Europe Versus Coronavirus – the Italian Archetype

The progression of the epidemic

Italy was the first European country to be affected by the epidemic. By February 23, 100 cases of infection had been identified in the peninsula: the spread then accelerated at an exponential rate. The symbolic threshold of 1 000 cases was crossed on February 29 and on March 10, more than 10 000 people were infected by the virus in Italy. The death toll followed an equally dramatic curve: between February 29 and March 15, the number of deaths linked to the virus rose from 30 to 1 800. On Tuesday, April 28th 2020, Italy recorded almost 200 000 cases of infection and 27 000 deaths, the highest death rate of all European countries at that date.

As with the figures from other countries, these official figures should be viewed with caution as they depend largely on the number of tests performed. On April 10, the Italian government's Special Commissioner for Coronavirus, Domenico Arcuri, announced that just under one million tests had been carried out in Italy since the start of the pandemic, and that 2.5 million tests would be distributed in the peninsula the following week. According to OECD figures, as of April 26, Italy was carrying out 29.7 tests per 1,000 people, more than Germany (25.1), while the number of tests being carried out in France was still uncertain. The proactive stance of Italy with regards to testing can be explained by the success of the strategy adopted by the Veneto region in the north of the country, which used mass testing to curb the rate of infection.
 
According to a study by the Instituto Cattaneo from April 1 2020, the effects of the crisis on mortality in Italy could be much higher than the government's figures seem to indicate. Comparing Italy's mortality over the period from February 21 to March 21 compared to previous years, the study reveals an excess mortality of 8 740 people, while the number of people whose death is officially linked to the virus over this period is 4 825. At a time when every state is counting its human losses, only this comparative analysis of excess mortality will make it possible to determine the true human toll of the crisis.

The industrial North particularly affected

When analysing the figures for infection and death in Italy, the very wide disparities between regions should be taken into account. With 73 000 cases of contamination and 13 400 deaths - almost half of all the deaths in Italy - Lombardy is by far the main victim of this crisis. By way of comparison, Emilia-Romagna, the second most-affected region, has "only" had 25 000 cases of infection and 3 400 deaths, with Sicily having 3 000 cases of infection and 230 deaths.

The fact that many Italians residing in the north left for the southern regions upon the announcement of the quarantine of the "red zone" did not result in a spread of the virus, which could have had dramatic consequences in the Mezzogiorno. The people who returned to their regions of origin were aware that they had come from strongly-affected regions and that the fragile health care system in the southern regions would not be able to cope with a dramatic increase of cases. They adopted social distancing measures that were essential for controlling the epidemic - thus complying with the appropriate communication campaigns developed by the southern regions.    
 
The rapid spread of the virus in Italy remains a subject of discussion. If, in the popular imagination, the "game zero" in Milan on February 19th between the Valencia and Bergamo soccer teams acted as a "biological bomb" by accelerating the spread of the virus, experts now agree that the virus had already been circulating in Lombardy since January. The particularly high population density in Lombardy’s cities, the high incidence of social contact - higher in Italy than in other European states - and the European and international dimension of these regions largely contributed to accelerating the spread.

The pictures of military convoys evacuating bodies of Covid-19 victims to Bergamo will remain, in the public opinion, an image of a country ravaged by war. In a letter entitled "A front-line testimony" published on March 10, 2020, Daniele Macchini, doctor at the Humanitas Gavazzeni hospital in Bergamo, described the state of the emergency rooms in the town that became the epicenter for the epidemic in just a few days: "There was a surreal atmosphere of silence and emptiness that we didn’t understand yet, awaiting a war that hadn’t yet begun and for whom many - myself included - did not think that it would ever come with such ferocity."
 
Despite the quality of the healthcare system in Lombardy, the Italian healthcare system was not prepared to deal with this epidemic. According to OECD and European Commission figures, health spending corresponds to 8.8% of GDP, one point less than the European average, and amounts to 2 483 euros per capita, 15% less than the EU average. Italian health spending had followed the evolution of European health spending until 2008; from then on, it started to decline, confirming the idea that the Italian health system was a victim of the austerity policy implemented in the years following the financial crisis. Before the outbreak of the epidemic, Italy had only 8.6 intensive care beds per 100 000 inhabitants, compared to 16.3 for France and 33.9 for Germany.

These figures should be put into perspective, bearing in mind that Lombardy, the most affected region, also has one of the most efficient health systems in Italy. Its public and private hospitals have long been considered a model of excellence for the rest of Europe. The saturation of its hospitals, the lack of medical equipment, and the lack of protection, particularly for healthcare workers, are now leading to the questioning of this model.

For the Italian author and journalist Roberto Saviano, this confidence in the Lombard healthcare system is one of the main reasons for Italy's failure. In a controversial op-ed entitled "Weakness is believing oneself invincible", the author of Gomorra denounced the role of the mafia and right-wing politicians in the erratic management of the crisis.

The four lessons to learn from Italy

"Some aspects of this crisis — starting with its timing — can undoubtedly be attributed to plain and simple sfortuna ("bad luck" in Italian) that were clearly not under the full control of policymakers. Other aspects, however, are emblematic of the profound obstacles that leaders in Italy faced in recognizing the magnitude of the threat posed by Covid-19, organizing a systematic response to it, and learning from early implementation successes — and, most importantly, failures." On March 27, 2020, an article published in the Harvard Business Review entitled "Lessons from Italy's response to the Coronavirus" sets out the main features of the crisis highlighted by the Italian example.

Faced with the rapid progression of the epidemic in Italy, only an immediate and massive response, involving the total mobilisation of the economy and society, would have been able to effectively contain the spread of the virus. Without denying the sometimes exemplary nature of the Italian response, the authors of this study reveal that "errors" inherent to the Italian government's strategy form a sort of matrix, which can demonstrate varying degrees of effectiveness in the management of the crisis by other European states. 
 
 Four elements of the Italian response deserve consideration:

• The first element concerns the "cognitive bias" that led Italy, like most European states, to neglect scientific advice and initially minimize the seriousness of the situation. This bias is often reinforced by economic considerations, as noted in the communication campaign launched by the Milan City Council with the slogan #MilanoNonSiFerma ("Milan won't close") to reassure investors a few days before the government quarantined Lombardy. After much procrastination and against the advice of Confindustria, the confederation of Italian industry, the government agreed to the calls of the President of the Lombardy region and imposed widespread lockdown measures on March 9, 2020. On that date, the country had already reported almost 400 deaths.  
   

• The third element concerns the difficulty for organizations - public authorities or health care systems - to modify their practices in accordance with the observed results. As we saw in the north of the country, two of the most affected regions, Lombardy and Veneto, chose opposing methods. While Veneto, by relying on screening to identify carriers of the virus and isolate them, succeeded in slowing the rate of contamination, Lombardy, known for the excellence of its healthcare system, made massive use of emergency hospitalisation without managing to prevent saturation of its hospitals. Extending the targeted strategy adopted by the Veneto region to other Italian regions would undoubtedly have enabled better control of the chain of infection.  
• The final element concerns the need for accurate and up-to-date data to monitor the evolution of the epidemic and to provide appropriate responses. The difficulty of accurately monitoring the progression of the virus and the lack of data on chains of infection and patient profiles now poses a particular problem for the post-lockdown phase.

Ending the lockdown

At a press conference on Sunday, April 26, the Council Chairman outlined the details of the plan to end lockdown. Starting on Monday, April 27, the sectors considered to be strategic - public works and export-oriented industrial sectors - were able to resume their activity. However "phase 2", which sees Italy entering a new normal, is not scheduled to begin until May 4. This phase 2 is accompanied by maintaining social distancing, the obligation to wear masks in public spaces, and the implementation of a new digital tracking application called "Immuni", created by the Milan-based company, Bending Spoons, with the support of the Santagostino medical center.
 

For the time being, the scientific committee has stressed that reopening churches and other places of worship would present too great of a health risk, prompting Italian bishops to protest. Italian schools will not be able to reopen until the beginning of September, which raises the question of childcare for parents who will have to return to work.

Conclusion

Italy, as the first European country to be affected by the epidemic, has suffered the full force of the crisis and paid the heaviest human toll to date. The situation in which Italian hospitals found themselves had the benefit of accelerating the perception of the scale of the crisis at European level. By choosing to implement drastic measures to contain the spread of the virus, Italy made an ethical choice - no doubt influenced by Catholicism - whose model has driven the responses adopted by the other European states.

With the collaboration of Victor Bus and Margaux Tellier 
 

Copyright : MIGUEL MEDINA / AFP