The lessons Italy has learned about its COVID-19 outbreak could help the rest of the world
Nature of hospital admissions and testing policy among 'mistakes' in country's coronavirus response
For the first time since coronavirus infections exploded in the small town of Lodi, Lombardy, the northern Italian region that would become the epicentre of the European outbreak, a remarkable sight has appeared in the hospital there: a few empty beds.
Health-care workers continue to issue strong warnings that Italy is far from being out of the woods, and on Wednesday morning, Italy's health minister extended the nationwide lockdown to April 13.
But the crushing pressure on northern Italian intensive-care units seems to be finally easing, providing if not a light at the end of the tunnel — deaths in Italy have surpassed 13,000 and still top 700 a day — then a distant flicker of hope.
Only carefully conducted epidemiological studies will bring to light exactly how and why COVID-19 took off in northern Italy with such speed. But in the midst of the emergency, experts say there are already lessons to be gleaned from Italy's fatal errors — and urgent messages for other parts of the world.
"The biggest mistake we made was to admit patients infected with COVID-19 into hospitals throughout the region," said Carlo Borghetti, the vice-premier of Lombardy, an economically crucial region with a population of 10 million.
"We should have immediately set up separate structures exclusively for people sick with coronavirus. I recommend the rest of the world do this, to not send COVID patients into health-care facilities that are still uninfected."
'Like throwing a lit match onto a haystack'
Already, Italian cities in other regions are doing this, as well as field hospitals in Milan and Bergamo, Lombardy, which are almost complete.
However, the virus was not only spread to "clean" — i.e. infection-free — hospitals by admitting positive patients. In early March, as the number of infected was doubling every few days, authorities allowed overwhelmed hospitals to transfer those who tested positive but weren't gravely ill into assisted-living facilities for the elderly.
"It was like throwing a lit match onto a haystack," said Borghetti, who spoke out against the directive at the time. "Some facilities refused to take in the positive patients. For those that did [take them in], it was devastating."
Along with the tragic misstep of putting infected people under the same roof as clusters of the most physically vulnerable, Borghetti and others point to a deeper structural factor that accelerated the outbreak in northern Italy: a highly centralized health-care system with large hospitals as its focus.
Under normal circumstances, these large hospitals are very effective, with a wide range of expertise under one roof. But as the go-to place for health services, they acted as conductors of infection.
"For the past 20 years, the region invested heavily in hospitals, which are now among the best in Europe," Borghetti said. "Unfortunately, we did not make the same investment in local health services: health clinics, rehab facilities, community nursing and family doctors. And as a result, we're drowning [in the epidemic]."
Testing policy 'was wrong'
Epidemiologists estimate the real number of infected in Italy, now officially more than 110,000, is likely at least 10 times that number. Affected areas in Italy began vast testing of even asymptomatic people in the last week of February, shortly after Patient One was discovered on Feb. 21. A week later, however, they began to comply with the government's requests to limit testing only to symptomatic cases.
"That policy of testing was wrong," said Guido Marinoni, president of the Medical Association of Bergamo, the hardest-hit city. "We should have extended testing to the relatives of positive people and the contacts of those relatives, at the very least."
This same loose grasp on the number of infected also applies to deaths, which researchers and mayors in Italy's north say could be four to six times higher than the official count.
Comparisons between the number of deaths in the four years prior to 2020 with the same period this year show a dramatic spike in mortality that the official death count of COVID-19 does not seem to adequately account for.
The gap, say experts, is the result of data being collected only on those who are hospitalized or who die in hospital with a positive test. Yet most people die at home.
"Many have died at home with undiagnosed coronavirus that exacerbated heart and lung complications," said scientist Luca Foresti, CEO of the Santagostino Medical Centre, Italy's largest out-patient clinic. Foresti has conducted a study on the mortality rate in four different towns in northern Italy: Nembro, Pesaro, Cernusco sul Naviglio and Bergamo.
"Another factor is that people with other unrelated illnesses, under normal conditions, would call an ambulance and be taken to emergency. But with hospitals overwhelmed, there were no ambulances" or hospital beds available, said Foresti.
He estimates 90 per cent of the additional deaths in northern Italy so far this year are from coronavirus and only 10 per cent due to unrelated illnesses.
Theories about spread don't bear out
In the early weeks after the virus took off here, many theorized about what was behind Italy's high case fatality rate (deaths per confirmed infections), a global outlier at a shocking 10 per cent.
Among the explanations were the country's aged population and a cultural propensity to socialize in groups, often cross-generational, as well as showing affection through touch — compared to Asia, where mask-wearing and social distancing are common even in non-pandemic times.
WATCH | How COVID-19 hit Italy
Experts say the full impact of these factors won't be clear until further studies are carried out.
"Luck is a fundamental determinant of contagion [at the beginning]," said Matteo Villa, a researcher at the Italian Institute for International Political Studies. "A virus can be introduced to a person who has little contact with others, or to a super spreader," which was the case with Italy's Patient One.
After it starts to take off, however, it follows the same exponential pattern.
The biggest takeaway from Italy, experts say, is that what happened here can happen anywhere.