Nino Cartabellotta is the president of the GIMBE Foundation (“Italian Group for Evidence-Based Medicine”). GIMBE has been studying and defending the Italian universal healthcare system for years, without hiding its inefficiencies. They annually produce a “Report on the sustainability of the National Health System,” full of data and analysis.
The management of the epidemic has not escaped their scrutiny. The government is flaunting the “Italy model,” which they say is being imitated all around the world, but Cartabellotta’s judgment is more nuanced: “Obviously, the ‘Italy model’ has both bright spots and darker ones, from which everyone should learn.”
What errors have been committed?
The overall error was made in the first weeks: wait-and-see policies and measures that were following the numbers known on that day, without taking into account that these were the result of actions, interventions and behaviors implemented, or not implemented, two to three weeks before. During this initial phase, both concerns about the country’s economy and frictions between the government and the regions were harmful factors. In other words, there was a lack of courage and determination to close down everything, immediately. The particular error we have paid most dearly for is the fact that there was no red zone in Alzano Lombardo and Nembro.
On what evidence should we measure the successes and failures of the Italian approach?
The success of the social distancing measures is clear for all to see: the percentage of growth of daily cases fell from 14.9% on March 19 to 4.1% on March 30. In the last few days, it has stabilized with modest daily variations, documenting a “plateau” phase rather than a real “peak.” Unfortunately, the worst indicator of failure are the deaths: on April 4, the official death count was 15,362, a number that is probably lower than reality, as well as influenced by the enormous overload of hospitals and intensive care units in Lombardy, where the raw case fatality rate is double (17.6%) compared to that of other regions (8.9%).
Where was the greatest failure of the emergency leadership?
The most outrageous failure has been, and continues to be, the inability to adequately protect professionals and health care workers: as of April 3, 12,052 of them were officially infected, which is a gross underestimation of reality. This inability has also been tied to the delays in the procurement of personal protective equipment, a process that was not started in time, failing to make use of the time advantage we had over other countries. More generally, the much-touted “single chain of command” has been missing: the regions have gone—and are increasingly going—their separate ways on aspects related to the organization of assistance. From the number of swabs carried out to the use of non-validated serological tests; from the “wild” experimentation with drugs to the methods of communication of the numbers of the recovered to the Civil Protection authority. It has been a condition of ‘emergency federalism’ which, when the dust settles, will have to be the object for profound political reflection.
The “Korea model” or the “Germany model”: which one should we have drawn inspiration from?
The manner of spread of the coronavirus has been different among the various countries of the world, as well as among the various Italian regions. There isn’t one model that is valid for everyone: the Korean model, for example, would have been impossible to apply in Lombardy, with the numerous hospital outbreaks. Each country should implement, on the basis of scientific evidence, their own “package” of preventive, diagnostic and care interventions, also in relation to the political, healthcare and social response it is able to put in place. The tools are the same for everyone (case tracing, quarantine, social distancing, etc.), but they must be timely, uniform and with high population buy-in.
What lessons should we draw from this for the future of healthcare?
First of all, Italian politics will finally have to decide whether to re-launch the National Health Service: the massive defunding of public health in the last 10 years and all the tools of stealth privatization (supplementary health funds, company welfare, opportunistic accreditation of private facilities, etc.) have left very deep scars. Secondly, it must be noted that the “loyal collaboration” between the government and the regions is not working at all, and cannot be the model to follow for our Republic, which is responsible for the protection of our health. Finally, we should remember to always maintain an up-to-date national pandemic plan: the one drawn up in 2003 on the occasion of the avian influenza outbreak would have given us a big helping hand in the management of COVID-19. Unfortunately, however, no one even remembered it existed.
