“You are asking me which criteria we use to choose who to hospitalise?” he takes time to rationalise the question.

“It is a complex question: in normal times it is decided upon the patient’s clinical condition,” explains the doctor of internal medicine in a Milan hospital who agreed to speak to TRT World on the condition of anonymity, “now the only regulatory principle is the number of available beds.”

A moral truth that clashes with the numbers put forward every day by the Lombardy Welfare Commissioner, Giulio Gallera. Critical care beds were brought to 1600 – an increase of 110 percent. However, that is still not enough.

“We are quashed by a huge ethical problem – continues the doctor – do we provide reception or treatment to patients? We choose right away who to treat, relegating those who we exclude to a greater chance of dying.”

Lombardy continues to be the epicentre of Covid-19 in Italy with 43 percent of the total cases. Numbers leave an enormous margin of error, as confirmed by the head of the Civil Protection Angelo Borrelli who said it is “presumable” that for each infected person detected there are ten more undetected.

In early March this year, the Italian Association of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) issued new guidelines that modified access to intensive care – nationally.

Predicting “a strong discrepancy” between the care needs and the resources of critical care, it ordered prioritising those who have “a longer life expectancy.”

Age and medical history are decisive factors. Every time a bed frees up, doctors in the ward have to decide who will occupy it: an additional emotional load for a community that is already on edge and working in exhausting conditions.

The most severe Italian health crisis since World War I is forcing doctors to take unprecedented decisions in times of peace.

Triage is the method used in emergency rooms where access to treatment does not take place based on the order of arrival but the priority of the patients’ conditions.

The same logic is applied in hospitals with insufficient means compared to the number of people that require treatment, such as in times of calamities or disasters. Prioritising in such a manner has profound ethical and moral implications.

“Already at the pre-triage, when the distinction between lung and non-lung patients occurs, we make the first choice. At this moment we only take patients with lung complications. If the doctors know there are two beds free out of 210, what to do if a third patient needs treatment? Every day this ethical problem arises, which is absolutely stressful; we cannot treat them all.”

“At the beginning, the criterion was age: between an 80-year-old patient and one of 60, I would pick the latter. Now we can’t even do this anymore because observation beds are finished and treatment ones even more,” says the doctor.

“So the comorbidity (the coexistence of several pathologies) and the clinical picture are main criteria. A diabetic, a cardiac or an obese patient – who are less likely to survive interstitial pneumonia compared to a person that is older but in better health – will risk waiting because the latter has more chances of surviving.”

The main discriminant is the respiratory aggravating factor that Covid-19 brings: hypoxemia or low blood oxygen.

“There are various degrees of breathing support: masks or nasal rings that administer a little oxygen; another mask equipped with a reservoir that keeps the respiratory field rich in oxygen; there is a third type, the CPAP, or high flow oxygen ventilator; the last resort is intubation,” he explains, “The CPAP is made with cylindrical helmets: to keep helmets inflated you need pressurised air but not all beds have oxygen and air outlets.”

Patients under the most invasive treatment – put in a pharmacological coma and with a tube passed through the throat to push air into lungs that no longer can expand independently – must have vitals monitored continuously.

“Not all bed stations have a power outlet or monitors that allow you to connect the needed equipment. It is not just a question of software but rather lack of infrastructure, and this is also a criterion for picking which patients to treat,” explains the doctor from Milan.

War footing

The whole national health system is affected. Wards have been reconverted, meaning that those with other ailments cannot be treated.

“It is as if we were at war and suffer side effects: all cardiology intensive units have been converted into Covid wards, so those who have a heart attack cannot be cured, like those who need cancer surgery. Hospital administrations struggle to talk to each other; we need to ask to transfer a cancer patient as if it were a personal favour.”

Warfare is a widely used metaphor these days. “I rather wind up with the earthquake metaphor: instead of the injured, we get patients with compromised lungs. Our first aid team, made up of doctors and nurses trained to cope with emergencies, was not used to seeing so many patients, so compromised, all at once, for days and days. By now we are only hospitalising patients with pneumonia,” explains Professor Roberto Cosentini, head of emergency medicine at the Papa Giovanni XXIII hospital in Bergamo city, the most recent epicentre of the epidemic in Lombardy.

“It is a difficult scenario from the organisational and logistical perspective but also the emotional and psychological one. It is as if every day there was an earthquake, a viral shock going on for a month, which in nature does not happen. A jolt, two jolts, then it settles down and the injured are rescued. Here we went on for a month – he corrects himself – 37 days.”

Cosentini speaks in the past tense as if the worst is already over, at least in Bergamo. “Our hospital was quickly reconverted to address the emergency with 350 Covid beds and 90 intensive care beds. As an ER, we became a sort of ‘breath unit’ organised on three levels of intensity.”

In Bergamo, residents say that the surreal silence of the empty city is broken only by the continuous sound of ambulance sirens. Funeral companies are overwhelmed; the army is in charge of carrying the coffins piling up. In the entire peninsula, proper funerals or memorials cannot be carried out as the virus decimates an entire generation, at least in Lombardy.

“Elderly with pre-existing conditions” they get called. In the local newspaper, the news pages have been replaced by obituaries: photos and names that return a face to the figures of this tragedy.

Hospitals are closed for visits, and Covid patients on the brink of death cannot say goodbye to loved ones. They die in solitude, without a caress— a shortage which doctors, nurses and volunteers often make up for through tablets and video calls.

“Patients are deprived of family comfort, it is additional suffering,” points out Cosentini with a heavy heart, “it is a very particular, very deep and close relationship with Covid patients. It is an exceptional situation, for us but also for the patients themselves, who are actually different from those we usually see. We both feel part of the same tragedy.”

When the Red Cross doctors go to pick up a critically ill patient from home, family waves from afar, without knowing if they will ever see each other again.

Going into battle unarmed

In the province of Bergamo alone 1,759 people have died from Covid-19, but there may be many more. Many deaths were not attributed to the coronavirus because they died at home and therefore were not swabbed, Bergamo’s Mayor Giorgio Gori told media.

“We cannot rule it out. Old people who have a very small reserve volume or in a compromised situation, are kept at home by their relatives,” comments Cosentini.

In the hardest-hit areas where beds are running out, relatives assist elderly patients at home until death. “Indeed, these deaths could have slipped Covid’s statistics. The paradox is that elderly and compromised patients hardly survive, and if they are hospitalised, they are taken away from their families,” he adds.

“In these cases, the decision whether or not to treat the sick falls on the one hand on the relatives and the other on the hospitals that have to manage less beds than the demand.”

Paola Pedrini, secretary of the Italian Federation of General Practitioners (FIMMG) of Lombardy defines the numbers released as “increasingly unreliable.”

She says that confusion over coronavirus emergency figures should not hide the responsibility of the generals in the “Caporetto” of Italian public health, referring to the Italian army’s humiliating defeat in World War I in the Battle of Caporetto.

The FIMMG asked that health workers be immediately put into safe care. Her anger is that many general practitioners in Italy have been left at the front line to manage all those patients and are not admitted to hospitals.

In the province of Bergamo, 130 out of 700 general practitioners contracted coronavirus. Italy has the highest number of infections among healthcare workers – 51 doctors have died so far.

“According to the indications of the World Health Organization (WHO), there are various degrees of protection, depending on the proximity to the patient. If you have to perform manoeuvres that allow the dispersion of flügge, those droplets that transmit the infection, you must wear specific devices,” explains the Milanese doctor. Devices and gear available at Milan or Bergamo’s hospitals – but hard to find elsewhere.

“They give us only one daily kit that we have to take off and put back on,” explains Loredana, a doctor who voluntarily reached the hospital of Desenzano del Garda in Lombardy, from her hometown in Abruzzo to support the emergency response.

“Whoever has the (Hazmat) suit is because he bought it from his own pocket, besides we have a cotton uniform on top of which we use a normal coat. Then FFP2-mask topped with a surgical one that I bring from home and not-insulating eyes protection.”

Another doctor comments: “Sticking to the military comparison, in the battle against an enemy called a virus – because in the wards it is a war-like situation – it’s simple to understand that if you send your soldiers in unarmed, they will die.”

Milan, Italy – “It is the time for national unity, the situation should not be used for political gains,” is tirelessly repeated by Giuseppe Conte, the prime minister of the nation with the highest number of coronavirus cases outside of Asia and the highest in the West.

The call for unity in such a time of crisis hides the widespread feeling that something better could have probably been done to reduce the risk of contagion.

To date, 455 people have been infected with the coronavirus, or COVID-19, in Italy. Of these, 12 people died, 116 patients are hospitalised with symptoms, 36 are in intensive care and 209 are in home-isolation, mainly in the northern regions. These were the latest figures released yesterday by the Commissioner for the Civil Protection Emergency, Angelo Borrelli.

The count rises daily. The statistics speak of one death in every 50 cases, mostly elderly with compromised medical histories.

Over half of the people who had tested positive to the swab, do not need hospital treatment: they have no symptoms but they could become a “plague spreader” and have to stay quarantined.

The government’s decision at the end of January to stop all flights from China was met with criticism.

“The only questionable measure was stopping only direct flights while neglecting those with an intermediate stopover,” says Maria Triassi, a hygiene professor at Federico II University of Naples and Director of the of University Department for Public Health.

“More airport transits meant more exposure to the flu hence the virus was allowed to travel. Besides, not much could be done. The weakest links are now the overcrowded emergency rooms, while quarantine measures are indeed effective”.

Based on Italian television and news reports however, it seems an apocalypse is approaching: supermarket shelves have been ransacked, half of Italy closed down museums, theatres and schools as a precautionary measure.

“I have the feeling that some institutions humour the emotional wave imposed by media rather than scientific opinions, ” Triassi tells TRT World, “schools have been closed down in cities with one million inhabitants where not even one infection was registered. It is never a good idea to juxtapose health and culture.

In the municipalities where the outbreak started – such as Codogno, a town in Lombardy region from which the contagion was believed to have spread in Italy – drastic measures have been imposed in an attempt to contain the spread of the disease.

Residents cannot leave, cultural, recreational, sports and religious events – both in public and private places – have been suspended, as well as classes in schools and universities (online schooling continues), museums, clubs and theatres are closed, competitions and exams are postponed.

Public offices have been shut down, except those providing essential services, while some companies let staff work from home. Guarded quarantines have been imposed on individuals who had contact with confirmed cases.

The inability to find “patient zero” – the first infected person who brought the virus to Italy – is making the national health system go nuts.

For a few days, officials in Italy believed the “patient zero” could be a man who had just returned from China, a friend of the 38-year-old man who was infected together with his pregnant wife. But apparently this is not the case and “patient zero” is yet to be pinpointed. That fact, or the lack of it, has instilled and exacerbated a feeling of vulnerability in the population.

To date, it is not known from whom and where the virus had spread in the country. What we do know is that some infections contracted by elderly people took place in a bar in Vo’, a small town in North-east Italy, on the evening of February 9. The bar was crowded thanks to the broadcasting of the Milan-Inter football derby.

Will Italy become isolated?

The Coronavirus has so far struck mainly in the north of the country, with only three cases in Sicily, one in the Marche region and one in Puglia, while two cases have just been confirmed in Naples. Perhaps the reason for this initial gap is a reflection of the economic divide between northern and southern Italy.

Italy’s economic engine is in the north, where contacts and exchanges with China are more frequent, while they are more sporadic in the south, where the Chinese migrant population is also more sedentary.

These days most Italian TV broadcasts consist of a doctor as a guest, often dispensing advice on hygiene, evaluating the work of authorities, or predicting the duration of the infection. It feels as if the scientific debate has moved from academia to the small screen.

Among these, Fabrizio Pregliasco, medical director of a Milan hospital and professor at the Faculty of Medicine of Milan University, has gained quite a lot of popularity.

“Government decisions are political and based on the principle of social distance, the objective is curbing a substantial share of contacts between people. In these cases, there is no right recipe on which type of activity to close or not, the aim is reducing an excessive concentration of people so to reduce also the share of seriously ill people,” the professor told TRT World over the phone.

“When the World Health Organization (WHO) issues a global alarm, countries must adopt measures according to scientific guidelines and Italy has taken them,” claims Walter Ricciardi, WHO member and recently appointed consultant to the Minister of Health, Roberto Speranza, in an attempt to reassure those countries in Europe that were beginning to dread travel restrictions on Italian citizens.

“Italians can travel. Conditions on travelling abroad have not changed,” Speranza reiterated yesterday, at the end of a meeting with his counterparts from France, Germany, Austria, Slovenia, Switzerland and Croatia as authorities scrambled to contain Europe’s biggest outbreak.

Meanwhile, with the contagion spreading to Europe, the Middle East and Asia, Beijing is strengthening measures against the “return contagion” announcing that people arriving from coronavirus-affected countries are required to stay in a 14-day self-quarantine.

Unlike other European countries, at the end of January, Italy closed direct flights to and from China. Like China, Italy is now also being increasingly isolated from other countries: British Airways has drastically reduced its connections to Milan.

According to Pregliasco, “It is difficult to say whether it is right or not to halt domestic and international connections, yet this allows reducing the chance of contagion. We are faced with two possible scenarios – he continues – either the measures taken prove to be useful and therefore we will move on to mitigate the phenomenon or we will have to deal with a widespread contagion, yet reduced for the natural course of the disease.”

The debate within the Italian scientific community is particularly lively these days. According to Maria Triassi, everything could end with the end of the winter, like the normal flu.

Fabrizio Pregliasco, on the other hand, believes the outcome may not be so linear and warns that the heat does not help respiratory diseases and open-air activities increase the chances of infection.

The virus infects the economy

Meanwhile, in many northern Italian cities, including Milan, fear has taken over the population. “Since the news of the first contagion came out, panic has spread among people. They wear masks and gloves. On the streets, in the metro or at bus stops the topic is just one: the virus. Everyone agrees that it is only a tougher flu but in fact, everything has stopped in the city, nobody goes out. In Navigli [the bars and nightclubs’ area of Milan] everything is closed, it looks like a zombie city,” says Aleko Carola, a guitarist who lives and works in Milan.

“All concerts and private lessons have a been cancelled, our sector is stuck and Milan is an expensive city to live in.” Via Paolo Sarpi, the Milanese Chinatown is deserted, Chinese shops and restaurants are closed, the street is a streak of lowered shutters, hotel face cancellations.

“The measures taken in Lombardy have made panic spread over the past weekend. There is no one around, the streets are empty, it is almost scary. Supermarkets have been stormed,” claims Mimosa Milano, a young entrepreneur who runs a catering business for major fashion events in Milan.

“Italian and international customers and brands have cancelled all the events booked from here to April. I’m thinking about how to reinvent myself in these three months, I can’t stand still, but nobody wants contacts with other people. Fear prevails – the fear of others – it is difficult to discern.”

Media too have played their role in spreading a feeling of panic. The Council of the Order of Journalists of Lombardy yesterday said it cannot avoid calling on directors, editors-in-chief and editors to maintain “scrupulous and careful compliance with the ethical duties imposed by law and by the ethical charts in health matters, in particular, in order to avoid a sensationalism that could give rise to unfounded fears or hopes.”

That the Italian economy is under heavy stress due to the coronavirus outbreak and the restrictions imposed, is a fact.

If the lockdown lasts until May, experts foresee the closure of 15,000 companies and the loss of 60,000 jobs. In the south, the contagion would put in crisis the only surplus sector – tourism – in one of EU’s poorest regions.

To date, the spectre of recession in Italy no longer seems to be a bugbear but a concrete risk. Shops have recorded a surge in sales of masks and sanitising products, which are nowhere to be found these days.

In a bookshop in Milan, a clerk shares that today’s best-selling books nationwide are “Spillover. The evolution of Pandemics,” a 2017 text by David Quammen, and “Blindness” by Jose Saramago, published in 1997. These two books best reflect the mood and atmosphere in Italy today.