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Europe Versus Coronavirus – the Italian Archetype

BLOG - 6 May 2020
Key Points
1

An "archetype" is an original model or an ideal, that a work is based upon. Italy was the first country in Europe affected by the epidemic and the one with the current highest number of deaths. The Italian case is the first example of a reaction to the virus in an industrialized and democratic society: Italy’s management of the epidemic has thus served as a model to the later-affected countries in Europe.
 

2

The spread of the virus on the Italian territory has been asymmetrical. The north of the country, Lombardy in particular, and to a lesser degree the Veneto, Emilio-Romagna, and the Piedmont regions, saw the largest concentration of cases while the south was relatively spared. 
 

3

In spite of a robust Italian healthcare system, especially well-developed in the regions most affected by the epidemic, Italy was unable to flatten the curve of infection early enough, leading to the saturation of its hospitals and a dramatic acceleration in the rate of deaths.
 

4

From the start of the crisis, the possibility of sacrificing a part of the population for the sake of herd immunity or economic activity was rejected. In Italy, the desire to protect the population as much as possible led to the introduction of unprecedented lockdown measures and the suspension of all activities considered not essential to the life of the country.
 

5

On Sunday April 26, the Prime Minister Giuseppe Conte presented the first measures to end lockdown, putting Italy on a path towards an uncertain future. 
 

Timeline

  • January 30: In Rome, two Chinese tourists test positive for the virus. Flights to and from China are suspended. The Council President and the Health Minister announce that "everything is under control".
  • January 31: Italy declares a state of emergency, allowing for the rapid mobilization of the resources for Civil Protection and releasing 5 million euros to deal with the health risk.
  • February 18: A first case of secondary transmission is identified in Codogno (Lombardy).
  • February 19: 45,000 fans attend "game zero" between Atalanta Bergamo and FC Valencia at the San Siro stadium in Milan. 
  • February 20: The first death due to Covid-19 is announced in the town of Vo’, in the Veneto region. Local elected officials enact partial lockdown measures in the towns in the Lombardy and Veneto regions having the first cases of infection. 
  • February 23: The government puts Italian towns under quarantine: nine in the Lodi province, in Lombardy, and one in the Padua Province, in Veneto. 50,000 are confined in total. 
  • February 24: With seven deaths and 229 confirmed cases, Italy is the third most-affected country in the world after China and South Korea. 
  • February 27: The city of Milan launches the campaign #MilanoNonSiFerma
  • March 4: The Prime Minister announces the closure of all schools and universities. The same day, France and Germany ban the export of medical equipment requested by Italy.
  • March 5: A constitutional referendum is postponed until an undetermined date.
  • March 8: A decree approved by the Council of Ministers introduces quarantine measures in northern Italy. Lombardy, part of Veneto, Emilia Romagna and Piedmont are affected: 15 million people - about a quarter of the Italian population - are confined. On the same day, mutinies break out in 27 prisons across the country.
  • March 9: 9,172 cases recorded in the country, 463 deaths, including 333 in Lombardy. The decree #IoRestoaCasa (I’m staying home) is adopted. Lockdown is extended to the whole country. All public spots are closed; travel is limited to the strictly necessary (health, food, and work when working remotely is impossible); all gatherings are prohibited and punishable by fines.
  • March 11: Adoption of a new decree from the Council of Ministers imposes the closure of all businesses except for pharmacies and grocery stores. A €25 billion plan to support the economy is presented by the Italian government.
  • March 12: Arrival of a team of Chinese doctors and shipment of medical equipment, resulting in an extensive communication campaign.
  • March 19: The number of deaths related to Covid-19 exceeds that of China (3,405 in Italy versus 3,245 in the Middle Kingdom).
  • March 20: Presentation of the study conducted by the University of Padua and the Italian Red Cross proving the success of testing in the city of Vo’ (Veneto). This success will result in a WHO call for mass testing.
  • March 21: 65 Cuban doctors and nurses land in Milan.
  • March 22: The Council Chairman announces that all non-essential activities are to be ceased.
  • March 22: An ordinance is adopted by the Ministries of Health and of the Interior prohibiting citizens from leaving their city of lockdown.
  • March 25: Increased penalties for failure to comply with lockdown.
  • March 26: A Russian military convoy arrives bringing medical equipment marked with "from Russia with Love".
  • April 1: Opening of a hospital in Fiera di Milano containing 53 intensive care beds, built in 10 days thanks to 21 million euros in private donations.
  • April 10: The government announces the extension of the lockdown until May 3. 
  • April 17: The Minister of Education announces that schools will not reopen until September. 
  • April 26: Giuseppe Conte gives details of the first lockdown-ending measures: reopening of parks, bars, and restaurants (for take-away only), manufacturing and construction on May 4; reopening of retail, museums, and other cultural venues on May 18. Private parties remain prohibited and a maximum of 15 people are allowed for funerals; travel remains limited within the town of residence. 

 
Analysis

Italy was the first country in Europe to be affected by the epidemic, and thus the first to implement a response to the crisis, radically breaking with the European concept of "normality". Deciding to quarantine the main outbreak spots of the epidemic by establishing widespread lockdown throughout the peninsula and choosing to suspend all activities not essential to the life of the country, Italy was the first country to demonstrate the ability of a Western, democratic state to take radical measures to combat the epidemic.
 

While other European states took advantage of the "Italian precedent" to anticipate possible developments in the situation, Italy was obligated to invent a new European model of response to the epidemic.

The President of the Council, Giuseppe Conte, established himself as the strong man of Italy during the crisis, sometimes disregarding the parliamentary tradition of the peninsula as well as the sovereignty of the regions. An analysis of Italy's response to the Covid-19 crisis should take into account both the material and institutional constraints on the leaders and the unprecedented context in which the Italian government made its decisions. While other European states took advantage of the "Italian precedent" to anticipate possible developments in the situation, Italy was obligated to invent a new European model of response to the epidemic. 
 

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 fact that this industrial region is also one of the most polluted in Europe could have also played a role in the rapid spread of the epidemic. Cross-referencing figures from the Environmental Protection Agency and the Civil Protection Agency, an Italian study has, in fact, established the relationship between fine-particle concentrations and the quick rate at which the Covid-19 epidemic spread to the north of the country.

A front-line testimony

The fact that this industrial region is also one of the most polluted in Europe could have also played a role in the rapid spread of the epidemic.

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 comparison between the Lombard and Venetian cases reveals the importance of mass screening and cooperation between hospitals and local doctors to contain the pandemic.

He also compared the strategy adopted by Lombardy to that of neighbouring Veneto: "Veneto relied heavily on screening asymptomatic people to identify contagion outbreaks and then acted quickly by isolating the affected territories. Unlike Lombardy, where contagion increased due to the lack of preparation by small hospitals, Veneto tried to limit the hospitalisation of patients by favoring home care". The comparison between the Lombard and Venetian cases reveals the importance of mass screening and cooperation between hospitals and local doctors to contain the pandemic. 

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 second element concerns the temptation for policymakers to adopt only partial and incremental measures, even though these measures only prove to be fully effective when taken systematically and simultaneously. In Italy, the lockdown measures and closures imposed progressively on the whole country were gradually reinforced, creating the impression of a race against the virus that was lost by the authorities. The measures were accompanied by exceptions - such as factories in Lombardy continuing to operate after lockdown was imposed there - which reduced or canceled out their effectiveness. 

The lockdown measures and closures imposed progressively on the whole country were gradually reinforced, creating the impression of a race against the virus that was lost by the authorities.

  • 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.
 

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.

This return to normal means the reopening of parks and gardens and the possibility to walk the streets freely again starting May 4. Museums and libraries are expected to reopen on May 18, while restaurants and cafés, which have until now been only open for take-away, will be able to reopen on June 1. Shopping malls will be able to reopen as early as May 4, while smaller shops will have to wait until May 18. Hairdressers will not reopen until early June.

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

 

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