Tormented Italy tries to get to grips with coronavirus epidemic

The image of dozens of military trucks coming out of Bergamo, carrying hundreds of coffins to available crematoriums, is a painful illustration of what is happening in Italy. Or to be more precise: in northern Italy.

A month after the discovery of the first Covid-19 breeding ground in Codogno, a village in the province of Lodi, 50km from Milan, Italy has recorded almost 60,000 cases of the coronavirus and 5,476 deaths, after a further 651 fatalities were confirmed on Sunday.

Nightmarish numbers, which exceed those of China; it's hard to think now that it all started with a single case.

Lombardy, the richest region in the country, is on its knees. Hospital departments and intensive care units overflow with patients with interstitial pneumonia connected to oxygen, waiting to be intubated, if space can be found for them.

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“What did we do wrong?”, one may ask.

"Like all western countries, we weren't ready to face a pandemic," says Ilaria Capua, an internationally-renowned Italian virologist who teaches at the University of Florida.

“Governments and some scientists underestimated what was going on in China and started to work on containment plans when the epidemic was already circulating undisturbed on their streets. Without a clear and strong line you lose control, even of the virus.”

Mistakes

Covid-19 had been circulating in Europe since December. "It took too long to recognise all the atypical cases of pneumonia that arrived in hospitals between January and February," says Capua. "We should have had a more open mind and think that Chinese coronavirus would become Italian, French, Irish and so on."

She points also to some mistakes made on hospital wards, where doctors and nurses have been infected and became the vehicle of the virus.

Italy had the misfortune to be the first western country in which the a big contamination broke out; “paradoxically, our government acted even before others, but it was still too late”, says Capua.

The hesitation at the beginning, the fear of collapsing the economy and the underestimating of the problem combined to withhold from,the population a true image of emergency.

On February 27th, only three weeks ago, Nicola Zingaretti, the secretary of the centre-left Democratic Party, which governs in coalition with the populist Five Star Movement, posted a photograph of himself having an anti-panic aperitivo in Milan. He was following the lead of the mayor, Beppe Sala, who at around the same time wore shirts with the motto "Milan doesn't stop".

Because of that, many people felt confident enough to go out for a walk and to have an aperitivo. Ten days later, Zingaretti tested positive for Covid-19.

Other countries, instead of learning lessons from Italy, followed the same path: underestimating the thret at first, then wavering, and finally acting.

‘Bigger catastrophe’

Italy is tormented by the deaths in Lombardy that keep growing despite the severe lockdown, and now has closed all factories.

"We are all trying to understand if something particularly strange happened there. Because if after Milan, [then] London, New York, Dublin, Paris and Berlin are next, it would be an even bigger catastrophe than what we could imagine," says Capua.

The virologist has a few different hypotheses: it could be that the strain of Covid-19 in Lombardy has mutated and become more aggressive, but the only way to confirm this would be to analyse all the virus sequences.

Or, the large number of cases could have to do with the age of the Italian population, the second oldest in the world. Especially in Lombardy, where the healthcare system works well despite cutbacks, there are many “super elderly” people with an array of pathologies – Covid-19’s favourite kind of victim.

Capua also thinks that ageing hospital facilities may have favoured the spread of the virus: "The Sars 1 virus was circulated through the air duct of the M Hotel in Hong Kong. What if the coronavirus also entered the ventilation systems of run-down hospital buildings? Certainly several cases of infections have occurred in hospitals," she says.

Pollution may also be a factor in Italy’s heavily-industrialised, densely-populated cites, where millions of daily work trips are made. According to the European Public Health Alliance, smog in urban areas causes hypertension, diabetes and respiratory diseases.

Extended families

The pieces are still being studied and put together so for now these are only hypotheses. But it is clear in Italy that the extended family model is prevalent, in whch the elderly are at the centre of society, taking care of their children and grandchildren until the end of their lives. This has left them more exposed to the risk of being infected by younger, often asymptomatic people.

Giovanni Sebastiani, a mathematician with the Italian National Research Council, spends his nights swimming in the data of the Italian epidemic. "In general, we can say that for half of the provinces that I have analysed, we are in the initial phase of decreasing the growth rate of the total number of cases. It is a small but progressive decrease, a small positive sign," he says.

Cases in Milan are on the rise, however. “Containment measures should have been implemented immediately and citizens should have been more respectful,” he adds.

Sebastiani says that if Italy locked down completely for 14 days, the spread of the virus would be over.

He is not so surprised by the numbers in Lombardy. “It was enough to look carefully at China. Today in Lombardy it is no longer possible to calculate the rate of fatality because we do not know how many true positives there are.”

Because swabbing is done only in severe cases, the authorities have no idea of the number of people infected with asymptomatic or with mild symptoms. “Some of the models that I am using say that in February there were 40 per cent to 50 per cent of cases of asymptomatic infections in the area of the breeding ground. And if this were the case, these figures would bring the fatality rate in Lombardy back to numbers similar to China.”

"Despite the numbers, our focus remains avoiding overload of our hospitals," says Pierluigi Vitale, director of infectious diseases at Sant'Orsola-Malpighi Polyclinic in Bologna, which is at the forefront of fighting Covid-19. The risk is that if there are not enough beds, respirators and doctors, the number of victims will continue to rise.

‘First phase’

In the south of Italy, where public healthcare on average lacks resources, the virus does not seem to have spread at the same rate as in the north, at least for now. But healthcare facilities are preparing for a potential emergency.

“It is not easy to fight against an alien that we’ve known for only three months,” says Viale. “We are doing our best to save people, but every death is a blow to the heart. I haven’t hugged my son for ten days and today he sent me a message: ‘Daddy, I miss you.’ I burst into tears during my meeting.”

But how long will it take until Viale will be able to see his son? And for everyone else to breathe a sigh of relief? Sebastiani closes by reminding us, “It must be underlined that there are great uncertainties, because we are only in the first phase, but between March 25th and mid-April, stabilisation could occur, that is, the growth rate could be zero or negligible. But be careful: this does not mean that it is over.”