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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 of 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.” These are the words of the mayor of Bergamo, Mr. Giorgio Gori, who in an interview recently given to the Italian Messaggero, described the toughest battle in recent decades that his city—among the worst-affected in Italy—and the entire Lombard region have been fighting. In fact, in the long list of tragic paradoxes this coronavirus is revealing in the eyes of Italians there is also the fact that Lombardy, deemed to be the “locomotive of Italy” and the peak of excellence of the national healthcare system, by a strange stroke of luck is bearing the brunt of the highest number of infections and fatalities. And while for weeks almost no one has dared to acknowledge it, lately some are starting to say out loud that, perhaps, something has not worked as expected in the highly efficient region that stretches 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, certified the leaks of regional management: within 48 hours, 1800 undetected patients were discovered in the province of Milan alone. These untested patients presented Covid-19 symptoms, and, forced into home isolation, have probably ended up infecting their cohabitants. In short, the number of positives in the region is likely to be highly underestimated, which may also explain the shockingly high lethality recorded in Lombardy.

 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 report of one certified patient for every ten undetected patients is credible.” Lombardy, however, appears to significantly weigh on that figure. As the mayor of Bergamo pointed out, “Too many people get to the hospital too late and in poor conditions, they must be intubated in intensive care. 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.” In this regard, some experts are suggesting that to alleviate the many healthcare facilities overloaded, it would be necessary to immediately start treating mildly symptomatic patients with the drugs that are proving to be more effective. According to Francesco Le Foche, head of Immunoinfectivology at  Policlinico Umberto I La Sapienza University of Rome, “We are wasting precious time, in the first week we have unresponsive artillery. 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 given to La Repubblica, he identified two main weaknesses within the regional management of the crisis. The first one is “not having placed a ‘red zone’ around Bergamo, as Giorgio Gori also asked;” the second one is that Lombardy “has focused on large hospital structures while penalizing the local social and healthcare network. There are virtually no more family clinics, the general practitioners have been abandoned with too many patients and have become producers of prescriptions. This did not happen in Emilia-Romagna or in Veneto.” It is no coincidence that, over the last few days, the Region has changed its strategy. Lombardy has started asking general practitioners to map the epidemic by making daily calls to patients and providing oximeters, in order to understand in real-time the amount of oxygen present in the blood of those at home.

Too Limited Test Capacity?

 Another matter of debate is the regional testing policy. Lombardy is reportedly testing fewer people—only those with severe symptoms—than regions like Veneto and Emilia-Romagna. According to some experts, widespread testing is essential to control the epidemic and dictate the adequate measures to curb it. However, that argument is more controversial than it seems. According to another school of thought, as the test can only provide a representation of a single moment, a person tested negative could become positive within 12 hours. In other words, widespread testing would only work provided that the test 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 epidemic. 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, 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 carriers.

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

 “We are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients,” thirteen doctors from Bergamo’s Papa Giovanni Hospital wrote in an article published in The New England Journal of Medicine. “Patients are transported by our regional system, which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line,” they pointed out. According to them, “This disaster could be averted only by massive deployment of outreach services.” In their view, “Pandemic solutions are required for the entire population, not only for hospitals. 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.” In other words, it is essential to set “a broad surveillance system with adequate isolation” and leverage “innovative tele-medicine instruments”. This approach “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.”

 Rough Questions on Lombardy Private Healthcare

 Another issue that has started coming up over the last few days is the impact that may have had the undeniable imbalance in favor of private providers within the regional healthcare system. 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 decades, even Italy has been witnessing increasingly large privatization of healthcare, while allocating fewer funds to strengthen the public system. Lombardy could represent a clear example of this trend, as shown by a series of in-depth analysis carried out by Maria Elisa Sartor and published on Salute Internazionale. From the mid-1990’s to 2018, public hospital beds were more than halved and, over the same period, private hospital beds increased considerably. In 2017, private healthcare providers—profit and non-profit—were given 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 number of public structures and the number of private ones is exactly 50% shared. But in some provinces, private providers’ overtaking has largely occurred: as in the metropolitan city of Milan (54.4%), in Como (66.7%), Bergamo (60.9%) and Mantua (60%).

On March 4, a regional resolution enabled, for at least the next 60 days, the use of health personnel from private structures and the provision of private hospital beds. The subsequent government decree did substantially the same for the whole national territory, 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 steps were taken too late and may not be enough. Among those, there is a doctor from a “large public hospital in Milan” who spoke, on condition of anonymity, 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. The private providers in a healthcare system like ours that can be said to be universalistic cannot play the role they are playing as they are playing it. It must be within the rules. […] In those structures, it is difficult to know what is being done. Especially during an emergency like this one.” In an article published a few days earlier, Lucarelli had posed other legitimate questions on this matter: “When outbreaks occurred in private clinics that were not yet converted to treat Covid patients, how many private clinics promptly reported the situation to the local health authorities?” And again, “How many took the risk of being closed instantly and losing revenues?”

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