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 nation to be slammed by the outbreak, and its official total of 26,600 fatalities lags behind only the US in the global death toll. Italy's first homegrown case was recorded February 21, at a time when the World Health Organisation was still insisting the virus was "containable" and not nearly as infectious as the flu.
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But there is also evidence that demographics and healthcare deficiencies collided with political and business interests to expose the 10 million people in the northern Italian region of Lombardy 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 the neighbouring Veneto region, 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 13,325, half of Italy's total.
By contrast, Lombardy's front-line doctors and nurses are being hailed as heroes for 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 and briefings with doctors, union representatives, mayors and virologists, as well as reports from Italy's Superior Institute of Health, national statistics agency ISTAT and the Organisation for Economic Cooperation and Development, which advises developed economies on policy.
Italy was the first European country to halt all air traffic with China on January 31, and even put scanners in airports to check arrivals for fever. But by January 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 February 21 case, 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 stabilisation, 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 hospitalisation, 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 within the public health system but outside Italy's regional hospital network.
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 pushed back at the criticism and defended its efforts. But the civil protection agency also 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 Lombardy 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.
Internal documents cited by Italian newspapers indicate the handful of serious pneumonia cases the Alzano hospital saw as early as February 12 were likely Covid-19. At the time, Italy's health ministry recommended tests only for patients who had been to China or been in contact with a suspected or confirmed positive case.
By March 2, the Superior Institute of Health recommended Alzano and nearby Nembro be sealed off as the towns in Lodi had been. But political authorities never implemented the quarantine recommendation there, allowing the infection to spread for a second week until all the Lombardy region was locked down March 7.
"The army was there, prepared to do a total closure, and if it had been done immediately maybe they could have stopped the contagion in the rest of Lombardy," said Dr Guido Marinoni, head of the association of doctors in Bergamo province. "This wasn't done, and they took softer measures in all of Lombardy, and this allowed for the spread."
Asked why he didn't seal off Bergamo sooner, Premier Giuseppe Conte argued the regional government could have done so on its own. Lombardy's governor, Attilio Fontana, shot back that any mistake "was made by both. I don't think that there was blame in this situation."
Lombardy has one-sixth of Italy's 60 million people and is the most densely populated region, home to the business capital in Milan and the country's industrial heartland. Lombardy also has more people over 65 than any other Italian region, as well as 20 per cent of Italy's nursing homes, a demographic time bomb for Covid-19 infections.
"Clearly, with the benefit of hindsight, we should have done a total shutdown in Lombardy, everyone at home and no one moves," said Andrea Crisanti, a microbiologist and virologist advising the Veneto regional government. But he acknowledged how hard that was, given Lombardy's outsize role in the Italian economy, which even before the pandemic was heading toward a recession.
"Probably for political reasons, it wasn't done," he told reporters.
Unions and mayors of some of Lombardy's hardest hit cities now say the country's main industrial lobby group, Confindustria, exerted enormous pressure to resist lockdowns and production shutdowns because the economic cost would be too great in a region responsible for 21 per cent of Italy's GDP.
On February 28, a week into the outbreak and well after more than 100 cases were registered in Bergamo, the province's branch of Confindustria launched an English-language social media campaign, #Bergamoisrunning, to reassure clients. It insisted the outbreak was no worse than elsewhere, that the "misleading sensation" of its high number of infections was due to aggressive testing, and that production in steel mills and other industries was unaffected.
Confindustria launched its own campaign in the larger Lombardy region, echoing that message, #Yeswework. Milan's mayor proclaimed that "Milan doesn't stop".
At the time, Confindustria Lombardy chief Marco Bonometti acknowledged the "drastic measures" needed in Lodi but sought to lower the sense of alarm.
"We have to let people know they can go back to life as it was, while safeguarding their health," he said.
Even after the Rome-based national government locked down all of Lombardy March 7, it allowed factories to stay open, sparking strikes from workers worried their health was being sacrificed to keep Italy's industrial engine rolling.
"It was a huge error. They should have taken the example where the first cluster was found," said Giambattista Morali of the metalworkers' union in the Bergamo town of Dalmine. "Keeping factories open didn't help the situation; obviously it worsened it."
Eventually, all but essential production was shut down nationwide March 26. Confindustria's national president, Carlo Bonomi, has been urging that industry be reopened, but in a safe way.
"The paradigm has changed," Bonomi told RAI state television. "We can't make Italians secure if we don't reopen factories. But how do we make factories safe to secure Italians?"
It's a tough sell, given Lombardy is still adding an average of 950 infections daily, while other regions add from a few dozen to 500 apiece, with most new cases registered in nursing homes. Italy is set to begin a gradual reopening May 4, leading with regions farther south where the outbreak is more under control.
Lombardy probably will be last to fully open, with its 73,000 confirmed cases, 70 per cent of Italy's total, and estimates that the real number could be 10 times that.
A COSTLY FIELD HOSPITAL
Perhaps no initiative better illustrates Italy's confused coronavirus response than the 200-bed field hospital built in less than two weeks on the grounds of Milan's convention center.
The hospital was unveiled to great fanfare on March 31, the fruit of a 21 million euro ($23m) fundraising campaign headed by Lombardy's governor, a member of the right-wing League party, to try to ease pressure on regional ICUs, which on that date were near capacity at 1324 patients.
The national civil protection agency opposed the plan, arguing it could never equip it with ventilators or personnel in time. Instead, the agency, which reports to the rival 5-Star-Democratic government in Rome, preferred smaller field units set up outside hospitals and a program to move critical patients elsewhere.
In the end, the Milan field hospital was barely used, treating only a few dozen patients. Since it opened, Lombardy has seen pressure on its ICUs fall considerably, with just 700 people needing intensive care today.
Fontana, the governor, defended the decision and said he would do it again, telling Radio 24: "We had to ... prepare a dam in case the epidemic overcame the embankment."
NURSING HOME 'MASSACRE'
While the regional government was focused on building the field hospital and scrambling to find ICU beds, its testing capacity lagged and Lombardy's nursing homes were in many ways left to fend for themselves.
Hundreds of elderly have died in Lombardy and across Italy in what one WHO official has termed a "massacre" of those most vulnerable to the virus. Prosecutors are investigating dozens of nursing homes, as well as measures taken by local health authorities and the regional governments that may have worsened the problem.
Lombardy has more nursing homes than any other region, housing at least 24,000 elderly, and it registered more dead at those facilities than others too. Of the 3045 dead from February 1 to April 15 in the region, 1625 were either positive for the virus or showed its symptoms, according to preliminary results from a survey by the Superior Institute of Health.
Of particular attention to prosecutors was the March 8 decision by the regional government to allow recovering Covid-19 patients to be put in nursing homes to free up hospital beds. The region says it required the homes guarantee the patients would be isolated, but it's not clear who was responsible to ensure that or whether anyone checked.
Even before that, staff at some homes said management prevented them from wearing masks for fear of scaring residents.
A March 30 regional decree, again aimed at easing pressure on Lombardy's ICUs, told nursing home directors to not hospitalise sick residents over 75 if they had other health problems. The decree said it was "opportune to treat them in the same facility to avoid further risks of decline in transport or during the wait in the emergency room."
For the elderly at a nursing home in Nembro, one of the hardest-hit towns in Bergamo province, the decree amounted to a death warrant. But it wasn't the first or only one that gave the home's managers the sense that they were being abandoned.
When management proactively barred visitors on Feb. 24 to try to protect residents and staff from infection, local health authorities responded by threatening sanctions and a loss of accreditation for cutting off family visits, said the facility's new director, Valerio Poloni.
In the end, 37 of the 87 residents died in February and March. Its doctor, as well as Poloni's predecessor as director, also tested positive, were hospitalised and died. A nursing home resident couldn't get admitted to the hospital in late February because the ER was too crowded.
The facility's health director, Barbara Codalli, said she was told to use her existing resources to treat the sick. "The patient returned a few hours later, and a few days later the patient died," she told La7 television.
To date, none of the surviving residents has been tested. Poloni said tests were expected to begin in a few days. Two more residents died so far in April, but the situation seems under control.
"We are tranquil," he said.