Leap in coronavirus cases tests limits of Italy’s health system

Rome, Italy – Thirty-six coronavirus patients have died in Italy over the past 24 hours, bringing the total number of deaths to 233, the country’s civil protection department has said.

Italy has struggled to contain the novel virus since February 20, when the so-called “Patient n.1” attended a local hospital in the northern town of Codogno.

Sixteen days later, the country has the highest death toll outside China, while the number of people suffering from COVID-19 leapt to 5,883, officials said on Saturday.

“The whole system was not ready for the emergency, but responded very quickly,” Lorenzo Casani, health director of a private clinic for elderly people near the quarantine area in southern Lombardy, told Al Jazeera on Friday.

Senior citizens and people suffering from chronic and acute diseases are at a greater risk of infection. This worries Casani since all his patients are at risk. For the first 10 days, he had no time off at all.

“All the personnel should have been properly informed and prepared in case of an emergency,” he said, stressing that the initial chaos was prompted by the lack of a unified contingency plan across the regions, comprising both private clinics as well as public hospitals.

“The bad luck dropped the bomb, and it exploded in our hands.”

Why Italy?

Almost a month before the start of the outbreak, the health ministry created a taskforce and suspended all flights to and from China, declaring a state of emergency. But the virus could have arrived in Italy before the travel ban was issued.

Sacco hospital in Milan studied three different genetic sequences found in the northern region of Lombardy, confirming COVID-19 weeks before doctors found “Patient n.1”.

“It is plausible that when COVID-19 landed in the country, it was still in incubation, and the infection developed into somebody with light or no symptoms at all,” Massimo Galli, head of the infectious disease department, told the newspaper, Corriere della Sera.

At the end of December, an uncommon number of pneumonia cases arrived at the hospital of Codogno in northern Italy, the head of the emergency ward, Stefano Paglia, told the newspaper La Repubblica. Some of these patients could carry the coronavirus, but doctors treated them as typical winter diseases.

Unfortunately, a decisive contribution to the spread of the infection was given by the health facility itself, due to the amount of medical staff and attendees going through the compound daily.

“The hospital acted as a multiplier,” Walter Ricciardi, executive board member of the World Health Organization (WHO) and consultant for the Italian health ministry, told Al Jazeera.

Ricciardi refuses to consider the country as a global black sheep.

“From an epidemiologic point of view, it is not plausible that Italy has stopped the flights from China and accounts for more cases than Germany and France,” he said.

Italy has tested more than 42,000 people so far, while other European Union countries performed significantly fewer controls. This scrupulous search inflated the tally, he said.

“The high number of checks brought the problem to light earlier. Germany and France are now following the same route.”

Drastic measures

To contain the outbreak, the government adopted drastic measures, establishing two quarantine zones in the northern regions of Lombardy and Veneto, where the epidemic surfaced.

Schools all over the country will remain off-limits for students until mid-March. Sporting events are held indoors. Public events that cannot guarantee a distance of one metre (3.3 feet) between the attendants are prohibited. And a referendum on cutting the number of Members of Parliament has been postponed.

To sustain the health system and reinforce the national economy, the government has announced an emergency plan of 7.5bn euros ($8.5bn).

“Both the WHO as well as the European Commission pledge the Italian reaction as a reference,” said Ricciardi, who believes the containment measures were necessary and well planned.

The weakness lay in the mixed structure of the National Health Service (SSN), with both the central government and the regional administrations sharing control of the system.

This approach led to some confusion during the early days of the outbreak when local governors adopted different approaches, sometimes leading to a clash with Prime Minister Giuseppe Conte.

“A single line of command both in decision making as well as in communication is highly desirable in these circumstances,” said Ricciardi.

Lack of doctors, wards

Italy built the SSN, its national health service, in 1978 following a “Beveridge structure” as a unified and centralised system with universal access to all the patients.

“In case of an epidemic, this is the best model, as it intercepts and treats all the cases,” Francesco Longo, director of the healthcare sector at Observatory at Bocconi University (OASI), told Al Jazeera.

However, concerns arise about the resilience of the SSN.

“The government ensured that the different regions were provided with new protective devices, such as masks, but we are still receiving reports about shortages,” Filippo Anelli, president of the National Federation of the Orders of Doctors, told Al Jazeera. 

The association of medical directors (ANAAO) sounded the alarm about the lack of beds in intensive therapy in Lombardy, where 95 percent of them are full.

All over the country, intensive care departments are hosting 567 infected patients, while the national capacity is 5,395 beds.

“If Lombardy struggles along, I am worried about what happens if the virus reaches the southern part of Italy, where we lack both personnel and equipment,” said Anelli.

According to OASI’s latest report, investment in public healthcare accounted for only 6.8 percent of the gross domestic product (GDP), which lags behind countries such as France and the United Kingdom.

“This means that the system works efficiently, but constantly saturates its productive capacity and has few resources when it comes to emergencies,” said Longo.

To face such shortages, the health minister arranged for a 50 percent increase of units in intensive care, doubled down the number of beds in infectious disease wards and laid the ground for the immediate enrollment of 20,000 new doctors and nurses.

Doctors from the army and less-affected areas are being dispatched to the red zone.

In Lombardy, Governor Attilio Fontana asked universities to advance the graduation of this year’s nurses and private hospitals are opening their doors to those in need of urgent care.

“This is a whole new experience for our system in terms of dimension, intensity and effort required to our SSN,” head of Superior Health Institute (ISS) Silvio Brusaferro said.

Longo does not doubt the outtakes of the crisis. “An efficient epidemiologic registration system, reserve productive capacity and a unique, authoritative voice: these are the lessons for countries facing such an outbreak,” he said.

The next two months will tell whether the current policies will help Italy in overcoming the spike in coronavirus infections.