It’s not the 12 or 14 hours a day working in the hospital that bothers Pierluigi Viale. What hurts Prof Viale most is not being able to give his best to everyone.
The director of infectious diseases at Sant’Orsola-Malpighi Polyclinic in Bologna says: “In the 40 years that I have done this job, I have never experienced the drama of saying ‘him yes’ or ‘him no’. Our standard practice is to intubate [for oxygen] all those who need it. Now we risk having to choose who has the most chance of surviving.”
It pains Viale to think back to a few days ago, when they decided not to bring an 85-year-old patient suffering from Covid-19 and other pathologies to the intensive care unit (ICU). “He probably wouldn’t have lived, but we couldn’t even try because there are no beds, and we have to ration our resources. It kills me.”
A few hours later, the man died.
There is an ambitious project to make 500 new spots in intensive care which, however, can only be done if the civil protection manages to get 500 respirators
All of the people interviewed for this article use the word “war” at least once.
The medical emergency – now a global pandemic – started on February 21st, in Codogno, a town in the province of Lodi, near Milan, where a 38-year-old was hospitalised with serious interstitial pneumonia; this was Italy’s first known case of coronavirus. There were 17 cases that day; a week later the country could count 252. Now, the number exceeds 12,000, and it is still not clear when the cases will peak.
Marisa Marzella, a general practitioner in the province of Milan, has seen elements of her work increase fivefold. “More than 100 people call me a day, before the coronavirus I received about 20 calls.”
Marzella is the first link in the chain, available 24/7, an important part of the system to reassure people and direct them to proper care. Her job is to prevent those who don’t really need care ending up in the hospital. “I have several patients who have the coronavirus, two are hospitalised.”
In this state of emergency there is a severe shortage of equipment, including masks, gowns and – above all – respirators: "The number of masks available is not sufficient," says Giulio Gallera, health and welfare regional minister in Lombardy. "There is an ambitious project to make 500 new spots in intensive care which, however, can only be done if the civil protection manages to get 500 respirators."
The more the numbers rise, the more people die, and the more doors close. On Wednesday, March 11th, Italy's prime minister Giuseppe Conte tightened measures that were already restrictive: in addition to closing schools, cinemas, museums and churches, cancelling football matches and other events, encouraging remote working and staying home, now all shops, bars and restaurants were also to close.
Only supermarkets, pharmacies, news stands and some other businesses can operate – and these under precise rules. “If we all respect [these measures], we will get out of this emergency faster,” said Conte. “The country needs the responsibility and sacrifice of 60 million Italians. We must stay apart today, to have warmer hugs and run faster together tomorrow.”
We have converted entire wards to accommodate infected patients. Nearly all of the specialist doctors have been reassigned to manage the emergency
In February, when Italians saw videos of deserted Chinese cities whose shops and schools had closed, they viewed them as they might an exotic film – a distant story that did not concern them. People continued to go to work, to travel, to have their aperitivos.
They washed their hands a few more times, but little more. Over a month and a half, they learned the hard way that this virus moves relentlessly, and that closing everything is the only medicine against its unstoppable propagation.
“Stay home. We are close to collapse, our health system is in danger of exploding,” a cardiologist working in a hospital in Milan tells The Irish Times. The doctor, who has just finished a 12-hour shift, asks to remain anonymous because they have not been authorised to speak to the press. “It’s a war . . . The hospital I work for, now is mostly dedicated to Covid-19 cases. We have converted entire wards to accommodate infected patients. Nearly all of the specialist doctors have been reassigned to manage the emergency. The emergency room is always full. There is an increasing need for beds.”
Contrary to popular belief, the disease is not only an older person’s illness, says Viale. “There is certainly a higher incidence among older people, but the young population is not immune. Even in our intensive care there are some,” says Viale. The numbers speak for themselves: 5.6 per cent of patients with Covid-19 are aged between 30 and 39; 10.7 per cent are 40-49; 17.4 per cent are 50-59; 17.7 per cent are 60-69; 21.4 are 70-79; and 18.4 per cent are aged over 80.
And Viale points out also that tumours, heart attacks, strokes, accidents, and broken legs do not go on vacation for the coronavirus. “With hospitals so troubled, it becomes difficult for us to take care of everything else.”
According to a report by the ministry of health, in 2017, in Italian public hospitals, there were 151,646 beds dedicated to ordinary hospitalisation, and 40,458 in private hospitals. There were approximately 5,100 ICU places.
To cope with the Covid-19 emergency, the government is preparing a plan to increase the number of ICU beds by 50 per cent. Some 10 per cent of those who fall ill need respiratory support and a complex treatment.
In Lombardy, the most affected region, there are 724 beds with breathing machinery. There are currently 440 patients in ICU and the number is increasing every day. The region has also increased the number of beds for those patients who do not yet need assisted respiration and do not yet require a tube to take oxygen to their lungs.
The government has also approved the extraordinary recruitment of 20,000 healthcare professionals.
DONATIONS, REORGANISATION OF HOSPITALS and the fast-tracking of graduation for medical and nursing students are measures that have helped keep northern Italy going, but the situation remains critical.
Lombardy, Emilia Romagna and Veneto have been hit hardest by the virus, but they are also the wealthiest regions with the best healthcare systems. "If Covid-19 were to spread the same way to the south, it would be a disaster," says anaesthesiologist Giuseppe Sofi.
The management of Italian healthcare is in the hands of each of the regions. “Due to bad investments and errors protracted over time, those of the south would not be able to withstand the impact of the virus . . . [But] by containing the south too, perhaps we can escape tragedy.”
OTHER REGIONS AND OTHER COUNTRIES, including Ireland, can learn lessons from northern Italy.
Viale describes the situation of those who have been hospitalised in northern Italy: “They are afraid, they feel very bad. They feel they are suffocating. Suffocation is one of the worst deaths. We do everything to help these people heal, but we don’t have many weapons yet: only closed doors and intensive care. If we want everyone to have the opportunity to be treated better, if we want to avoid having to choose who to save, everyone must respect the rules.”
The cardiologist who speaks to The Irish Times is also angry with people who do not respect the rules – and with those who introduced those rules too late. “If people took too long to understand that we were not kidding, it is the politicians’ fault. They downplayed the situation 10 days ago. ‘It’s a bad flu, nothing more,’ they said. I would have liked to invite them to the hospital wards, to look into the eyes of the frightened people who cannot breathe.”
Roberto Burioni, professor of microbiology and virology at the Vita-Salute San Raffaele University, says that other countries are “10 to 15 days behind us”. “The virus will behave for them as it is behaving here. If they apply our same measures, they would be able to contain the spread and avoid the disaster that we are experiencing.”
France – which has just announced the closure of schools – is roughly at the point Italy was at 10 days ago. Germany, the United Kingdom and the United States are slightly behind. Spain is a little ahead in diffusion.
“They look like us two weeks ago,” adds Viale, “the doctors know the right thing to do, we are in contact with many international colleagues. The problem is politics and economy. It is not easy to convince a nation to sacrifice. I am sure that in a few days they too will start moving, they have no choice. Sooner is better than later”.
MANY ITALIANS WONDER ALOUD how it is possible that in just three weeks everything changed so radically: with now more than 1,000 deaths. The country has lived in peace since the end of the second World War. Now it is afraid, its people closed in their homes watching motionless cities from their windows.
Emanuela Celant is one of a number of people now emerging from quarantine (they include the 38-year-old “Patient One” in Codogno). A Facebook post by Celant recounting her experience has “gone viral” in recent days. “My name is Emanuela, I am 42 years old, I am getting out of preventive quarantine now, I was closed up for 15 days at home with my seven-year-old son and my 76-year-old mother.
“My husband is in intensive care, intubated since February 24 due to coronavirus, my father is in intensive care, intubated because of coronavirus. I have a duty to make you understand that it is not a joke: the virus can affect anyone.”
But if there is one thing this dangerous, aggressive virus has done, it has united Italy a little more. The heroic actions of the health personnel, the generosity of the young people who shop for the elderly and the many donations to hospitals, are stories we will remember.
It’s not just doctors who deserve our thanks, but all medical workers – and often their families too. “I usually work in the emergency room, I take care of swabs. I took a lot of them,” says a young nurse working in Milan.
“I am protected by a suit, gloves, mask and glasses. I don’t know if the person I am dealing with is positive or not. I do my job with the utmost care and I hope not to get sick.” She is afraid. Many doctors and nurses get sick. On March 10th, Roberto Stella, president of Medical Guild of Varese, died in the city of Como from respiratory failure linked to coronavirus.
“My parents are over 60,” says the nurse. “I haven’t seen them in three weeks because I don’t want to risk getting them sick. But I chose this job because it is my passion, and we will overcome this too.”
“I’ll never forget the call of a woman who, a few days ago, was crying on the phone because her father had just died in our ward,” Viale says, “she was devastated because he had died alone in an aseptic room, with no one nearby because they were all in quarantine. I had meetings and many things to do, but listening to her seemed like the most important thing I could do”.
And amid the warlike conditions, GP Marisa Marzella remains optimistic. “I’m positive if we stick together, we’ll get out of it.”