Analysis. The court-appointed expert found many different instances of negligence: wards not reorganized, a lack of swabs, poor staff training on the use of masks, which would soon run out.

The Bergamo Covid inquiry finds deadly mix of poor planning, secrecy and improvisation

When we read the proceedings of the Bergamo investigation into the initial management of the COVID outbreak in Valseriana, the expert report requested by the prosecution and prepared by microbiologist Dr. Andrea Crisanti serves as a guiding thread, because it helps organize the enormous amount of information gathered by the magistrates. The answers Dr. Crisanti was appointed to find concern three issues: the Alzano Lombardo hospital outbreak, indecisions about the red zone in Alzano Lombardo and Nembro and the failure to implement the national anti-pandemic plan. Let’s look at these in order.

What happened at the Pesenti Fenaroli Hospital in Alzano shows the extent of the unpreparedness of the healthcare system in the face of the virus. On February 23, 2020, after the first two swabs that came back positive among patients, the hospital was closed. But the virus had already spread through the facility, as the expert report reconstructs: “As of February 23, 2020, 41 COVID patients were already hospitalized.” Thirty of them would not survive. In addition, as of February 23, at least 55 healthcare workers at the hospital were already infected.

The court-appointed expert found many different instances of negligence: wards not reorganized, a lack of swabs, poor staff training on the use of masks, which would soon run out. To make up for these shortcomings, as the expert report highlights, employees were even allowed “to use the masks from the fire kits” and “to reuse FFP2 masks.” For the poor management of the hospital outbreak, the magistrates have started criminal investigations against Bergamo East Health Authority managers Francesco Locati and Roberto Cosentina, former hospital health director Giuseppe Marzulli and Bergamo Health Protection Agency director Massimo Giupponi.

What happened at the Alzano hospital was one of the consequences of the failure to implement an anti-pandemic plan, the expert report claims. The fact is that at that point, the Technical Healthcare Committee (CTS), the government and the regional administration had no less than two plans available. The first was the 2006 one against an influenza pandemic, in force but never updated. The second was the one drawn up at the request of the CTS by the experts of the Bruno Kessler Foundation: this would have triggered the red zone as early as March 3, as the CTS asked the government to do at the time; however, the government delayed the decision.

“Prime Minister Conte,” Dr. Crisanti wrote, “stressed that the red zone should be used sparingly because it has a very high social, political and economic cost” and “decided to think about it.” The lockdown was only triggered on March 8, for the whole country.

The anti-COVID plan was kept a secret so as not to spread fear among the public. As a result, it couldn’t be communicated to the local governments that were supposed to implement it. With one plan outdated and another confidential, the expert report concludes that “the response to the pandemic was left to the assessments of the CTS, which improvised in the moment based on the contributions and experience of its members.” This explains the passing back-and-forth of responsibility for the Alzano and Nembro red zone, which persuaded the prosecutors to add so many people to the register of suspects: CTS technical experts, Health Ministry and Civil Protection officials, Minister Speranza and Prime Minister Conte, Lombardy President Attilio Fontana, his Health Councillor Giulio Gallera and the General Director of the regional healthcare authority Luigi Cajazzo.

If the suspects are sent to trial, their defense will undoubtedly bank on the lack of information that was available around an unknown virus. It’s a serious argument, and many “judicial experts” already predict that the cases will be easily dismissed. However, the fatalist view that it will all end in “all guilty, nobody found guilty” is unjustifiably being extended to other faults that have no connection to the mitigating circumstances of the emergency.

The 2006 anti-pandemic plan, which was in effect although not updated, is not only a manual for responding to a pandemic: it also explains how to strengthen defenses before the virus arrives. In “Phase 1,” when there is no potential threat, the plan requires the government and regions to establish “a national stockpile of personal protective equipment, (…) diagnostic kits and other technical support,” define “local/regional procurement arrangements in the immediate aftermath,” initiate “intensive training of health workers on the pandemic” with “regular exercises on the Plan, including the chain of command and control.”

This work needed to be done in quieter times, not in January-February 2020, when the whole world was competing for masks and equipment. The consequences of these failures are shown in vivid detail in the Alzano hospital disaster, but they also hampered emergency management across the region. This is why regional officials, responsible on a par with the government for implementing the anti-pandemic plan, have also been put under investigation.

The Lega-led junta in charge of the region had been moving in the opposite direction in previous years. In 2019, as an investigation by the weekly magazine l’Espresso revealed, it had even rewarded with an incentive the general managers of the region’s health care companies who had been able to “avoid cost increases due to rising departmental inventories” of diagnostic kits: in effect, rewarded for thinning out the inventories. The disaster in Lombardy had already begun.

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