Paramedics transporting a suspected coronavirus patient to a hospital in Rome. Photo / Nadia Shira Cohen, The New York Times
The country's experience shows that steps to isolate the coronavirus and limit people's movement need to be put in place early, with absolute clarity, then strictly enforced.
As Italy's coronavirus infections ticked above 400 cases and deaths hit the double digits, the leader of the governing Democratic Party posted a picture of himself clinking glasses for "an aperitivo in Milan," urging people "not to change our habits."
That was on February 27. Not 10 days later, as the toll hit 5,883 infections and 233 dead, the party boss, Nicola Zingaretti, posted a new video, this time informing Italy that he, too, had the virus.
Italy now has more than 59,000 recorded infections and more than 5,400 dead, and the rate of increase keeps growing, with more than half the cases and fatalities coming in the past week. On Saturday, officials reported 793 additional deaths, by far the largest single-day increase so far. Italy has surpassed China as the country with the highest death toll, becoming the epicentre of a shifting pandemic.
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The government has sent in the army to enforce the lockdown in Lombardy, the northern region at the centre of the outbreak, where bodies have piled up in churches. On Friday night, authorities tightened the nationwide lockdown, closing parks, banning outdoor activities including walking or jogging far from home.
On Saturday night, Prime Minister Giuseppe Conte announced another drastic step in response to what he called the country's most difficult crisis World War II: Italy will close its factories and all production that is not absolutely essential, an enormous economic sacrifice intended to contain the virus and protect lives.
"The state is here," he said in an effort to reassure the public.
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The tragedy of Italy now stands as a warning to its European neighbours and the United States, where the virus is coming with equal velocity. If Italy's experience shows anything, it is that measures to isolate affected areas and limit the movement of the broader population need to be taken early, put in place with absolute clarity, then strictly enforced.
Despite now having some of the toughest measures in the world, Italian authorities fumbled many of those steps early in the contagion — when it most mattered as they sought to preserve basic civil liberties as well as the economy.
Italy's piecemeal attempts to cut it off — isolating towns first, then regions, then shutting down the country in an intentionally porous lockdown — always lagged behind the virus' lethal trajectory.
"Now we are running after it," said Sandra Zampa, undersecretary at the Ministry of Health, who said Italy did the best it could given the information it had. "We closed gradually, as Europe is doing. France, Spain, Germany, the US are doing the same. Every day you close a bit, you give up on a bit of normal life. Because the virus does not allow normal life."
Some officials gave in to magical thinking, reluctant to make painful decisions sooner. All the while, the virus fed on that complacency.
Governments beyond Italy are now in danger of following the same path, repeating familiar mistakes and inviting similar calamity. And unlike Italy, which navigated uncharted territory for a Western democracy, other governments have less room for excuses.
Italian officials, for their part, have defended their response, emphasising that the crisis is unprecedented in modern times. They assert that the government responded with speed and competence, immediately acting on the advice of its scientists and moving more swiftly on drastic, economically devastating measures than their European counterparts.
But tracing the record of their actions shows missed opportunities and critical missteps.
In the critical early days of the outbreak, Conte and other top officials sought to downplay the threat, creating confusion and a false sense of security that allowed the virus to spread.
They blamed Italy's high number of infections on aggressive testing of people without symptoms in the north, which they argued only created hysteria and tarnished the country's image abroad.
Even once the Italian government considered a universal lockdown necessary to defeat the virus, it failed to communicate the threat powerfully enough to persuade Italians to abide by the rules, which seemed riddled with loopholes.
"It is not easy in a liberal democracy," said Walter Ricciardi, a World Health Organization board member and a top adviser to the health ministry, who argued that the Italian government acted on the scientific evidence made available to it.
He said the Italian government had moved at a much faster clip, and took the threat much more seriously, than its European neighbours or the US.
Still, he acknowledged that the health minister had struggled to persuade his government colleagues to move more quickly and that the difficulties of navigating Italy's division of powers between Rome and the regions resulted in a fragmented chain of command and inconsistent messages.
"In times of war, like an epidemic," that system presented grave problems, he said, adding that it perhaps delayed the imposing of restrictive measures.
"I would have done them 10 days before, that is the only difference."
For the coronavirus, 10 days can be a lifetime.
On January 21, as top Chinese officials warned that those hiding virus cases "will be nailed on the pillar of shame for eternity," Italy's culture and tourism minister hosted a Chinese delegation for a concert at the National Academy of Santa Cecilia to inaugurate the year of Italy-China Culture and Tourism.
Michele Geraci, Italy's former undersecretary in the economic development ministry and a booster of closer relations with China, had a drink with other politicians but looked around uneasily.
"Are we sure we want to do this?" he said he asked them. "Should we be here today?"
With the benefit of hindsight, Italian officials say certainly not.
Zampa, the health ministry undersecretary, said in retrospect she would have closed everything immediately. But in real time, it wasn't that clear.
Politicians across the spectrum worried about the economy and feeding the country, and found it difficult to accept their impotence in the face of the virus.
Most importantly, Italy looked at the example of China, Zampa said, not as a practical warning, but as a "science fiction movie that had nothing to do with us." And when the virus exploded, Europe, she said, "looked at us the same way we looked at China."
But already in January, some officials on the right were urging Conte, their former ally and now political enemy, to quarantine schoolchildren in the northern regions who were returning from holidays in China, a measure aimed at protecting schools. Many of those children were from Chinese immigrant families.
Many liberals criticised the proposal as populist fearmongering. Conte declined the proposal and responded that the northern governors should trust the judgment of education and health authorities who, he said, had proposed no such thing.
But Conte also demonstrated that he was taking the threat of contagion seriously. On January 30, he blocked all flights in and out of China.
"We are the first country in Europe to adopt such a precautionary measure," he said.
Over the next month, Italy responded swiftly to coronavirus scares. Two sick Chinese tourists and an Italian returning from China received care from a prominent infectious disease hospital in Rome. A false alarm led authorities to briefly confine passengers on a cruise ship docked outside of Rome.
When a 38-year-old man went to the emergency room at a hospital in Codogno, a small town in the Lodi province of Lombardy, with severe flu symptoms on February 18, the case did not set off alarms.
The patient declined to be hospitalised and went home. He got sicker and returned to the hospital a few hours later and was admitted to a general medicine ward. On February 20, he went into intensive care, where he tested positive for the virus.
The man, who became known as Patient One, had had a busy month. He attended at least three dinners, played soccer and ran with a team, all apparently while contagious and without heavy symptoms.
Ricciardi said Italy had the bad luck of having a super spreader in a densely populated and dynamic area who went to the hospital not once, but twice, infecting hundreds of people, including doctors and nurses.
"He was incredibly active," Ricciardi said.
But he also had not had any direct contacts with China, and experts suspect he contracted the virus from another European, meaning Italy did not have an identifiable patient zero or a traceable source of contagion that could help it contain the virus.
The virus had already been active in Italy for weeks by that time, experts now say, passed by people without symptoms and often mistaken for a flu. It spread around Lombardy, the Italian region that has by far the most trade with China and the home of Milan, the country's most culturally vibrant and business-centered city.
"Who we call 'Patient One' was probably 'Patient 200,'" said Fabrizio Pregliasco, an epidemiologist.
On Sunday, Feb. 23, the number of infections clicked past 130 and Italy sealed off 11 towns with police and military checkpoints. The last days of Venice Carnival were canceled. The Lombardy region closed its schools, museums and movie theaters. The Milanese made a run on the supermarkets.
But while Conte again commended Italy for its firm hand, he also sought to downplay the contagion, attributing the high numbers of infected to Lombardy's overzealous testing.
"We have been the first ones with the most rigorous and accurate controls," he said in an address to the nation. "We have more people infected because we made more swabs."
The next day, as infections surpassed 200, seven people died and the stock market plunged, Conte and his health aides doubled down.
He blamed the Codogno hospital for the spread, saying it had handled things in "a not completely proper way" and argued that Lombardy and Veneto, another northern region, were inflating the severity of the problem by diverging from global guidelines and testing people without symptoms.
As Lombardy officials scrambled to free up hospital beds, and the number of infected people rose to 309 with 11 dead, Conte said on February 25 that "Italy is a safe country and probably safer than many others."
On Friday, Conte's office offered an interview on the condition that he could answer questions in writing. When sent questions, including those about his past statements, he declined to respond.
Reassurances from leaders confused the Italian population.
On February 27, Zingaretti posted his aperitivo picture. That same day, the country's foreign minister, Luigi Di Maio, the former leader of one of the governing parties, the Five Star Movement, held a news conference in Rome.
"In Italy, we went from the risk of an epidemic to an infodemic," Di Maio said, disparaging media coverage that highlighted the threat of the contagion, and adding that only "0.089 per cent" of the Italian population was quarantined.
In Milan, only miles from the center of the outbreak, the mayor, Beppe Sala, publicised a "Milan Doesn't Stop" campaign, and the Duomo, the city's landmark cathedral that is a draw for tourists, reopened. People went out.
But on the sixth floor of the regional government headquarters in Milan, Giacomo Grasselli, who is the coordinator of the intensive care units throughout Lombardy, saw the numbers going up and quickly realized that it would be impossible to treat all the sick if the infections continued unabated.
His task force worked to match the sick to beds in intensive-care units in the nearest possible hospitals and appropriate dwindling resources. At one of the daily meetings of about 20 health and political officials, he told the regional president, Attilio Fontana, about the growing numbers.
An epidemiologist showed the curves of infection. There was a catastrophe facing the region's well-respected health system. "We need to do something more," Grasselli told the room.
Fontana, who had been pressing the central government for tougher action, agreed. He said that the mixed messages from Rome and the easing of restrictions had led Italians to believe "that everything was a joke, and they kept living as they used to."
He said he appealed for tougher national measures in video conferences with the prime minister and other regional presidents, arguing that climbing numbers of cases threatened to collapse the hospital system in the north, but that his requests were repeatedly turned down.
"They were convinced that the situation was less serious and they did not want to hurt our economy too much," said Fontana.
The government started providing some economic assistance, which would later be followed by a 25 billion euro ($47 billion) relief package, but the nation became divided between those who saw the threat and those who didn't.
Zampa said that it was around that time that government learned that infections in the town of Vò, the virus epicentre of the Veneto region, had no epidemiological link to the Codogno outbreak.
She said that the health minister, Speranza, and Conte deliberated about what to do and within the day, they decided to close down much of the north.
In a surprise 2 a.m. news conference on March 8, when 7,375 people had already tested positive for coronavirus and 366 had died, Conte announced the extraordinary step of restricting movement for about a quarter of the Italian population in the northern regions that serve as the country's economic engine.
"We are facing an emergency," Conte said at the time. "A national emergency."
A draft of the decree, leaked to Italian media, pushed many Milan residents to rush to the train station in crowds and attempt to leave the region, causing what many later considered a dangerous wave of contagion toward the south.
Yet the following day, most Italians were still confused about the severity of the restrictions.
To clarify the issue, the interior ministry issued "auto-certification" forms that would allow people to travel in and out of the locked-down area for work, health or "other" necessities.
In the meantime, some regional governors independently ordered people coming from the newly locked-down area to self quarantine. Others didn't.
The broader restrictions in Lombardy also effectively lifted the quarantine on Codogno and other "red zone" towns linked to the original outbreak. Checkpoints disappeared. Local mayors complained that their sacrifices had been wasted.
A day later, on March 9, when the positive cases reached 9,172 and the death toll climbed to 463, Conte toughened the restrictions and extended them nationally.
But by then, some experts say, it was already too late.
Italy is still paying the price of those early mixed messages by scientists and politicians. The people who have died in staggering numbers recently — more than 2,300 in the last four days — were mostly infected during the confusion of a week or two ago.
Roberto Burioni, a prominent virologist at the San Raffaele University in Milan, said that people had felt safe to go about their usual routines and he attributed the spike in cases last week to "that behavior."
The government has urged national unity in obeying its restrictive measures. But Saturday, hundreds of mayors from the hardest-hit areas told the government those measures were fatally insufficient.
Leaders in the north are desperate for the government to crack down harder.
On Friday, Fontana complained that the 114 troops the government deployed were insignificant, and that at least 1,000 should be sent. On Saturday, he closed public offices, work sites and banned jogging. He said in an interview that the government needed to stop messing around and "apply rigid measures."
"My idea is that if we had shut everything in the beginning, for two weeks, probably now we would be celebrating victory," he said.
His political ally, Luca Zaia, the president of the Veneto region, preempted the national government with his own crackdown, and said that Rome needed to enforce "a more drastic isolation," including closing all stores and prohibiting public activities other than commuting to work.
"Walks should be banned," he said.
Zaia has some credibility on the issue. As new infections have proliferated around the country, they have significantly dropped in Vò, a town of about 3,000 people that was one of the first quarantined and which had the country's first coronavirus death.
Some government experts attributed that turnaround to the strict quarantine that had been in place for two weeks. But Zaia had also ordered blanket tests there, in defiance of international scientific guidelines and the national government. The government has argued that testing people without symptoms is a drain on resources.
"At least this slows down the virus' speed," Zaia said, arguing that testing helped identify potentially contagious people without symptoms. "And slowing down the virus' speed allows the hospitals to breathe."
If not, the overwhelming number of patients would crater health care systems and cause a national catastrophe.
Americans and others, he said, "need to be ready."
Written by: Jason Horowitz, Emma Bubola and Elisabetta Povoledo
Photographs by: Nadia Shira Cohen, Alessandro Grassani,Andrea Mantovani © 2020 THE NEW YORK TIMES
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