to the World Health Organization (WHO) for tracking and reporting alerts on transmissible diseases.
The NNES is responsible for
- identifying health problems related to epidemics, endemics, and risks throughout the autonomous communities;
- participating in the individual and collective control of public health problems throughout the autonomous communities, and ensuring coordination between surveillance and decision making by the competent health authorities for the prevention and control of public health problems;
- executing epidemiological analysis to identify changes in and the evolution of the abovementioned public health problems, as well as any other epidemiological research;
- providing operative information for planning purposes;
- distributing information to all designated operative levels; and
- contributing the development of related statistics for official use.
The NNES’s surveillance activity involves the systematic collection of epidemiological information, its analysis and interpretation, and the distribution of results and recommendations.
The NNES is composed of (1) a basic surveillance system that includes obligatory notifications about diseases, epidemics, and outbreaks, as well as microbiological information; (2) specific systems of epidemic surveillance based on case records, surveys, watch systems, and other methods that could be applicable to the surveillance of AIDS and other preventable immune diseases; and (3) any other surveillance system that the MPH and the autonomous communities, within their jurisdiction and through the Interterritorial Council of the National Health System (Consejo Interterritorial del Sistema Nacional de Salud), believe necessary to develop in order to control specific problems or use as a complement to other measures.
The basic surveillance system of the NNES includes a list of diseases that are required to be reported. The required report refers to new cases of these listed diseases that appear each week and constitute a concern. Attending physicians both from the public and private sector are the agents responsible for the reporting. The same procedure is applicable at the autonomous communities level, which then transfers all the reported information to the MPH. The information collected must reach the MPH no later than three weeks after the first case is reported.
All practicing physicians and health centers, both public and private, that first detect the outbreak of an epidemic are required to immediately report the outbreak to the MPH. An “outbreak” is defined as a significant increase in the number of cases; the presence of a case in an area that was free of such disease; the presence of cases of acute, collective poisoning due to consumption, handling, or accidental causes; and the presence of any catastrophic incident that may affect the health of the community. The NNES may also rely on networks of “monitoring physicians,” and on networks to trace diseases selected by the designated health authorities in predetermined geographic areas.
Additional regulatory measures have been implemented to address certain diseases, such as AIDS and SARS, that are considered to be or could become an epidemic of serious proportions. Spain created and maintains a national AIDS registry for epidemic surveillance purposes. The autonomous communities also keep registries of AIDS cases in their respective territories and have an obligation to report them to the central health authorities every three months. Although no SARS cases were found in Spain, Real Decreto 350/2003, now superseded, created the Inter-Ministerial Commission for the Surveillance of SARS to coordinate the response to the illness throughout the national territory. The Decree also required coordinated actions and information sharing in case of an outbreak. In addition, the Scientific Committee on SARS was created to provide scientific support and to advise the Inter-Ministerial Commission. By 2011 this Commission was no longer operative.
The NHS is the enforcement authority that manages cases of infectious diseases. Each province and autonomous community has the power to order the isolation of infected individuals and to impose restrictions on their movements to prevent placing others at risk. The same power is assigned to mayors at the municipal level if a case falls under their jurisdiction.
Violations of health safety directives may result in criminal charges for provoking a risk to life, physical integrity, and the health of the population or environment—offenses that are punishable by imprisonment of six months to two years, a fine, and the inability to hold public office or practice a profession for three to six years.
IV. Transparency of Public Health Crisis Management System
The MPH is the enforcement authority of the NNES, ensuring the coordination and uniformity of information, as well as its evaluation and analysis, throughout the country. Information of a personal nature, managed as a consequence of the application of the NNES, is otherwise to remain confidential. Personal data in databases may be used without the owner’s consent only when the information is required in urgent cases or to carry out epidemiological studies. The MPH also coordinates such information with the European Union (EU), the WHO, and other international organizations.
The MPH is required to immediately inform the autonomous communities of any epidemic outbreak so that pertinent controls and preventive measures may be set up. Reporting such data also ensures compliance with international health standards, such as the international reporting of diseases subject to quarantine and those subject to special surveillance by the WHO and the EU.
The MPH issues updated press releases to keep the population informed of any health threat. During the latest health epidemic alerts, such as the swine flu outbreak in 2009 and the recent Ebola virus outbreak, the MPH, through the Center for the Coordination of Health Warnings and Emergencies (Centro de Coordinación de Alertas y Emergencias Sanitarias), issued recommendations to the population via the Internet and all other major media, as requested by the WHO.
V. Current Crisis
The MPH, in cooperation with the health authorities of the autonomous communities, the Institute of Health Carlos III (Instituto de Salud Carlos III), and scientific societies, has established a protocol to deal with the Ebola virus. The protocol reflects the recommendations of international organizations and experts to ensure the early detection and diagnosis of possible Ebola cases and to adopt immediate control measures.
The MPH has also established a procedure applicable to all points of entry into the country to make sure that all airplanes and ships coming from Ebola-affected areas meet the applicable health standards. Information pamphlets for passengers coming from these areas, and for any passenger arriving in Spain, have been published and made available online.
In spite of all the preventive measures, Spain had the first confirmed case of Ebola virus contracted outside Africa. The infected woman, a nurse named Teresa Romero, was treated in a Madrid hospital. She had been part of a medical team treating two Spanish missionaries with Ebola, who had been brought back to Spain from Sierra Leone and Liberia. Both died in the hospital in Madrid in August and September 2014. Romero is reported to have entered the room of one of the missionaries who later died. Six other people were also placed in quarantine, while around fifty other healthcare workers were placed under observation because of their interaction with the nurse and the two missionaries who died.
On October 10, 2014, in response to what appears to have been a failure in established protocols, the Spanish government created a Special Committee on the Management of Ebola (Comité Especial en la Gestión del Ébola), headed by the Vice President of the Spanish government, to supervise, coordinate, and manage all actions by and resources from the state necessary for the management of the virus.
The Minister of Health, Ana Mato, informed Congress that the revised procedures applicable for the early detection of Ebola would include the daily monitoring of anyone known or suspected to have come into contact with Ebola victims, and that even minor increases in body temperature would be taken as a likely sign of their being infected.
At the same time, supervision would be tightened in hospitals when staff remove protective body suits, since Romero appears to have been infected when her glove brushed against her face while she was removing her suit. Closed circuit television cameras would also likely be installed in isolation units. On November 5, 2014, Romero was released from the hospital free from Ebola.
Prepared by Graciela Rodriguez-Ferrand
Senior Foreign Law Specialist
 Constitución Espanola art. 1(3), Dec. 27, 1978, Boletín Oficial del Estado [B.O.E.], English translation available at http://www.boe.es/legislacion/ documentos/ConstitucionINGLES.pdf.
 Id. art. 66(1).
 Id. art. 2.
 Id. art 143(1).
 Id. art. 43.
 Id. art. 148(1)(xx), (xxi).
 Id. art. 149(1)(xvi).
 Id. art. 149(1)(xvii).
 Id. art. 50.
 Id. art. 38.
 Id. art. 38(2).
 Real Decreto 200/2012, Jan. 23, 2012, http://boe.es/diario_boe/txt.php?id=BOE-A-2012-1034.
 A. Gonzalez Bueno, Manual de Legislación Farmacéutica 43 (Aranjuez, 1999).
 Ley 14/1986 art. 38.3, as implemented by Real Decreto 65/2006, Jan. 30, 2006, http://boe.es/diario_boe/txt.php? id=BOE-A-2006-1916.
 Real Decreto 1418/1986, June 13, 1986, sobre Funciones del Ministerio de Sanidad y Consumo en Materia de Sanidad Exterior [Royal Decree 1418/1986, on the Powers of the Ministry of Public Health and Consumer Affairs in Matters of External Health] (now the MPH), http://www.boe.es/buscar/act.php?id=BOE-A-1986-18374.
 Id. art. 2(1.1).
 Id. art. 2(1.4).
 Id. art. 2(2.4).
 Id. art. 40(12).
 Id. art. 40(13), implemented by Decreto 605/2003, May 23, 2003, por el que se Establecen Medidas para el Tratamiento Homogéneo de la Información sobre las Listas de Espera en el Sistema Nacional de Salud [Decree 605/2003, May 23, 2003, Establishing Measures for the Homogeneous Treatment of Information on the Waiting Lists of the National Health System], http://www.boe.es/buscar/act.php?id=BOE-A-2003-11266.
 Id. art. 40(16), implemented by Decreto 605/2003.
 Id. art. 41.
 Ley Orgánica 3/1986 de Medidas Especiales en Materia de Salud Pública [Organic Law 3/1986, on Special Measures in Matters of Public Health] art. 1, Apr. 14, 1986, http://www.boe.es/buscar/act.php?id=BOE-A-1986-10498.
 Ley Orgánica 4/1981, June 1, 1981, de los Estados de Alarma, Excepción y Sitio [Organic Law 4/1981, June 1, 1981, on States of Alert, Exception and Siege] art. 1(1), http://www.boe.es/buscar/act.php?id=BOE-A-1981-12774.
 Id. art. 4(2).
 Id. art. 1(2).
 Id. art. 5.
 Id. art. 7.
 Id. art. 6.
 Id. arts. 11, 12(1).
 Id. art. 12 (2).
 Ley 14/1986 arts. 8, 38.
 Id. arts. 111–113, as implemented by Real Decreto 375/2001 por el que se Aprueba el Estatuto del Instituto de Salud “Carlos III” [Royal Decree 375/2001, Approving the Bylaws of the “Carlos III” Institute of Health], Apr. 6, 2001, http://www.boe.es/buscar/doc.php?id=BOE-A-2001-8157.
Real Decreto 375/2001 Estatuto del Instituto de Salud “Carlos III” art. 19(6)–(9).
 Real Decreto 2210/1995 por el que se Crea la Red Nacional de Vigilancia Epidemiológica [Royal Decree 2210/1995, Creating the National Network of Epidemic Surveillance], Dec. 28, 1995, http://www.boe.es/buscar/ act.php? id=BOE-A-1996-1502.
 Id. art. 1.
 Orden Ministerio de Sanidad y Consumo [Order of the Ministry of Health], SCO 3870/2006, Dec. 15, 2006, art. 1 https://www.boe.es/diario_boe/txt.php?id=BOE-A-2006-22360.
Real Decreto 2210/1995 art. 2.
 Id. art. 3.
 Id. art. 4.
 Id., Annex I. The list includes, among others, botulism, brucellosis, cholera, diphtheria, hepatitis A and B, leprosy, meningitis, malaria, polio, tetanus, and tuberculosis.
 Id. art. 9.
 Id. art. 12.
 Id. art. 16.
 Id. art. 15.
 Id. arts. 28–30.
 Id. arts. 31–36.
 Real Decreto 350/2003, Mar. 21, 2003, https://www.boe.es/buscar/doc.php?id=BOE-A-2003-5851 (superseded by Real Decreto 776/2011, de 3 de junio , por el que se Suprimen Determinados órganos colegiados y se establecen criterios para la normalización en la creación de órganos colegiados en la Administración General del Estado y sus Organismos Públicos [Royal Decree 776/2011, June 3, , Dissolving Some Collegiate Entities and Establishing Normalization Criteria for Creating Collegiate Entities Within the General Administration of the State and Its Public Agencies], http://www.boe.es/boe/dias/2011/06/04/pdfs/BOE-A-2011-9736.pdf).
 Id. art. 2.
 Id. art. 3.
 Orden Ministerio de Sanidad y Consumo [Order of the Ministry of Health], SCO/1134/2003, May 6, 2003, B.O.E., May 10, 2003.
 Real Decreto 776/2011, Annex, B.O.E. No. 133, June 4, 2011, p. 10.
 Real Decreto 1030/2006, Sept. 15, 2006, Annex III, § 5.1(1), http://www.msssi.gob.es/profesionales/prestaciones Sanitarias/CarteraDeServicios/docs/RD_1030_2006_act25072014.pdf.
 Código Penal y Leyes Penales Especiales art. 348 (Navarra, Thomson/Aranzadi 2007).
 Real Decreto 2210/1995 arts. 1–5.
 Id. arts. 15–21.
 Id. art. 8.
 Ley Orgánica 15/1999 sobre el Tratamiento de Datos Personales [Organic Law 15/1999, on the Treatment of Personal Data in Databases] art. 11(2)(f), Dec. 13, 1999, https://www.boe.es/buscar/pdf/1999/BOE-A-1999-23750-consolidado.pdf.
Real Decreto 2210/1995 art. 6(1), (2).
 Id. art. 19.
 Id. art. 6(3).
 Centro de Coordinación de Alertas y Emergencias Sanitarias, Actualización Epidemiológica: Brotes de Enfermedad por Virus Ébola en África [Epidemiological Update: Outbreaks of the Ebola Virus in Africa] (Oct. 27, 2014), http://www.msssi.gob.es/profesionales/saludPublica/ccayes/alertasActual/ ebola/docs/Actualizacionn 15BIS(27.10.14)EPI-EVE_Africa_2014.pdf.
 Medidas del Gobierno de Espana [Measures by the Government of Spain], Gobierno de España, Comité Especial para la Gestión del Ébola (Oct. 12, 2014), http://infoebola.gob.es/2014/10/10/que-medidas-esta-tomando-el-gobierno-de-espana/.
 Información sobre el Brote de Enfermedad por Virus ébola (EVE), Información para los Ciudadanos/Viajeros [Information on the Outbreak of the Ebola Virus, Information for Citizens and Travelers], Ministerio de Sanidad, Servicios Sociales e Igualdad, https://www.msssi.gob.es/en/profesionales/saludPublica/ccayes/alertasActual/ ebola/infCiudadanos.htm (last visited Nov. 17, 2014).
 Elisa Silió & Emilio de Benito, Una Sanitaria de Madrid, Primer Contagio por Ébola Fuera de África [A Health Professional in Madrid, First Ebola Infection Outside Africa], El País (Oct. 7, 2014), http://elpais.com/elpais/2014/ 10/06/ciencia/1412611515_352524.html.
 Santamaría Presidirá un Comité Especial para la Gestión de la Crisis del Ébola [Santamaría Will Head a Special Committee for the Management of the Ebola Crisis], La Vanguardia (Oct. 10, 2014), http://www.lavanguardia. com/politica/20141010/54417805465/santamaria-presidira-comite-especial-gestion-crisis-ebola.html.
 Mato Analizará Esta Tarde con las CCAA los Cambios en los Protocolos Frente al ébola [This Afternoon Mato Together with ACs Will Analyze Changes in the Protocols Applicable in Ébola Cases], La Vanguardia (Oct. 10, 2014), http://www.lavanguardia.com/local/20141010/54416960358/mato-analizara-esta-tarde-con-las-ccaa-los-cambios-en-los-protocolos-frente-al-ebola.html.
 Los Fallos del Caso de Romero Llevan a Ana Mato a Cambiar en los Protocolos [Mistakes in the Romero Case Cause Ana Mato to Change Protocols], El País (Oct. 9, 2014), http://politica.elpais.com/politica/2014/10/09/ actualidad/1412838533_047257.html.
 Teresa Romero Recibe Este Miércoles el Alta Hospitalaria Tras Casi un Mes de Ingreso [Teresa Romero Is Discharged from the Hospital Wednesday Nearly a Month After Admission], La Vanguardia (Nov. 5, 2014), http://www.lavanguardia.com/vida/20141105/54418948378/teresa-romero-recibe-alta-ebola.html?rel=rosEP.
Last Updated: 06/09/2015