About the COVID learnings in Italy
(Anche in Italiano qui). What are the learnings about COVID in Italy? What went wrong? What went well? Where did we get lucky? What is currently worrying? The intent of this document is to learn from failure so that “all contributing root cause(s) are well understood, and, especially, that effective preventive actions are put in place to reduce the likelihood and impact of recurrence”. The hope is that these learnings will be useful to other countries that are starting to face the disease. We are all in this together.
The document is inspired by the blameless culture so “it must focus on identifying the contributing causes of the incident without indicting any individual or team for bad or inappropriate behaviour”. There are two main differences from typical blameless analysis as COVID is not a closed incident, but instead an outbreaking pandemic, and therefore talking about post-mortem is not appropriate in this case. This analysis is based on what has been observed during the initial month of the pandemic in Italy. New consideration may emerge in the future.
What went wrong
Confusing news messages during the initial weeks (“Covid is just a flu”). Scientists indicated the immediate danger posed by the disease since late January 2020. However, their alert went unlistened for more than one month. Several sources actively minimised the impact of COVID by saying, without any scientific evidence, that the disease was just another flu. As a consequence, Italy lost a critical time window to contain the disease.
Confusing news messages (“Covid impacts only the elderly”). During the initial month several sources claimed that this disease was impacting only the elderly. While it is true that the mortality is higher for older people, it is now dramatically evident that the virus can impact younger people. As a consequence, Italy underestimated the immediate danger for the whole population.
Confusing news messages (“Covid is dangerous only if you have other diseases”). During the initial month, several sources claimed that this disease was impacting only people with additional diseases. While it is true that the mortality is higher for people with obesity, heart problems, diabetes, and hypertension, it is also true that during the last century we came to understand how to cure these diseases, bringing Western world average life expectations to 70–85 years in the absence of COVID. As a consequence, Italy underestimated the immediate danger for the population.
Denying mentality (“This is not happening here”). Our normal social-psychological behaviours are not well adapted to the behavioural changes required. In particular, there was a tendency to think of COVID as a problem over there, and then as an isolated incident in Lombardy. There was some victimisation of Chinese people, whilst there was incredulence that one’s friends and family, or oneself could be carrying the disease.
Confusing tradeoffs between the disease’s danger and the need of preserving the economy. Different parts of the society actively pushed against the need of lockdown. Several sources pushed to keep business running to minimise the economical impact. However, it is now evident that the immediate economical loss is minimal when compared to the expected economical loss during the next months. As a consequence, Italy lost a critical time window to contain the disease. Due in part to confusing new messages (above), decision makers found themselves in a no-win situation — had stronger more decisive measures been taken sooner, and even assuming that such additional actions could have contained the outbreak, it would have seemed in retrospect that there had never really been a problem and that damage had been done to the economy for no reason.
Confusing lockdown measure during the initial weeks. During the initial 3 weeks Italy progressively increased the lockdown measures. At the beginning about 50.000 people had been impacted by the lockdown, then about 11 million, then the whole country with progressive degrees of severity. Each time the decision appeared to be based on contagion’s data observed during the previous few days. Humans are used to thinking linearly while the virus spreads with an exponential rate. As a consequence, Italy lost a critical time window to contain the disease.
Lack of discipline in respecting the designated lockdown areas. During the initial 2 weeks several people left the designated lockdown areas and moved to other parts of the country. Many of these people were not respecting the required quarantine measure. As a consequence, COVID spread faster in Italy.
Covid testing areas not separated from other areas in hospitals. During the initial few weeks, hospitals had no separated testing areas. As a consequence, COVID spread faster in Italy.
Sub-optimal backtracking for positive cases. When a positive case is identified, the authorities try to identify all the people who have been in touch with the case during the previous 2 weeks. However, this process is based on fragmented memories provided by individuals going through significant emotional stress. As a consequence, COVID spread faster in Italy.
Not enough masks. Italy does not have enough masks. This has a dramatic impact on doctors, the first line of defense, as well as on other critical sectors such as distribution, police, and army. This has also an impact on the remaining part of the population that is not able to protect itself effectively. As a consequence, COVID spread faster in Italy.
Not enough tests. Italy does not have enough tests. While the number of tests is increasing daily, with more than 300,000 people tested by the end of March, 2020, there is evidence that we are running at capacity. As a consequence, COVID spread faster in Italy. Please refer to the article “About the 9.5% COVID19 lethality observed in Italy and about unsolved problems to be considered before thinking about a massive test policy” for deeper discussion about problems to be solved before thinking about a massive test policy in Italy.
No tests for positive and asymptomatic. It has been estimated that 60% of people who are positive for the virus remain asymptomatic. Currently, there is no policy in place to test this part of the population. However, it is clear that testing the asymptomatics has been instrumental in containing the contagion in other countries such as Korea. As a consequence, COVID spread faster in Italy.
No tests for recovered asymptomatics. Currently there is no policy in place for testing this part of the population. However, identifying the people who developed COVID antibodies is critical for maintaining the country’s stability, offering assistance to sick people and to people who might be infected in the future, and for keeping the economy going.
Not enough Intensive Care Units (ICU) and oxygen. A significant part of people affected by COVID need immediate help with oxygen and ICUs. However, hospitals are everyday running close to their maximum capacity and they have had to come up with new creative ways to increase the capacity. As a consequence, people are exposed to a higher mortality risk in Italy.
Long process to buy critical equipment. Oxygen, masks, and ICUs are normally paid for from 30 to 90 days after delivery. Increased demand worldwide has made this form of payment not possible anymore (because of the implications for cash flow on the producers and resellers).
Lack of a national health protocol to deal with pandemics. Italy has no protocol to deal with pandemics. Doctors are doing an amazing job risking their lives but they did not have in advance all the necessary training to face the emergency.
Lack of legislation to deal with the emergency. Italy has a set of laws based on Roman rights which evolved over centuries. However, the government had to struggle to impose sanctions on people violating the quarantine because this event was not covered by our laws.
First western country struck by COVID. Although COVID had already impacted Asia in December 2019, Italy was the first impacted country in Western world. It is unclear whether western social or economic behaviors might facilitate the spreading of the disease.
Minimal support from European community and NATO. Although some support from the EU and NATO has been provided there is clearly room for improvement. We are all in this together.
Lack of international coordination. Different countries adopted independent containment measures with limited mutual learning. It is unclear how this will help to solve the pandemy. We are all in this together.
Lethality conditioned to test exceeded 10%. Lethality conditioned to test passed 10%, almost doubling the declared lethality in Hubei China. It is still unclear why this is the case. Please refer to the article “About the 9.5% COVID19 lethality observed in Italy and about unsolved problems to be considered before thinking about a massive test policy” for deeper discussion about the observed lethality.
What went well
Sense of solidarity helped to enforce discipline. After an initial period, a strong sense of solidarity emerged in the population. In turn, this helped to enforce natural discipline.
Increase of ICU capacity from 6,000 to 8,300 in a few days. After an initial period, the ICUs’ capacity has been increased
Moving patients with critical symptoms to different geographical areas with ICU capacity. The army played an essential role in redistributing critical patients across the country.
Existing communications infrastructure sufficient for many workers to continue working from home. This has highlighted the fact that some people’s movements are not strictly necessary.
The speed of many companies to convert from office work to smart working. In a short time, converted practice has allowed them to comply with lockdown measures and keep their employees working.
Bumping elbows meme was an example of a positive message. It’s also a small but practical containment measure — hand-shaking and kissing (outside of immediate family) could usefully be consigned to the past.
160 million Euro have been donated by Italian citizens. Common citizens donated to hospitals and institutions that are managing the emergency.
Hundreds of millions have been donated by private companies, banks and financial institutions. Solidarity emerged naturally in all the sectors of the economy.
Public health system provided assistance to the population. Italy has a public health system offered freely to all the population and this condition has helped the poorest.
Where we got lucky
Nearly 8,000 doctors have volunteered for Italy’s coronavirus task force. Lombardia made a call for 300 doctors to help, answered by nearly 8000 doctors. It has been an act of love and pride.
Initial international cooperation. Some nations offered an initial collaboration (China, Russia, Cuba, France, and Germany). However, more solidarity is in order.
Food distribution is fully operative. Groceries have food and the distribution channels are still fully operative. However, long queues are present in the markets by consequence of reducing in store capacity by spacing people out.
Internet infrastructure worked. Internet infrastructure sustained the significant increase in traffic with no significant delay. Some video conferencing tools struggled with demand.
People rapidly adapted to work-from-home (WHF) policies. Although WFH was not a largely adopted practice in Italy, the population rapidly adapted to it.
Students rapidly adapted to study-from-home policies. Students embraced this new way of learning with relatively small problems.
Institution of a centralised phone number to provide COVID assistance. This number helped to provide assistance in many critical situations. However, long waiting queues have been observed.
What is currently worrying
More than 70% of those who tested positive have not recovered yet. Thanks to lockdown new positives went from ˜26% daily to ˜7% daily. However, the total lethality conditioned to the test is above 10% and trending upwards, and the total recovered at only around 12% and trending upwards — https://tinyurl.com/covid-italy
The 25 billion initially allocated by the Italian government are a very small part. Most likely a larger amount of money is needed to restart. The European Council has not yet found an agreement on how to resolve the situation at European level, postponing the 15-day decision. More effort is needed to distribute the 25 billion to people or companies.
Thanks to many people who commented this document.
We are all in this together.