Chiara Berardi, Marcello Antonini and Professor Francesco Paolucci unpack what went tragically wrong in Italy.
ON THE 19th March, 2020, Italy reached a tragic record: the number of COVID-19-related deaths exceeded those of China, where the pandemic started. The death rate decreased on the 25th and 26th March. But on the 27th, the situation worsened as the death rate sharply rose by 46% compared to the previous day.
The total number of deaths has reached 13,155. In one month, Italy has become the nation with the highest number of deaths (in China there have been 3,326 deaths since December 2019, in Spain 11,198).
To date, the total number of infected people, including the victims and the healed, reached 119,827, second only to the U.S. The most affected region in Italy is Lombardy (~10 million people) with 47,520 cases to date, which had 8,311 deaths by the 3rd of April.
In Italy, the contagion curve was slightly decreasing but the peak has not been reached yet, as reported by the President of the Health Research Institute.
What went wrong with Italy and why?
The COVID-19 fatality rate is higher among people aged 60 years and older (73.2% of total deaths). The Italian population is the second oldest population in the world (median age 45.9) after Japan (median age 46.9) with 22% of the population over 65, the oldest in EU).
This longevity comes with a significant rate of morbidity. 40% of the total population have a chronic condition and nearly 21% are affected by multi-chronic conditions. Pre-existent conditions show a high correlation with the fatality rate as 88% of patients who died had at least one underlying comorbidity.
Up to date, the Italian case fatality rate (12.2%) is far above the average of the top 10 most affected countries (case fatality rate: China (4%) ; U.S. (2.5%); Spain (9.3%); Germany (1.3%), Iran (6.1%); France (9.9%); Switzerland (3%); UK (9.8%); South Korea (1.7%)).
The Italian death rate might be higher because of how it is recorded. The death count includes all people that died in the hospital, who were confirmed to have COVID-19.
In other countries, deaths are reported only if there is a direct correlation to COVID-19 and no post-mortem test is performed. The National Institute of Health reported that only 12% of deaths have a direct causality with COVID-19 in Italy.
The Italian system does not have adequate resources to handle the pandemic. For instance, Germany is equipped with 28,000 ICU beds while Italy had only 5,218 before the emergency. On 20th February, the first case of coronavirus was detected in Codogno, Lombardy.
Despite contact tracing, authorities failed to identify patient 0. The regional health system promptly started to collect epidemiological data, strengthening regional laboratories and creating dedicated paths while also upgrading ICU. These actions were complemented by measures to limit the spread of infection such as case isolation, contact tracing, and the definition of a quarantined area.
Despite Lombardy having the highest regional number of ICU beds (859) before the pandemic, the sharp increase of people with severe disease saturated the capacity of the region which was forced to increase the number of beds available by 208. The epidemic in Italy started before patient 1 was detected and its transmission potential was very high.
At the time of the first detection, the epidemic had already spread in most municipalities of southern- Lombardy. Even a healthcare system in the richest region in Italy, deemed one of the best systems in the world by a 2015 World Health Organisation (WHO) report, was not adequately prepared to face the emergency.
The lack of personnel to test patients and the laboratories to process tests had a significant impact on the increase in mortality. Test timing, alongside supportive measures such as quarantine, social distancing and business lockdown, play fundamental roles in limiting the spread of the virus. The high Italian death rate might be also the result of a selection bias in testing.
The Italian Government prioritised the testing for people with more severe symptoms due to the limited resources available to face the emergency. This bias might increase the mortality rate by reducing the total numbers of confirmed cases, as the test strategy is not widespread.
The Italian per capita healthcare expenditure is 3,428 USD (PPP) in 2018, below the OECD average of 3,994. The hospital standards and the ability to deal with emergencies are challenged by years of spending reviews and shrinking budgets. Myopic policies established that the maximum number of acute hospital beds and the bed occupancy index must be between only 80% and 90% (12).
Health care was weakened by a cut in public funding of over 37 billion euros in 10 years. This inevitably translated into a drop in the level of care: over 70,000 beds have been lost in the last 10 years.
The decision making was delayed by disputes between the regions and the central Government regarding testing strategies but also the speed of the interventions such as building up testing laboratories, medical personnel and hospital capacity.
The gradual lockdowns (the emergency areas were expanded three times before the total lockdown) of northern cities and regions created a massive shift of people to southern Italy, contributing to the virus spreading around the country. From the 7th March to the current date, the total cases in the southern regions, which have the weakest health care systems, increased by 2000%.
The inconsistency of the communication strategy at a political level influenced people’s behaviour from unawareness to panic. In the early contagion phases, political leaders provided misleading reassurances to people, making them underestimate the importance of following the institutional guidelines for preventing the contagion.
There are a number of individuals who are not complying with Government mandates. From the 11th to the 30th March, the Italian authorities reported 110,000 people, as they did not comply with compulsory home isolation measures.
The Italian health system surveillance should have been much more prepared considering the demographic and epidemiological profile of the population, with a high proportion of people older than 60 years old and with pre-existent comorbidities at risk.
Despite the economic measures (suspension of fiscal compact, pandemic emergency purchase program) the role of European institutions remains marginal as there is a lack of coordination and unitary policy in helping member states to deal with the COVID-19 emergency.
Chiara Berardi is an Italian researcher at the University of Newcastle, who is particularly interested in health economic and policy topics. Marcello Antonini is a PhD candidate in Health Economics at the University of Newcastle. Francesco Paolucci is Professor of Health Economics & Policy at the Faculty of Business & Law, University of Newcastle and the School of Economics & Management, University of Bologna.
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