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On January 29, when Italy detected and isolated its first coronavirus cases – two Chinese tourists – authorities were sure they had put together the safest protection system in Europe.
The following day, Italian Prime Minister Giuseppe Conte immediately declared a state of emergency for six months, and made Italy the first country to block flights from China. “We can reassure all the citizens, the situation is under control,” he said. “We expected cases in Italy too.”
But by March 11, the country had the second-highest number of infections outside China. In a press conference where the number of journalists was limited to prevent the spread of the virus, the head of the Italian Civil Protection Angelo Borrelli laid out the latest figures. Barely twenty days after the first locally transmitted case, authorities had confirmed 12,462 cases, 827 people had died and 1,028 were in intensive care units.
With the epidemic now rapidly spreading to other European countries – France, Germany and the UK have recorded sharp rises in cases – Italy’s experience is serving as a case study and a warning for other governments about how quickly and decisively they need to act. But how did this happen? Why did Italy have so many deaths so quickly? And most of all, could this have been prevented?
Although it’s too early to be certain, there is growing consensus among scientists that fatal cases of coronavirus have not, in fact, hit Italy “quickly”. Scientists we’ve spoken to believe that the virus circulated unnoticed in the country from at least mid-January – thriving because so many of the infected had no symptoms at all, or only mild symptoms like a cough and a mild temperature. This is consistent with recent research suggesting that the virus can be spread by people who do not yet show any symptoms.
“At the moment, it looks like the outbreak already started in early January, so it had time to grow to a considerable size,” says Christian Althaus, a computational epidemiologist at the University of Bern. “The initial infected cases can be missed and the virus can spread freely.”
There could be different reasons why these initial contagions were not spotted, says Nino Cartabellotta, a prominent health researcher and president of the GIMBE foundation. “One, it could be that some suspected pneumonia cases were not tested [for coronavirus],” he says. For example, reports emerging in Italian media suggest that hospitals in the outbreak area observed unusually high numbers of pneumonia cases one month before the outbreak. (These have not been confirmed as coronavirus cases yet.)
“Two, it could be that there weren’t any severe cases, that they only emerged in a clinically mild way,” says Cartabellotta. “And three, it depends on the level of attention that health policies place on [finding] the coronavirus.”
The coronavirus resurfaced on 18 February, when a 38-year-old man went to the A&E of the hospital in the sleepy northern town of Codogno. He reported high temperature for two days, his parents said, but the medical staff did not diagnose him with coronavirus and after the visit he was allowed to return home.
When his symptoms got worse and he returned to the hospital, he was confirmed to be the first locally transmitted case in Italy. At this point, Italy still only had four imported cases, but this patient could have enabled the virus to spread within the hospital, infecting medical workers and patients with already fragile health. (He is recovering, but still in a hospital in nearby Pavia.)
On February 23, After more cases and the first two deaths were detected, authorities put about 50,000 people in Codogno and 10 other towns under lockdown. More measures were imposed on nearby Milan, Italy’s economic engine, including the closure of schools and a 6PM curfew for bars and restaurants.
But the alarming thing for other countries is that there doesn’t seem to be anything that Italy did particularly wrong. It seems to have been down to chance. “There is nothing special about Italy in reference to this virus, other than the fact that its health service reacted very quickly and that it was the first western country to react,” says Ilaria Capua, a virologist specialising in zoonotic diseases – infectious diseases spreading from animals to humans – and director of the One Health Centre of Excellence at the University of Florida.
Others suggest that Italy was the first to detect the coronavirus, but not necessarily the first country where the coronavirus arrived. Stefano Rusconi, an associate professor of Infectious Diseases at DIBIC Luigi Sacco, University of Milan, says that other countries did not do a better job of spotting undetected cases. “On the contrary, Italy, or rather, Lombardy, carried out a very considerable number of coronavirus tests that allowed it to quickly discover many more cases of infected people.”
He says it looks unlikely that Italy could have done anything to completely prevent the virus from entering. “The only thing we could have done is introducing the current lockdown on 30 January, a decision that was impossible and unthinkable at the time,” he says. Even stopping flights from China might have had no influence at all, he says – new, provisional research suggests that the coronavirus reached Italy from Germany.
Even after the first measures, Italy’s already weak economy took a sharp hit. The tourist industry faced waves of flight and holiday cancellations, while Milan’s stock market lost 6.8 per cent between February 21 and February 25 and people took to supermarkets to stock up on food.
Faced with a choice between public health and the economy, but with only a few hundred confirmed cases in the country’s north, politicians across the spectrum tried to keep their feet in both shoes. Many sought to mitigate the economic downturn, sending mixed messages to the population.
Lombardy governor Attilio Fontana (of the far-right League) told the regional parliament the coronavirus was “just a little more than normal flu” on February 25. The next day, the region relaxed restrictions on bars and restaurants only three days after passing them. The leader of the centre-left Democratic Party (PD) Nicola Zingaretti went to a public aperitivo in Milan, warning the country to be careful but avoid “destroying life or spreading panic” and to “give signs of recovery and rebounding”. The mayor of Milan Giuseppe Sala (also of the PD) launched a campaign called “Milan doesn’t stop”, encouraging the Milanese not to be afraid.
Meanwhile, the epidemic slowly reached the very politicians making these decisions. Just a few hours after Lombardy eased rules for bars, Fontana confirmed one of his assistants had been infected. He announced he would work in “a kind of self-isolation”. Days later, on March 7, Zingaretti announced he had the coronavirus.
Authorities took additional measures. On 1 March, when cases numbered 1,577, they imposed limited restrictions on social life in northern regions. Three days later (with 2,706 cases) schools and universities were shut nationwide.
But some argue these decisions were not enough. Cartabellotta has been a critic of the decision not to take stricter measures at this time – like extending social restrictions to the whole country or even emulating China’s lockdown. “Waiting strategies have always favoured the spread of the virus,” he says.
Roberto Burioni, a virologist at the San Raffaele University Hospital in Milan and a prominent medicine communicator, has explained the importance of lockdowns by arguing that the coronavirus crisis is not a sudden event like “a meteor arriving on our head”. Rather, he said, it’s like “being in a car that is going against a wall, just press the brake and we are safe. But the pedal we must press all together, 60 million Italians.”
In early March, hospitals in Lombardy began to be overwhelmed. Doctors on the frontline began saying they had been hit by a “tsunami” of patients. Some reported working 25 additional hours per week, others had worked for over 14 hours a day, for 24 days in a row. Some medical workers were infected, making shifts harder and longer and working conditions tougher.
Some of this strain is down to the symptoms caused by the virus, which are relatively rare. “It’s a pathology that puts pressure on the health service locally,” says Francesco Longo, director of the Centre for Research on Health and Social Care Management at the Bocconi University of Milan. “A particular hospital might be used to treating two or three cases of pneumonia per day – then suddenly it has to treat 40 per day. Nobody can deal with demand ten times higher than normal.”
But Longo says that the underfunding of the Italian health service might have made the crisis worse. “National health services should work at 80 or 90 per cent of their capacity, leaving the rest to deal with emergencies and peaks of demand,” he says. “The Italian health service has been working at, let’s say, 95 per cent for some time. Ordinary stress was already high when the coronavirus hit.”
But without full-blown lockdowns, Italians continued to be on the streets. Every day, pictures surfaced of packed ski resorts, free cultural events or people enjoying drinks in crowded places. “These people must have thought they were on the Titanic, and so spent their time drinking and dancing the waltz while the ship sank,” says Rusconi.
By the time the government decided to put first Lombardy, then the whole country under partial lockdown (it’s not as strict as China, with industrial production, agriculture and the transport of goods still continuing) on March 8, contagions and burden on the health service had grown exponentially. Hundreds had died across the country, with the death rate appearing to reach eight per cent in Lombardy, much higher than the one recorded until now.
Italy’s high average age could be a factor in this. The elderly are more likely to have pre-existing conditions, and almost a quarter (22.6 per cent) of Italy’s population is aged 65 or higher – the highest number in the EU and among the highest in the world. Capua says there are differences in how the data is gathered and presented in different countries, so comparing deaths could be misleading.
On February 27, Italy took the decision to only test people with symptoms, meaning that the official data only detects a fraction of the infected. “[Since then] we are only observing the tip of the iceberg,” says Cartabellotta. “In other words, if we could know all the positive cases, the lethality rate would decrease.”
This means the spread is likely to be much larger than it appears, and that Italy does not currently have 15,113 cases – but probably many thousands more. The same could be happening in other European countries, which seem to be following Italy’s curve of contagions. “They will have a similar number of cases,” Cartabellotta says. “We think there might be an explosion within a week.”
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