How Italy spiraled from a perfectly healthy country to near collapse in 24 days as the coronavirus took hold
Wracked by the coronavirus pandemic, Italy's healthcare system is crumbling. The country's aging population, coupled with a lack of adequate medical resources, is overwhelming doctors and forcing them to make impossible decisions about which patients to save. The entire country is on lockdown, and more than 1,000 people have died. Here's how the situation got so dire so quickly. Visit Business Insider's homepage for more stories.
This week, doctors in Italy have been forced to make choices that no one, least of all people who have taken an oath to protect lives, should face: Who lives and who dies? As the country's coronavirus caseload has skyrocketed — more than 15,000 people have been infected and at least 1,000 have died — healthcare workers on the front lines are confronting a worst-case confluence of a contagious new virus, an aging population, and shortage of hospital beds. Doctors are now prioritizing young and mostly healthy COVID-19 patients because their chances of survival eclipse those of the elderly. "We do not have free beds in intensive care units," Lorenzo Casani, the health director of a clinic for elderly people in Lombardy, told Time. Doctors, he added, must "make this horrible choice and decide who is going to survive and who is not going to survive … who is going to get a monitor, a respirator, and the attention they need." The tragic triage is reminiscent of the choices made on a battlefield, and indeed, Italy is now at war. The country reported its first coronavirus case less than four weeks ago, on February 20. Now the scale of the country's outbreak is second only to China's. In response, Italian officials seem to have tried everything: They shut down schools, ordered shops to close, emptied the country's wildly popular tourist destinations, quarantined dozens of cities, and then expanded that "red zone" to lock down the entire country of 60 million people. "We all must give something up for the good of Italy. There is no more time," Prime Minister Giuseppe Conte said in a televised address. 'From one day to another, it was empty' Isabella Castoldi, a 25-year-old resident of Florence, told Business Insider that when news of the coronavirus emerged in Italy, few people she knew took the threat very seriously. "We underestimated the coronavirus," Castoldi said.
Because the illness originated in China, she added, it seemed "very, very far away." Castoldi even went to Milan to get a tattoo on February 28. The coronavirus had breached northern Italy by that point — hundreds were sick. After returning from her trip, she went to work at a popular ice cream store steps from the city center. "We usually have a very, very long queue that extends outside the door," Castoldi said. "Then, from one day to another, it was empty." As she and a co-worker counted the shop's daily earnings, she said, realized they'd made "thousands of euros" less than normal. "That's when we started to realize that maybe this is more serious than we thought," Castoldi said. A series of lockdowns On February 23, the Italian government put almost a dozen towns — those in which the most coronavirus cases were reported — on lockdown. About 50,000 people were affected. Major landmarks were closed, the annual Venice Carnival was canceled, Giorgio Armani held its runway show at Milan Fashion Week in an empty theater. By February 26, less than a week after the first reported case, 12 people had died. Castoldi said she began to notice "overflowing" supermarkets as people panic-bought toilet paper, meat, and pasta. A week-and-a-half later, on March 8, Conte cordoned off an area of the country containing 16 million people. The quarantine came as Italy's coronavirus case total approached 6,000; its death toll had surpassed 230. But news of the impending closure leaked ahead of time, prompting thousands of people to flee parts of northern Italy the day before it went into effect. Roberto Burioni, a professor of virology at Milan's Vita-Salute San Raffaele University, told The Guardian that the leak triggered unnecessary travel as people rushed south. "Unfortunately some of those who fled will be infected with the disease," he said. Because Castoldi had been in Milan, which was part of the closed-off region, she reached out to her doctor and was instructed to self-quarantine. She shut herself in her bedroom, venturing out for just a few minutes each day with a mask on, since she lives with her father and brother. Her cat, Bilbo, hung by her side. On Monday, Conte announced an unprecedented nationwide lockdown. "All the measure of the red zones are now extended to all of the national territory," Conte said at a press conference. He announced a "stay at home" policy, a 6 p.m. curfew, and a ban on public gatherings. By that point, over 9,000 people had contracted the coronavirus and over 460 were dead. 'We do not have enough doctors' On Tuesday, the first day of Italy's nationwide lockdown, Italy recorded its highest leap in fatalities in a single day: 168 new coronavirus deaths were reported. Conte announced that most shops, save for pharmacies and grocery stores, would close. As of Friday, the country's coronavirus death toll — a basic calculation that divides the number of deaths by the total number of cases — was at about 7%. It's a grim reflection of Italy's struggles, given that the global death rate has been hovering around 3.4% for weeks. "We were not prepared. We do not have enough doctors for the people. We do not have an organized plan for pandemics," Casani told Time.
Italy's investments in its national health service, Servizio Sanitario Nazionale, amount to 6.8% of its gross domestic product, according to Time. "The continuous cuts — to care and to research — are obviously a problem right now," Casani told the magazine. Another reason Italy's healthcare system appears to be so overwhelmed is that the country's population, on average, is the second-oldest in the world, after only Japan. The coronavirus is far more deadly to older people — a study from the Chinese CDC found that the death rate among those above 80 years old was nearly 15%. Italy's National Institute of Health has estimated that 58% of patients who have died so far were over 80 and another 31% were in their 70s, according to Reuters. 'An age limit for access to intensive care' Given the lack of resources and strains on Italy's hospitals, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care has given nurses and doctors "catastrophe medicine" guidelines to follow as they navigate the deteriorating situation. "It may become necessary to establish an age limit for access to intensive care," the document says, according to a translation in the Atlantic. It adds: "What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients." In other words, older people are now a lower priority for treatment in Italy, since their chances of survival are slimmer. The guidelines also suggest doctors and nurses de-prioritize patients with underlying health conditions, since the coronavirus is more fatal for those groups, too. "We decide based on age, and on health conditions," anesthesiologist Christian Salaroli told Italian daily Corriere della Sera on Monday, "just like all war situations."
'The war has literally exploded' Dr. Daniele Macchini, who works at the Humanitas Gavazzeni Hospital in Bergamo, penned an anguished Facebook post earlier this week, calling the coronavirus a "tsunami that has swept us all." His thoughts, shared in Italian, were translated by Dr. Silvia Stringhini, an epidemiologist at Geneva University, the New York Post reported. "The war has literally exploded and battles are uninterrupted, day and night," Macchini wrote.
Doctors are no longer known for their specialties as "surgeons, urologists, orthopedists," he added. They are all trying to treat the same illness, and the testing swabs just keep coming back "positive, positive, positive." Macchini said he has seen medical staff with "tears in their eyes because we can't save everyone." "We no longer see our families for fear of infecting them. Some of us have already become infected despite the protocols," he wrote. On Tuesday, Italy's medical community took another blow: Roberto Stella, the 67-year-old president of the Medical Guild of Varese, died in Como from respiratory failure caused by COVID-19, CNN reported. "His death represents the outcry of all colleagues who still today are not equipped with the proper individual protection needed," Italy's National Federation of Doctors and General Practitioners said in a statement. Roberta Re, a nurse at Piacenza hospital in Emilia-Romagna, told the Guardian that she also lost a colleague: a 59-year-old doctor who she considered a good friend. "It's an experience I would compare to a world war," Re said. "But it's a war that isn't fightable with traditional arms — as we don't yet know who the enemy is and so it's difficult to fight. The only weapon we do have to avoid things getting even worse is to stay at home and to respect the rules, to do what they did in China." In Venice, that's what Castoldi is now trying to do. Her self-quarantine has ended, so she can now roam the house and spend time with her family inside. She remains symptom-free. From her room, Castoldi has posted several warnings on social media, discouraging influencers and others around the world from spreading coronavirus jokes and memes. "Unless an outbreak like this affects us directly, it's easy to believe it never will," she said.
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Italy sees a glimmer of hope in its high rate of coronavirus infections — more people whose antibodies can potentially be used to treat those still hospitalized
Italy's high infection rate may mean they have more people able to donate plasma to help...Italy's high infection rate may mean they have more people able to donate plasma to help treat people severely suffering from COVID-19, according to CNN. Several studies have shown that antibodies in plasma from recovered patients or people who were infected with the virus could be successful at treating severe coronavirus patients. However, an effective antibody test has yet to be developed. Visit Business Insider's homepage for more stories. Italy is looking for a silver lining, after being the epicenter of the coronavirus outbreak in Europe with over 165,000 infections. According to CNN, the country that now has the highest death toll is hoping to use antibodies from those who recovered from COVID-19 to treat those still battling the virus. A doctor told CNN that the high number of infections means there are more people who can donate plasma. "Good can come out of this. We had such a huge outbreak, [that] now we have many potential donors," Fausto Baldanti told CNN. Business Insider previously reported that donor blood plasma from a recovered patient was being tested as a possible coronavirus treatment. The antibodies in the plasma could help fight against the virus in a patient's body. According to CNN, the use of plasma or even whole blood from recovered patients has been used to treated patients with other illnesses. According to Business Insider, two recent studies of plasma from people who recovered from COVID-19 used to treat those still severely ill with the virus have been promising. Baldanti is a virologist at the University of Pavia San Matteo Hospital, in the Lombardy region of Italy. Lombardy was the epicenter of Italy's outbreak and accounts for the most infections and deaths. At one point the region pulled doctors out of retirement and asked to have nurses close to finishing their degrees graduate early to help with the influx of cases. Baldanti told CNN he hopes "this plasma treatment can be crucial for controlling the infection in patients admitted to intensive care units," but the treatment is only in an experimental phase in the country. How helpful largely depends on developers creating a reliable and proven way to test for coronavirus antibodies, according to CNN. According to Business Insider, several companies including Abbott have launched new antibody tests that they aim to make available in the near future. CNN reported that the Food and Drug Administration recently tightened restrictions on antibody tests in the US after previous relaxed rules caused low-quality tests. In Italy, Giancarlo Maria Liumbruno, the director-general of the Italian National Blood Center is looking to have an antibody test available in weeks. "We should have a serological exam (blood test) that is approved to test if someone has antibodies by the end of April. We will start selecting the first donors by the end of the month," Liumbruno told CNN. However, trials of this process have already started in some hospitals in northern Italy. Plasma from patients who recovered and tested negative for at least two weeks is used on those still battling COVID-19. Italy has more than 1.7 million blood donors that the country could screen to see if they've had COVID-19 and now have antibodies that could fight the virus, Liumbruno told CNN. Their goal is to have repeat volunteers with antibodies donate plasma that could be used. Scientists would screen to see who is best to have their plasma used. Join the conversation about this story » NOW WATCH: How the Navy's largest hospital ship can help with the coronavirus
Italy, Spain, and France reported declines in daily coronavirus death tolls. Their governments don't plan to lift national lockdowns and social distancing rules anytime soon.
Italy, Spain, and France each reported slight declines in daily coronavirus death tolls on Sunday. The...Italy, Spain, and France each reported slight declines in daily coronavirus death tolls on Sunday. The three countries responded to the coronavirus with strict national lockdowns in early to mid-March, and they have no imminent plans to loosen those restrictions. During an appearance on NBC's "Meet the Press," Italian Prime Minister Giuseppe Conte reminded his country that social distancing "is the only way to defeat the pandemic altogether" and pleaded, "Stay home as much possible. Do not go out." Visit Business Insider's homepage for more stories. After weeks of bleak headlines, a handful of European nations — Italy, Spain, and France — on Sunday reported a drop in coronavirus death tolls. Italy has the highest death toll of any country impacted by the coronavirus. At least 15,889 people are dead as of Sunday, up from 15,364 on Saturday — an increase of 525 deaths, which is the country's smallest increase in daily deaths since March 19. Sunday also marks the third day of declines in Italy's fatalities, following 766 deaths on Friday and 681 on Saturday, according to statistics website Worldometer. The number of new cases also fell from 4,805 on Saturday to 4,316 on Sunday, bumping up the total caseload to 128,948. "We are suffering very much. It's a devastating pain," Italy's Prime Minister Giuseppe Conte said on NBC's "Meet the Press" on Sunday. Conte put the country of 60 million residents on lockdown on March 10, and then proceeded to restrict movement even internally. People have been ordered to stay home, but those who emerge for work or essential business, including going to grocery stores or pharmacies, have to cover their noses and mouths. Since the lockdown was imposed, Italian police officers have fined more than 175,000 people for violating the rules, the Hill reported. "Our response has not been perfect, maybe, but we have been acting [to] the best of our knowledge," Conte said to NBCs Chuck Todd. "Today, I see that our model is implemented by other countries and its validity has been acknowledged by the [World Health Organization], and the results so far indicate that we are on the right path." When the unprecedented step was first announced, Conte planned to keep the strict restrictions in place until April 3. He has since said that they will be in effect till at least April 13. However, he told NBC on Sunday that he cannot yet say for certain when the containment measures will be lifted. Medical experts across the globe have said that social distancing is the only way to reduce the rapid rate at which COVID-19 spreads. The goal, they say, is to "flatten the curve" of the infection so that local healthcare systems aren't overrun by patients. The United States, however, has adopted a more piecemeal version that relies on states' authorities making these tough decisions. As of Sunday, more than 1.26 million people have tested positive for the coronavirus and over 69,000 are dead. Of those cases, 331,200 are located in the US, where almost 9,500 people are dead, based on data compiled by Johns Hopkins University. 'Stay home as much possible' Meanwhile, Spain, the second-worst-hit country with a caseload of 130,759 and 12,418 deaths, also saw a drop in daily coronavirus deaths for the fourth consecutive day. This means 674 people died on Sunday, compared to 749 on Saturday, 850 on Friday, and 961 on Thursday, Worldometer shows. Spanish Prime Minister Pedro Sanchez introduced a two-week lockdown on March 14, which was first extended to April 11 and then April 25 as the country struggled to cope with an escalation in COVID-19 cases, Bloomberg said. Similar data came out of France as well. At least 90,864 French residents have tested positive for the coronavirus and 7,575 are dead. The nation's death toll went up by 518 on Sunday, but that jump is a sharp drop from previous days. Based on Worldometer, France confirmed 1,355 deaths on Thursday, 1,120 on Friday, and 1,053 on Saturday. As is the case in other parts of Europe, France went on lockdown on March 17. Although initially mandated for 15 days, the stay-at-home order will remain in place through April 15. Prime Minister Édouard Philippe said that a second extension is likely, France 24 reported. Moreover, he said, "it is likely that we are not going to see an end to confinement that would happen in one move everywhere and for everyone." Conte, acknowledging that he is asking the Italian public for a "great sacrifice," reminded them that "it's the only way to defeat the pandemic altogether." "Stay home as much possible. Do not go out," he said.Join the conversation about this story » NOW WATCH: Why bidets are better than buying countless rolls of toilet paper