A highway in Northern Italy is quiet as the country is in lockdown due to the Coronavirus Covid-19 outbreak March 2020. Photo / AP
Reminiscent of a nation at war, it was an image that shocked Italy – a convoy of army trucks taking dozens of coffins away from a city that was so overwhelmed by the coronavirus catastrophe it could not cremate them fast enough.
The lorries rumbled through the empty, ghostly streets of Bergamo, a city which has found itself at the heart of Italy's devastating contagion.
"I would never have imagined that we would see a convoy of army trucks carrying coffins. These are terrible days, without precedent," Giuseppe Conte, the prime minister, said this week.
From having a handful of cases just a month ago, Italy now has the grim distinction of being the country with the most deadly coronavirus outbreak – more than 9000 people have died and 80,000 have been infected.
The last week has seen heartbreaking, morale-sapping days when the daily death toll reached close to 800 people.
But as the rate of new infections stutters and Italians pray they may finally be able to see chinks of light at the end of the tunnel, a reckoning is under way.
What did Italy do right, what did it get wrong and what can other countries such as Britain learn from the Italian nightmare?
One factor that put Italy at a big disadvantage was that the coronavirus was probably swirling around the country well before it was officially detected in late February. Experts believe it may have been in northern Italy as early as January or even December, with doctors assuming it was regular flu.
The core of the outbreak was identified in 10 towns outside Milan and on February 22 they were placed under quarantine as a closed red zone.
But the government veered between alarm and complacency. Even as people started dying, there were decidedly mixed messages given to the Italian public.
The mayor of Milan launched a campaign called "Milan Non Si Ferma" or "Milan Doesn't Stop", assuring people that all would be well and life should continue as normal.
Beppe Sala issued a mea culpa this week – saying he may have made a mistake in launching the campaign.
"At the time, it seemed to capture the spirit of Milan. Even the scientists could not give us an unequivocal interpretation of the gravity of the situation. But if I made a mistake – well I'm here now, doing my bit every day," he said.
On February 19, despite growing alarm, the authorities allowed 46,000 football fans to pour into San Siro Stadium in Milan to watch a Champion's League match between Bergamo's team, Atalanta, and Valencia.
The head of the Civil Protection Agency, which is spearheading the country's fight against the virus, admitted this week that the decision was a mistake.
"It was potentially a detonator," contributing to the spread of the virus, said Angelo Borrelli. "But we are only able to say that now because we have the benefit of hindsight."
Giorgio Gori, the mayor of Bergamo, one of the cities worst hit by the virus, said the game was "among the sad explanations" for the high infection rate.
On February 27, Italy's foreign minister told the international press in Rome that they were unfairly exaggerating the crisis.
Luigi di Maio held up a map of Italy, insisting that the area under lockdown represented just 0.05 per cent of the country and that the number of people who were affected represented 0.089 per cent of the total population.
He criticised "alarmism and false information", appealing to tourists and investors to keep coming to Italy.
The authorities were walking a tightrope – on the one hand wanting to protect public health, but on the other desperate not to harm tourism, investment, business and industry, at a time when Italy's economic growth was already woeful.
Attilio Fontana, the governor of Lombardy, repeatedly urged the national government to impose stricter measures, but he was overruled – ministers in Rome did not want to shut down the country's economic engine in the north.
But as infections spread and the number of deaths rose, the red zone was extended on March 8 from the 10 towns to a vast area of northern Italy, encompassing the regions of Lombardy, Veneto and Emilia-Romagna.
The news was leaked the day before, with the result that an estimated 20,000 people in the north fled southwards before the shutdown was officially enacted.
They were heading back to ancestral towns and villages which their parents and grandparents left decades ago in search of jobs in the north.
Many went by trains – which were described by one expert as "biological bombs" that risked spreading the virus.
Just a day later, the prime minister announced that the whole of Italy was being placed on lockdown – an entire country of 60 million people subjected to stringent quarantine rules.
By now, the contagion felt like a runaway train. The infection spread to cities like Bergamo and Brescia, where there were not enough intensive care beds and doctors and nurses wept with exhaustion.
Some officials believe now that those cities should have been placed under an immediate, even more draconian lockdown.
"Not imposing a red zone around Bergamo, as the mayor of the city was calling for, was an error," said Sala, the mayor of Milan.
He pointed to another factor – that years of budget cuts in the health system have reduced the number of GPs and local clinics. People with coronavirus were instead treated in big hospitals.
"The hospitals have become centres of diffusion for the virus. When you have lost the capacity to make home visits, you expose yourself to these risks," he said.
The virus has taken a heavy toll on Italian doctors and nurses – more than 6000 medical staff have been infected and nearly 50 doctors have died.
"Paradoxically, at a time when most of Italy is shut up at home, hospitals are the only places where thousands of people find themselves brought together in close contact," Pierluigi Lopalco, a professor of hygiene at the University of Pisa, told La Repubblica newspaper.
A dozen Italian doctors recently wrote a joint letter, saying health systems worldwide had to be switched from hospital-based care to home-based care in the battle against Covid-19.
In a letter to the New England Journal of Medicine on March 22, they said "Western healthcare systems have been built around the concept of patient-centred care," but the Covid-19 pandemic requires home-based care.
Keeping patients at home rather than sending them to hospital would help contain the pandemic, they said.
As the number of deaths and cases skyrocketed, the government brought in more and more stringent measures. But it appeared to be too little, too late.
When a delegation of experts from the Chinese Red Cross came to Milan last week, they criticised Italy for not doing enough to stop the spread of the virus.
"Here in Milan, there isn't a very strict lockdown policy. Public transportation is still working, and people are still moving around," said Sun Shuopeng, the vice-president of the Chinese Red Cross.
"It is time to close economic activities and prohibit the movement of people. Everyone must stay at home, in quarantine."
His stark warning was underlined in grim fashion just a few hours later, when
Italy surpassed China as the country with the most people killed by the virus.
Since then, the Italian death toll has continued to surge alarmingly and has not even reached its peak.
There is dispute, however, over its true scale. Many experts, including Borrelli, the head of the Civil Protection Agency, now believe the true number of infections may be up to 10 times the official figure.
With 600,000 infections or more, that would bring the fatality rate down to 1-2 per cent, commensurate with countries like China.
But no one knows for sure. The only way to find out would be to conduct random testing, to get a clearer idea of what percentage of the population is infected. Italy currently only tests people who display symptoms.
"If you don't have the right data, you can't make the right decisions," said Guido Cozzi, a professor of macroeconomics at the University of St. Gallen in Switzerland.
"There should have been more testing in the earliest stages."
Widespread testing, enforced lockdown zones of badly-hit locations and active surveillance of positive cases have emerged as the only way of halting the spread of the virus.
Italy's mistakes should not be made by countries like Britain, which are a couple of weeks behind the trajectory.
"I would urge any government to conduct random sampling so that they can understand what is going on in the population," said Cozzi. "In the UK, they have the resources to do that."
As Italy's north continues to battle the outbreak, there are fears that "biological bombs" could explode in the south, posing an enormous challenge to regions known for poor public health services.
"There is a real chance of adding a tragedy of the south to the tragedy of the north," said the governor of Campania, the southern region that includes Naples.
The Italian authorities argue that they were the first in Europe to confront the pandemic and that it posed agonising decisions for a Western democracy. "No-one in Italy or Europe was prepared for all this," said Giulio Gallera, the regional official in charge of health for Lombardy.
"In the last month we were hit by a tsunami," said Alberto Mantovani, a prominent immunologist in Milan.
But Italy knows it made mistakes and is beginning to acknowledge them.
Other countries, including Britain, do not have the excuse of navigating unchartered waters. They have a duty not to repeat Italy's errors.
"We acted with determination and we were the first in Europe to do so," Conte, the prime minister, told parliament in Rome this week. "History will judge us, but now is the time for action."
• Covid19.govt.nz: The Government's official Covid-19 advisory website
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