As Italy prepares to emerge from the West's first and most extensive coronavirus lockdown, it is increasingly clear that something went terribly wrong in Lombardy, the hardest-hit region in Europe's hardest-hit country.
Italy had the bad luck of being the first Western country to be slammed by the outbreak, and its official total of 26,000 fatalities lags behind only the U.S. in the global death toll. Italy's first homegrown case was recorded Feb. 21, at a time when the World Health Organization was still insisting the virus was containable and not nearly as infectious as the flu.
But there also is evidence that demographics and health care deficiencies collided with political and business interests to expose Lombardy's 10 million people to COVID-19 in ways unseen anywhere else, particularly the most vulnerable in nursing homes.
Virologists and epidemiologists say what went wrong there will be studied for years, given how the outbreak overwhelmed a medical system long considered one of Europe's best, while in neighboring Veneto, the impact was significantly more controlled.
Prosecutors, meanwhile, are deciding whether to lay any criminal blame for the hundreds of dead in nursing homes, many of whom don't even figure into Lombardy's official death toll of 13,269, half of Italy's total.
By contrast, Lombardy's front-line doctors and nurses are being hailed as heroes f or risking their lives to treat the sick under extraordinary levels of stress, exhaustion, isolation and fear. One WHO official said it was a miracle they saved as many as they did.
Here's a look at the perfect storm of what went wrong in Lombardy, based on interviews with doctors, union representatives, mayors and virologists, as well as reports from the Superior Institute of Health, national statistics agency ISTAT and the Organization for Economic Cooperation and
Development, which advises developed economies on policy.
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Italy was the first European country to halt all air traffic with China on Jan. 31, and even put scanners in airports to check arrivals for fever. But by Jan. 31, it was already too late. Epidemiologists now say the virus had been circulating widely in Lombardy since early January, if not before.
Doctors treating pneumonia in January and February didn't know it was the coronavirus, since the symptoms were so similar and the virus was still believed to be largely confined to China. Even after Italy registered its first homegrown case Feb. 21, doctors didn't understand the unusual way COVID-19 could present itself, with some patients experiencing a rapid decline in their ability to breathe.
After a phase of stabilization, many deteriorated quickly. This was clinical information we didn't have, said Dr. Maurizio Marvisi, a pneumologist at a private clinic in hard-hit Cremona.
There was practically nothing in the medical literature. Because Lombardy's intensive care units were already filling up within days of Italy's first cases, many primary care physicians tried to treat and monitor patients at home. Some put them on supplemental oxygen, commonly used for home cases in Italy.
That strategy proved deadly, and many died at home or soon after hospitalization, having waited too long to call an ambulance.
Reliance on home care will probably be the determining factor of why we have such a high mortality rate in Italy," Marivi said.
Italy was forced to use home care in part because of its low ICU capacity: After years of budget cuts, Italy entered the crisis with 8.6 ICU beds per 100,000 people, well below the OECD average of 15.9 and a fraction of Germany's 33.9, the group said.
As a result, primary care physicians became the front-line filter of virus patients, an army of mostly self-employed practitioners who work outside Italy's regional hospital system.
Since only those with strong symptoms were being tested because Lombardy's labs couldn't process more, these family doctors didn't know if they themselves were infected, much less their patients.
With so little clinical information available, doctors also had no guidelines on when to admit patients or refer them to specialists. And being outside the hospital system, they didn't have the same access to protective masks and equipment.
The region was extremely behind in giving us protective equipment and it was inadequate, because the first time, they gave us 10 surgical masks and gloves, said Dr. Laura Turetta in the city of Varese. Obviously for our close contact with patients, it wasn't the correct way to protect ourselves.
The Lombardy doctors' association issued a blistering letter April 7 to regional authorities listing seven errors" in their handling of the crisis, key among them the lack of testing for medical personnel, the lack of protective equipment and the lack of data about the contagion.
The regional government and civil protection agency defended its efforts, but acknowledged that Italy was dependent on imports and donations of protective equipment and simply didn't have enough to go around.
Some 20,000 Italian medical personnel have been infected and 150 doctors have died.
Two days after registering Italy's first case in the province of Lodi, sparking a quarantine in 10 towns, another positive case was registered more than an hour's drive away in Alzano in Bergamo province.
Whereas the emergency room of the Lodi-area hospital was closed, the Alzano ER reopened after a few hours of cleaning, becoming a main source of contagion.
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