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Coronavirus Puts Into Question Lombardy’s Long Recognized Healthcare Efficiency

Over the last few days, the crisis has triggered a debate on the weaknesses of a system that has long been praised as one of the best in Italy.

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Italians are legitimately proud of their national public healthcare, which in 2000 was regarded, by the World Health Organization’s ranking, as the second-best in the world after France. However, over the last few days, the Coronavirus emergency has triggered a debate on the weaknesses of Lombardy's system, traditionally described as a peak of excellence in the national healthcare system, and on the Region's management of the crisis.

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“The main weaknesses concern the territorial public health services, which in Lombardy, despite the efforts we are all making, are not as solid as those of other Northern regions, such as Veneto and Emilia-Romagna. Unfortunately, we now have proof of that. The network of general practitioners, which is the first key bulwark against contagion, has been wiped out by the disease, 140 out of 800 doctors here.” This is how Bergamo mayor Giorgio Gori, in a recent interview with the Italian newspaper Il Messaggero, described the toughest challenge in decades that his city (among the worst-affected in Italy by COVID-19) and the whole Lombardy region have recently faced. 

Among the several paradoxes laid bare by the pandemic, what is happening in Lombardy is worth mentioning. The Region, deemed to be the financial “locomotive” of the country and the peak of excellence in the national healthcare system, by a strange stroke of luck is bearing the brunt of the highest number of COVID-19 infections and fatalities. And while for weeks almost no one has dared to acknowledge it, some are now starting to say it out loud: something must have not worked as expected in the highly efficient Region stretching under the shadow of the iconic “Madonnina.”

 In Lombardy and Beyond, Thousands of Undetected Patients

One figure in particular, which emerged in the last few hours, exposed the alleged flaws in Lombardy’s management of the crisis: within 48 hours, 1,800 undetected patients have been discovered in the province of Milan alone. These untested patients showed COVID-19 symptoms, and, forced into home isolation, have probably ended up infecting their cohabitants. In short, the number of infected persons in Lombardy is likely to be highly underestimated — which may also explain the shockingly high lethality recorded in the area.

However, this is not an exclusively Lombard problem. A few days ago, the head of the Italian Civil Protection, Mr. Angelo Borrelli, suggested that, throughout Italy, “the estimate of one certified patient for every ten undetected patients is credible.” Lombardy, however, appears to significantly weigh on that figure.  “Too many people get to the hospital too late and in poor conditions, so that they must be intubated in intensive care,” Mr. Gori said. “Many just can’t get there and die at home, they are almost all elderly with pneumonia, undetected COVID-19 cases. It is difficult to provide assistance with oxygen, to detect these people in time and there is no room for everyone in the hospitals. We would need a stronger territorial network, now there is a race to strengthen it,” he explained.

Some experts are suggesting that to alleviate the many healthcare facilities that are overloaded with patients, doctors should start treating even mildly symptomatic people with the drugs that are proving to be most effective. “We are wasting precious time, we have unresponsive artillery in the first week of contagion,” Francesco Le Foche, the head of Immunoinfectivology at Policlinico Umberto I – Sapienza University of Rome, said in a recent interview. “For those patients, nothing is done in Italy today, they are often not pinpointed and those detected are simply placed in trustee home isolation.”

The mayor of Milan, Mr. Giuseppe Sala, has shared similar concerns. In an interview with La Repubblica, he identified two main weaknesses in the regional management of the crisis. The first one has to do with local authorities’ lack of promptness, as in the very early days of the pandemic they failed to establish a ‘red zone’ around Bergamo to limit the spread of the virus. The second one relates to how the local healthcare system works: Lombardy, Sala said, “has long focused on large hospital structures while penalizing the locally widespread social and healthcare networks. There are virtually no more family clinics, the general practitioners have been abandoned with too many patients and have become suppliers of prescriptions. This did not happen in Emilia-Romagna or Veneto.” It is no coincidence that, over the last few days, Lombardy has tried to change its approach. The Region’s government has started asking general practitioners to map the pandemic by making daily calls to patients and providing oximeters. By doing so, it might be easier to gauge in real-time the amount of oxygen present in the blood of those isolated at home.

Too Limited Testing Capacity?

Another matter of debate is the Region’s testing policy. Lombardy is reportedly testing fewer people — only those with severe symptoms — than Regions like Veneto and Emilia-Romagna. According to experts, widespread testing is essential to control the epidemic and dictate adequate measures to curb it. However, that argument is more controversial than it seems. According to a different school of thought, testing as many people as possible is no panacea, since a person who tested negative could quickly become positive within 12 hours. That is why an approach based on widespread testing would only work provided that tests could be repeated on each patient several times over a particular period of time — which is simply not a viable option.

The iconic “Madonnina” of Milan Cathedral by Antonella Martino.

Doctors Without Adequate Protections

Meanwhile, news reports are documenting more and more cases of doctors and health personnel who died in an attempt to fight the pandemic. On March 26, the National Federation of Medical Orders counted 36 cases. On March 16, the Lombardy branch of the Italian Federation of Family Physicians urged the Health Protection Agencies, the Lombardy Region, and the Ministry of Health to provide “complete kits and an adequate number of protective devices of suitable quality to contain both the risk of contracting the virus and exposing the population to involuntary contagion.” They also demanded to “ensure that all doctors, nurses and study personnel and, in the case of positivity, family members and cohabitants are adequately tested.” A few days earlier, the Federation itself had revealed how doctors in Lombardy were forced to work most of the time without adequate personal protective equipment and risked being turned into unaware COVID-19 spreaders.

Hospitals and Medical Centers Likely to Become Covid-19 Carriers. Weak Surveillance on the Territory

According to thirteen doctors working in Bergamo’s Papa Giovanni Hospital, too many mistakes have been made at virtually all stages of the pandemic response. “We are learning that hospitals might be the main COVID-19 carriers, as they are rapidly filled with infected patients, facilitating transmission to other patients,” they wrote in an article published in The New England Journal of Medicine. “Patients are transported through our regional healthcare system, which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers without surveillance; some might die, including young people, which increases the stress of those on the frontline,” they highlighted. According to them, this disaster could be averted “only by a massive deployment of outreach services.” But in their view, the entire population, not only hospitals should be provided with pandemic solutions. “Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals. Early oxygen therapy, pulse oximeters, and nutrition can be delivered to the homes of mildly ill and convalescent patients,” they said. In other words, setting “a broad surveillance system with adequate isolation” and leveraging “innovative telemedicine instruments” are key to fighting COVID-19. Such an approach, they concluded, “would limit hospitalization to a focused target of disease severity, thereby decreasing contagion, protecting patients and health care workers, and minimizing consumption of protective equipment.”

Tough Questions on Lombardy’s Private Healthcare System

But over the last few days, another question arose: how did the regional healthcare system’s undeniable imbalance in favor of private providers affect Lombardy’s handling of COVID-19?  Italians are legitimately proud of their public national healthcare system, which, in 2000,  the World Health Organization regarded as the second-best in the world after France. However, over the last few decades, the country has been witnessing increasingly large privatization of healthcare, while fewer and fewer funds have been allocated to strengthen the public system. Lombardy is a clear example of this trend, as a series of in-depth analyses carried out by researcher Maria Elisa Sartor and published on Salute Internazionale shows. From the mid-1990s to 2018, public hospital beds were more than halved and, over the same period, private hospital beds increased considerably. In 2017, private healthcare providers — both in the profit and non-profit sectors — handled 35% of hospitalization cases, which accounts for 40% of the total amount spent by the Region for those services. In the same year, private actors provided 42% of outpatient visits and exams, which amounts to 43% of the total value for this type of service. The numbers of public structures and private ones are exactly 50% shared. But in some provinces, private providers’ overtaking has largely occurred, like in the metropolitan city of Milan (54.4%), in Como (66.7%), Bergamo (60.9%), and Mantua (60%).

On March 4, a resolution enacted by the Region allowed the use of health personnel from private structures and the emergency provision of private hospital beds for at least the next 60 days. A subsequent national decree extended this rule to the whole peninsula, also providing for the possibility of expropriation of private structures in exchange for compensation “equal to 100 percent of the value.” However, some believe that those provisions came too late and may not be enough. Such is the opinion of a doctor working in a “big public hospital in Milan,” who anonymously spoke to the Italian journalist Selvaggia Lucarelli. “In Lombardy, every healthcare company is a small kingdom. And that’s another big problem in our Region. The private provider decides what he wants to do and what he does not want to do,” he explained. “Many private facilities became COVID facilities weeks after the pandemic began. It is very difficult in a vertical subsidiarity system like this to take a strong, joint and coherent action. […] In those structures, it is difficult to know what is being done. Especially during an emergency like this one,” he said.

In an article published a few days earlier, Lucarelli had posed a few other legitimate questions: “When outbreaks occurred in private clinics that were not yet converted to treat COVID patients, how many of them promptly reported the situation to the local health authorities?” And again, “How many took the risk of being closed instantly and losing revenues?” Answers will come with time — and will likely force Lombardy and the entire country to rethink their healthcare policies.

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