Articoli
scritto con Maria Tavernini, foto di Andrea De Franciscis
per The Poilis Project
The global outbreak of COVID-19 has confronted countries across the world with an unprecedented emergency to manage. Focusing on the situation in southern Italy, the article analyzes how the pandemic has revealed lasting structural fragilities and inequalities that are triggering a socio-economic crisis on top of the health emergency.
“Here we survive, we rig-up, we try to move on, in every way we can. It’s already difficult for us to make it to the end of the day, can you imagine what it’s like after three months with no income?” asks Salvatore, 50, as he takes long puffs from a cigarette, filling the air of his living-room with thick smoke. A father of five, he has worked all possible jobs, all of them in the informal sector, since he left school aged 7. Without a formal contract or social security, his name is nowhere to be found in the employment databases. He has done everything to make ends meet: plumber, carpenter, tailor, electrician, mechanic. Before the lockdown, his daily-wage work as a bricklayer was barely enough to put bread on the table. When the lockdown was imposed following the COVID-19 outbreak, his life-line got interrupted and, with no savings at hand, he experienced the hardest time in his life. “We are used to suffering, but this was worse,” he says with a mix of shame and resignation. For many in Southern Italy, the lockdown turned out to be a crisis within the crisis that mainly affected vulnerable and marginalized groups as well as informal workers.
Streets are usually packed and loud in Naples, where life’s hustle and bustle are the main feature of Southern Italy’s biggest city. Laid at the foot of one of the most dangerous volcanos in the world – the majestic Vesuvius, a sleepy giant and yet a constant threat to the inhabitants – the city leans on a tuff halfmoon that encircles the Gulf of Naples, right at the center of the Mediterranean Sea. A crossroad of cultures, Naples fulfils the stereotypes it is associated with: noisy, frantic, dirty. Its old center is a maze of dark alleys separated by wide avenues paved during the “rehabilitation” – the urban regeneration carried out during the unification of Italy and after the cholera epidemics. It is a restless hive of activities with its busy markets, its smells and sounds. During the lockdown days, however, the stillness and silence that reigned in the streets felt unreal – it was as if someone had pressed the pause button.
Despite a propension towards chaos, a bad reputation as rule-breakers and a lower diffusion of the virus compared to the wealthier Northern Italian regions, people in Naples have been strict in obeying the nation-wide lockdownimposed in mid-March in an attempt to curb the spread of the disease. The usually crowded and teeming streets now emptied of people and life had something sinister. People would lean out of the window in despair, as if they were waiting for something to happen – like prisoners waiting for their release. Policemen were deployed at every corner to check on the compliance with the ever-changing Prime Minister’s decrees that, piece by piece, eroded personal freedoms in the name of public health.
After quarantining two “red zones” in Northern Italy, as coronavirus kept spreading, in early March the government imposed draconian containment measures across the country. In the Northern regions – the epicenter of the contagion accounting for most of the cases – the pandemic overwhelmed what was believed to be one of Italy’s most efficient health care systems, which are funded by the State but administered at the regional level. While the socio-economic divide between North and South is rooted in history and stems from structural and infrastructural differences, the pandemic and the longest lockdown in Europe exacerbated it. The North is the economic engine of the country and, even though COVID-19 decimated an entire generation, for the sake of saving the economy many factories never came to a real halt thus helping the virus spread. In Lombardy, the region where Milan is located, the mortality rate was among the highest in the world. It was feared, however, that in the poorer and lesser industrialized South the virus would wreak havoc to the already fragile healthcare system and that the effects of the economic crisis triggered by the lockdown would be more intense and will have deeper consequences. Here people are used to expedients to survive and, as expected, the repercussions for those who were already at the margins of society have been devastating. The pandemic disrupted their fragile survival mechanisms making social inequalities even starker, thus creating new marginalities.
Hidden in the winding lanes of Montesanto district in Naples, there is a two-story building known as Sgarrupato(“crumbling” in the local dialect) where volunteers from the Spazio DAMM and the activism and resistance movement 7 Novembre provided food to some 350 families who were struggling to make ends meet during the lockdown. Maria, wearing mask and gloves, is packing bottles of tomato sauce and other essentials to be distributed in the adjoining Quartieri Spagnoli. “We are unemployed ourselves, but we try to help those who are in need. As public institutions are absent and the parameters to access food stamps are so strict, many people are cut out,” she says as other volunteers gather outside the building to distribute grocery bags to an ever-growing list of families in need. From a small volunteering activity, this grassroots food distribution grew to become a fully-fledged assistance service that helped contain the emergency as well as the risk of criminal infiltrations in the gaps left by the State. The solidarity net in Naples in fact reached a capillarity and efficiency that went way beyond the institutional one. “Many self-managed mutualism networks have come together in these difficult times. They are partly made up of political activists, but also lots of people from civil society, from the singer to the mechanic, to the taxi driver who is currently not working,” explains Alfonso De Vito, who is part of a local housing rights movement. These grassroots mutualism networks – made of too many organizations to name them all – have helped some 2,000 families get by. “This cross-section of society is the most beautiful part of this terrible story – says De Vito – but this narrative cannot be an alibi for the institutions not taking responsibilities.”
With unemployment rates three times higher in the South than in the North and a strong incidence of irregular work, the cash shortage and the bureaucratic slowness of economic aid packages made the risk of social tensions in Southern Italy a concrete perspective. Early into the lockdown, intelligence agencies warned the authorities of “a potential danger of spontaneous and organized riots and rebellions” in the South: due to cash shortage, many families were struggling to fetch a meal, pay the rent and fulfill the most basic needs. “In Naples and its metropolitan area there are segments of the population who live off daily subsistence. In the lockdown phase, this type of economy disappeared completely: people went from an income of 20 euros per day [22 USD], to null. The people working in this segment are the most vulnerable because they cannot benefit from any social safety-net or public welfare,” explains Prefect of Naples Marco Valentini. With government emergency aid packages reaching late and only a fraction of the needy, it was solidarity and mutualism to help people cope with the most immediate need of the crisis: hunger. The city’s response to the socio-economic emergency was an incredibly efficient network of self-organized collectives that provided families with low or no income with groceries and homeless people with a hot meal. This social lifeline was the product of volunteering and grassroots donations.
Besides secular and Catholic organizations, there was also an effective collaboration with the Buddhist and Senegalese communities. Many private citizens also set up to prepare and distribute food to those who could not abide by the rule of #iorestoacasa (I stay home). At noon in Piazza Mercato, a long, ordered queue slithers from the Mensa dei Poveri (soup kitchen). “We are the angels of the epidemic,” says Father Francesco, while Stefano, a yoga teacher, and other volunteers from Responsabilità Popolare are preparing food in the canteen next to the Basilica del Carmine. When the lockdown was announced, many homeless shelters – including showers and lockers – and soup kitchens were shut down out of sanitary concerns. “Before the pandemic, we used to distribute around 150 meals a day, now we prepare 700,” says the Carmelite Father in a rare pause from the fervid kitchen activity. “Food is not a problem, we can manage, but for many it is impossible to follow the basic hygiene rules: it is a sanitary emergency.” Many have resorted to washing in the subway’s toilets. It is an army of people sharing old and new vulnerabilities: homeless, migrants, clochards, but also people made poor by the pandemic. These days, poverty is spreading at a fast pace in different segments of society.
Among the groups relying on food aid there are also the so-called “new poor.” In a situation where marginalities are overlapping and piling up, the lack of cash put many families at risk of losing the roof over their head. Many tenants never formally signed a lease: a widespread malpractice encouraged by owners themselves in order to avoid taxation. Residents without a regular contract were not able to access rent aid measures and are now in danger of losing their homes. “We are falling into a much poorer economy. The risk is that after the health pandemic, there will be an evictions’ pandemic,” warns De Vito from the housing rights movement. “The economy has come to a halt and so has the income for many people. How will they pay the rent when the aid is over?” More than 64,000 rent aid requests were filed in Campania (the region where Naples is located), while 10,000 are the eviction procedures in place and many more are expected later in the year. Three months of cash flow crunch have taken a heavy toll on the population and on the economy. The fear is that criminal organizations could profit from the economic discomfort many families – and businesses – are presently faced with.
Camorra –the organized crime syndicate from the region of Campania and one of the different mafias that exist in Italy like the ‘Ndrangheta in Calabria, the Sacra Corona Unita in Puglia and Cosa Nostra in Sicily – is a complex organized crime phenomenon whose history goes back to the 19th Century. Until the 1980s, the Camorra was mainly focused on controlling the territory through racketeering, prostitution, weapons and cigarette smuggling. Since then, the Camorra has also acquired a significant presence in other European countries due to its role in international drug trafficking. With the 1980 earthquake in Irpinia, the Camorra began to meddle with public funds for reconstruction: the new business consisted in setting up construction enterprises, and then influencing policies by guaranteeing support and bribes to local politicians in exchange for tenders. From the 1980s onwards, the Camorra went transnational – making use of the deregulation imposed by the globalization – making huge illegal profits that constantly need to be re-invested and laundered. Public administrations are also exposed to criminal infiltrations as the aim of the mafias is to manage and convey public money on activities which are relevant to their scope.
Monitoring the many ways in which organized crime adapts to changing conditions is a real priority in a city like Naples. “Here, the risk of criminal infiltrations is a very sensitive issue due to the significant presence of organized crime. Our first worry is to prevent organized crime from providing criminal welfare,” explains Prefect Marco Valentini. “There are ongoing investigations on the role that the Camorra tried to play during the lockdown phase, particularly in the provision of food aid to families in need,” he asserts. Yet, according to the Prefect, the current post-lockdown phase is the most delicate. In terms of prevention, authorities are implementing a number of measures in view of the economic restart in September, considered a critical date. “Since organized crime has considerable cash, it is possible that through new and old usury mechanisms – not only loans but also donations – criminal organizations may take advantage of the difficult situation that small businesses and companies are facing.”
The lockdown costed the Italian economy 47 billion Euro (52 billion USD) each month, 10 of which in the South. Svimez, a non-profit organization promoting the study of South Italy’s economy, foresees that in 2020 the country will face a Gross Domestic Product (GDP) contraction of 9.3 percent: 9.6 percent in the Centre-North and 8.2 percent in the South. A recent study by the same non-profit shows that the North-South economic divide will further deepen during this year: while the costs of the lockdown and the GPD collapse will be heavier in the Northern regions, the Center-North of the country will lose 600,000 jobs and the South 380,000. Hence, the latter – already in recession before the pandemic – will proportionally suffer the greatest impact of the crisis in terms of occupation and its growth will be halved by next year. In the Southern regions there are also the highest rates of poverty and shadow economy, according to data by the national statistical institute. Families living in relative poverty are estimated at just over three million, with the Southern regions of Calabria, Campania and Sicily registering the highest incidence. Shadow economy and informal work are also more present in the South than in the North: Calabria is the region where the weight of the underground and illegal economy is the greatest, with 20.9 per cent of the total added value, followed by Campania and Sicily. In those segments, money has stopped circulating, hence a part of the population has stopped spending.
In July 2o2o, two months after the lockdown has been lifted, streets in Naples are again bustling with people: as life seems to flow back city’s veins, the emergency is far from over. Even though streets are busy again, it is clear that business is not fully back yet. Many restaurants and shops have not lifted their shutters and the cash crisis is palpable. “We have a 50 percent drop in the sales of Margherita pizzas,” states Coldiretti, the association of food producers. “We work mainly with takeaway, but tables are empty,” explains Antonio Improta from Pizzera 22 in the Pignasecca district, one of the oldest open-air market of the city of Naples. “The distance between tables imposed by the institutions has more than halved the seats. Due to the economic crisis, many people prefer to do without eating out.” In a city where restaurants were usually always full, and dining out is reasonably cheap, it is unusual to see them so empty. As pizza consumption acts as a market indicator, numerous restaurants, bars, clothing stores and other activities are also gasping for air. The collapse of pizza sale is a significant warning for a city like Naples: the drastic downsizing of its market is the mirror of a “post-war” economy.
The battle against the virus has often been compared to a war, as if the word pandemic were not enough telling of the emergency many countries have experienced. In the current post-lockdown phase, many analysts are setting parallels with the 1945 post-World War II recovery. The frequent reference to post-war times in the media – despite the obvious differences – has a self-delusional function aimed at encouraging the population and boosting national unity. Yet, while in post-war economy the demand could not find a corresponding offer, the opposite is happening today: goods on offer are available, but there is little cash and even less will to spend it. The fear is that, in an era that has witnessed an unprecedented interconnection and globalization, it will take much longer than in post-war times for economies to recover. United Nations Secretary-General Antonio Guterres said that the “economic impact will bring a recession that probably has no parallel in the recent past.” The shock effect of the COVID-19 emergency also revealed all the flaws and injustices of our societies, worldwide.
In Italy, the economic system runs on two-speeds with the country spit in two: North and South of Rome, the national capital. The lockdown plunged Southern Italy’s absolutely precarious economies into a deep crisis. “Given a widespread cash problem,” says Luigi Cuomo, racketeering expert at Libera, an association working against mafias “today there is both a strong demand and an equally strong supply of loans by organized crime. The reopening [of activities after the lockdown] prompted the need for cash, but the Italian banking system is among the most obtuse and medieval banking systems in Europe. The failure in granting legal credit allows illegal, criminal credit to flourish,” he continues. The Mafia – a term originally associated with the Sicilian Mafia, now often used collectively to include all regional criminal outfits – lends money not only to grow its capital but also to infiltrate legal businesses to launder its own capitals. “All usurers are criminals, but Mafia’s usury is growing at a concerning pace in recent years – explains Cuomo – it not only produces income, but it also infiltrates businesses: it launders illicit capital by putting it back into the legal market, it ousts troubled entrepreneurs by first taking control of the company and then of its ownership.”
The Prefecture of Naples is closely observing the phenomenon. “We are constantly monitoring changes in shareholder structure, or company transfers, or branches of it,” says Prefect Valentini. “Stock markets and transfers are a spy: if data is anomalous it leads to suspicion of a criminal intervention aimed at influencing the life of that company.” Even more than any other business, mafias observe the market trends and adapt to the changing context. During the COVID-19 pandemic, the Camorra also reinvented itself in new sectors: the most important is the business of PPE [Personal Protective Equipment], such as the production of gowns and masks, says Valentini. However, usury is the first resort for an activity in crisis. Usury is also an effective money-laundering mechanism: the social emergency caused by the coronavirus has been a great opportunity in this sense. “By lending money, they [the criminal cartels] risk very little and have huge returns. Today they do not even need to coerce people into their illegal money-lending schemes, victims are already flocking towards them. At first sight, the usurer appears as a comforting figure, the one that comes to help you – says Cuomo – a honeymoon that in some cases can last long, in other cases less. Only then, victims will begin to seek help and report.”
It is too early now to assess the impact of usury during the COVID-19 pandemic, according to former racket victim and judicial witness Luigi Ferrucci, President of the Italian Federation of anti-racket and anti-usury associations (FAI), figures will emerge in the long run. In the last two months the Prefecture of Naples has received 26 reports from entrepreneurs who stood up to oppose criminal harassment and have faced increasing difficulties to reintegrate their companies into the healthy productive fabric of the country. “People who fall into money lending schemes take time before they ask for help. We have introduced a new tool, an online listening desk that allows victims to get in touch with us and talk to our experts. We have to be attentive in detecting new dynamics and this can be done only at the grassroots level.” According to Libera’s Cuomo, the State must think of new loan models, not necessarily through the banking system, “whose strict and inaccessible credit regulations make [the banks] victims of their past mistakes,” he explains, “It is necessary to allow private individuals to lend money [in a regulated manner] in competition with banks, so as to trigger a virtuous mechanism and annihilate usury.”
Time is crucial in this context. “The State must act before Mafia does,” urges Rosario Stornaiuolo of the consumers’ association Federconsumatori. “European aid packages must reach small entrepreneurs before the Camorra lends them money first and then usurps their companies, thus also benefitting from public aid.” It is a call for de-bureaucratization in a country where procedures are often lengthy and complex. Camorra is no longer the same as in the 1970s or 1980s, it has evolved both in scope and reach. “Today it is entrepreneurial, it is run by white-collar, educated people who are able to understand these mechanisms.” Food catering and tourism are the main sectors under observation in Naples after the COVID emergency. “Before COVID, these were driving sectors of the city’s economy,” recalls the Prefect Valentini, “Especially in recent years, Naples witnessed an exponential increase in tourism: these sectors are the most exposed now.” The city center, until recently turned into a touristic amusement park, is spectral these days: all activities related to the tourism business are suffering a lack of customers and are at risk of going bust and could hence easily become targets of criminal infiltrations.
Unlike other entrepreneurial actors, Camorra seems to have an infinite availability of cash that needs to be pulled back into the market. Camorra, though, like every other business, has suffered from the current crisis: its supply chain was partially disrupted and experts agree that usury is the only upward activity to produce hegemony in this context. “We believe the lockdown affected also the criminal economy,” says Libera’s Fabio Giuliani. The lower segments of the drug trade – the open-air drug-dealing markets – and their relative profits suddenly dropped. Fabio Giuliani explains that “the drug-dealing outposts where users buys drugs from local criminal cartels have suffered significant losses, to such an extent that the demands for methadone by people who could not fetch their doses during the lockdown has significantly increased.” Despite the losses, the Camorra is the only big player in the market economy that still has cash availability in a time of recession. “In some districts in Naples the criminal cartels have distributed food aid and handed out money, from 50 to 500 Euro,” explains Fabio Giuliani. “A parastatal welfare aimed at building consensus in a specific territory, Camorra knows how to build strong ties and a solid economy.”
In this unfolding crisis, the mafias are trying to increase their hegemony. Prevention seems to be entrusted entirely to civil society associations engaged in providing assistance against usury. These civic networks represent a great moral asset, but they are certainly not enough at an operational level. “Associations and cooperatives against the mafias are experiencing a great crisis,” admits Fabio Giuliani. “It seems that there are always other priorities. Today, the top priority is revitalizing the economy at any cost. During the lockdown, it was the civil society to keep the boat afloat. The focus is now on recovery, while the social network that has proven crucial during the crisis has been placed on the back burner. Today,” warns Giuliani “Camorra has an even greater infiltration capacity compared to the 1980s,” the years of its last boom and uprooting. A chilling warning for a city that has paid – and still pays – a high price for the pervading presence of organized crime.
scritto con Maria Tavernini per TRT World il 30/3/2020
Guidelines in Italy require hospitals to limit the number of people admitted for treatment.
“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.”
Interviste sul taccuino sono la sbobinatura sommaria ma completa di interviste realizzate per servizi giornalistici.
Questa intervista, a un medico che ha preferito restare anonimo, è stata raccolta insieme a Maria Tavernini per un servizio su TRT World.
Dottore, con quali criteri attuate il triage, ovvero la scelta di quali pazienti ospedalizzare e quali no?
Una domanda complessa, bisogna rispondere su due piani: “sul quadroi clinico” sarebbe nelle condizioni normali il parametro più corretto, adesso il criterio è “quanti posti abbiamo”. Si pone un grande problema etico, al paziente prestiamo cura o accoglienza? Scegliamo da subito chi curare e quindi chi non curare relegando a maggiori possibilità di morire. Fare tutto per tutti non è più possibile. Già al pre-triage, quando avviene la distinzione tra pazienti polmonari e pazienti non polmonari compiamo la scelta. In questo momento nella mio ospedale pazienti senza complicazioni polmonari non ci sono più. Abbiamo solo pazienti con problemi respiratori che hanno il primo accesso al pronto soccorso internistico. Qui i medici sanno che al momento in ospedale su 210 posti letti possibili ne ha due liberi, arrivano tre pazienti che meriterebbero il ricovero e al terzo paziente cosa si fa? Ci si sta ponendo questo problema etico assolutamente importante, e per certi versi stressante.
E il terzo su quale criterio lo escludete?
Su chi ha meno comorbidità a prescindere dall’età. All’inizio il criterio era l’età: hai ottanta anni? preferivo trattare e davo la precedenza a un sessantenne. Ma adesso non possiamo fare più nemmeno così perché i posti di osservazione sono finiti, i posti di trattamento sono assolutamente finiti quindi la presenza di comorbidità e il quadro clinico del paziente sono criteri che ti aiutano perché forniscono margini di scelta. Quindi il paziente diabetico, o il paziente cardiopatico, o ad esempio un obeso che ha meno probabilità di sopravvivere se affetto da una polmonite interstiziale a fronte di un altro paziente magari più vecchio ma con un quadro clinico generale splendido, senza altre patologie, allora io ho maggiori probabilità di tirar fuori dal problema questo ultimo paziente, quindi l’altro aspetta. Ci si può organizzare, in alcuni casi il paziente molto grave viene intubato ma lo puoi tenere così solo 24 ore e poi gli devi trovare un post, gli hai dato 24 ore di possibilità ma dopo non puoi più seguirlo. Considerate che abbiamo mandato molti pazienti in altre province e in altre regioni, alcuni anche in Germania.
È come se la politica del male minore avesse fatto breccia in un campo moralmente scevro come la cura.
Preferisco parlare di effetti collaterali, c’è una guerra che richiede determinate condizioni e tra gli effetti collaterali c’è che adesso non trattiamo chi ha un infarto acuto. Tutte le terapie intensive di cardiologia sono attualmente impegnate per il trattamento Covid quindi chi ha un infarto non ha cura. Un altro effetto collaterale è non riuscire per tempo fare interventi a pazienti oncologici. Manderemmo, avremmo mandato, manderemo, dipende anche da questioni burocratiche, insomma dovremmo mandare i nostri pazienti oncologici all’Istituto Nazionale dei Tumori, ma la nostra struttura amministrativa non si è preoccupata fino all’altro ieri di avvisare quell’istituto. Quindi noi avvisavamo i nostri colleghi di quell’ospedale ma ci muoviamo sul piano del favore personale, senza nessun atto amministrativamente riconosciuto. Ci sono condizioni che richiedono una urgenza respiratorie e altre cose che non possono essere trattate.
Quale è l’umore tra gli operatori sanitari?
Queste cose vengono vissute male dagli operatori sanitari, è chiesto a noi medici di decidere della vita delle persone. Ci sono vari gradi di sostegno alla respirazione: la mascherina o gli anelli nasali che consentono di somministrare un po’ di ossigeno al paziente, c’è una seconda mascherina dotata di un reservoir che tiene l’ambito respiratorio piuttosto ricco di ossigeno, c’è poi una terza fase la cpap che crea una pressione positiva che permette all’ossigeno di entrare, poi c’è l’intubazione vera e propria. La cpap viene fatta con dei caschi cilindrici, chiusi e adattati alla clavicola dentro al quale viene messo il paziente e l’ambiente è assolutamente ricco di ossigeno, ma per tenerli gonfi c’è bisogno di aria compressa. E non tutte le postazioni ospedaliere sono munite di bocchettino per l’aria compressa e uno per l’ossigieno. Altri pazienti, quelli con un tubo per la gola, devono avere i caratteri vitali monitorati costantemente, e non tutte le postazioni letto hanno la presa di corrente o i monitor che consente di allacciare le apparecchiature necessarie per questo monitoraggio. Non è una questione solo di software ma proprio di carenza infrastrutturale dei nostri ospedali, e anche questo è un criterio per scegliere quanti pazienti trattare e quanti no. Questa situazione, la continua costrizione a questo tipo di decisione vengono vissute male dagli operatori sanitari, è chiesto a noi medici di decidere della vita delle persone.
Siete protetti, come state messi a Dpi (Dispositivi di Protezione Individuali)?
Secondo le indicazione dell’OMS ci sono vari gradi di protezione a secondo della vicinanza al paziente. Se devi svolgere manovre che consentono la dispersione di goccioline di flügge, ovvero quei veicoli di trasmissione dell’infezione, devi avere un dispositivo specifico. Dispositivo che all’ospedale di Milano ora è arrivato ma che altrove è ancora insufficiente.
scritto con Maria Tavernini per TRT World il 24/3/2020
Italy fights an uphill struggle against the coronavirus on every front.
Naples, ITALY –– “Let us unite!/We are ready to die/Italy has called,” is the chilling cry that unites millions of Italians leaning out from windows and balconies. The lockdown was imposed throughout the peninsula on March 11.
The national anthem is among the songs collectively belted out by Italians locked inside their homes during the Covid-19 pandemic in an attempt to instil a little optimism among a frightened population.
Perhaps, it is also to ward off the psychological effects of the war bulletin broadcast every day at the same time, that defines the outlines of a health tragedy.
Every day at 6PM a press conference by the head of the Civil Protection, Angelo Borrelli, reads outs the daily figures: yesterday there were 601 deaths (the day before 651), which brings the total number of deceased up to 6077. The newly infected are 3780, less than the day before when 3957 were registered, bringing the total to 50,418; the recovered ones are 408, totalling 7432; 3204 people are in intensive care, 195 more than yesterday.
These figures convey the epic proportions of an outbreak that is bringing Italy’s national health system to its knees.
Five days ago, Italy surpassed China’s fatalities, becoming the country with the most deaths from the coronavirus. China tops the list of total cases with 81,496, followed by Italy with 63,927 and the US with 26,747.
While restrictions in Italy are forcing the population to stay home, the contagion has not ceased though it has marginally slowed down for the second day in a row.
Experts assure it will take longer to see the curve finally flatten.
The epicentre continues to be in the northern region of Lombardy: the outbreak has moved from Lodi to Bergamo and Brescia. The confirmed cases in the region are 28,761 and the number is growing by over 3,000 every second day.
In Lombardy alone, 1,183 people are in intensive care and 3,776 have died, making up 68 percent of the deaths in Italy. The images of rows of military trucks waiting to transport bodies out of town have been seen around the world and have perhaps made even the most reluctant Italian stay home.
The virus spread to southern Italy, even if not in as high numbers, was helped by the “great exodus” of people who returned from the industrial north to the south during the night the first decree was leaked – the one that would have locked down Lombardy.
The trauma of caregiving
At the forefront of the fight against the virus in the red zone is an army of doctors, nurses and health workers who carry out their duty in debilitating conditions.
“I have never been afraid to work and I don’t think about the risks. But when I finish, I hope to go home without bringing the virus with me because I have a family, three children. The fear persists, even if I do everything according to the procedures,” Antonio, a nurse, confesses to TRT World.
Antonio has been a nurse for 40 years in the hospital of Seriate, Bergamo, which has been turned into one of the three Covid-hospitals in Lombardy.
“My ward used to be a cardiology intensive care, now we have seven intubated patients and we are learning things that we were not used to performing. It’s hard to keep up the mood when you see these patients alone, clinging to us as they do not have anyone else close now. In our ward patients are in a state of pharmacological coma, but in other wards, it is emotionally excruciating seeing them gasping for air while you cannot do anything for them.”
The medical staff dealing with the emergency are the ones who are paying the highest cost of this crisis. The shortcomings of the national health system’s performance in Italy, given the high number of people who need intensive care, are exacerbated by structural deficiencies.
In the name of austerity, some 40 billion euros ($43 billion) have been cut out from the Italian public health system in the last ten years, making the emergency even harder to handle.
Italy is also the country with the highest number of infected among the medical staff, 4824, double that of China.
“There are no devices for everyone in the wards, there are no helmets for all patients and fans are scarce. The staff is protected but if you get dirty and need to change gears, the risk is not having enough. Even masks are running out. We start the shift with our dedicated mask hoping that we don’t get to need a second one,” says Antonio, his voice breaking up, “it is quite an emotional load for us. I have been dreaming of all this for a month now, every night.”
Italy has 12.5 critical care beds per 100,000 compared to the around 29 per 100,000 that Germany has. The country at the forefront of Europe’s battle against the new Coronavirus and the deadliest hotbed, is now planning to build new wards through private donations.
“The numbers are clear, the public health service was to be strengthened: we have 50,000 doctors less than what would be needed, especially in the wards that are proving the most important: intensive care units. In the West, not only in Italy, we used to believe that pandemics were something of the past, that these kinds of epidemics only occurred in Asia. We were not prepared for this,” says Ernesto Burgio of the European Cancer and Environment Research Institute (ECERI) in Brussels and President of the Scientific Committee of the Italian Society of Environmental Medicine (SIMA).
“The responsibilities are systemic, I believe that politicians have not been sufficiently supported. We need to trace back to the history of the epidemic in China: they set a starting point, they predicted and faced the peak of infections. They closed the Hubei region and did what ought to be done: monitor and control everyone.”
The Italians, he said, made an error in judgment.
“We did it too late and in a convulsive manner. We initially barred only small red zones: errors that we are paying for now because we were neither prepared nor informed.”
Burgio hopes that the restrictive measures will work, although late, but, it’s too early to say.
“At this point making predictions is very difficult because we don’t know how many asymptomatic and paucisymptomatic (few symptoms) carriers are around.”
One of the unsolved mysteries is the mortality rate. In Italy, it is a little under 10 percent, much higher than that of China, at 3.8, or South Korea, 1.1. This figure is calculated from the number of deaths and the total number of infected, but in Italy, only 125,000 tests have been carried out so far.
Some governors have requested the entire population to be swabbed in order to get the real proportions of the contagion, but doctors agree on the futility of that operation at this stage.
“Large-scale swabs could have initially been made in the largest possible area around the identified cases and their contacts so that the virus could not spread, ” explains Burgio but, “dabbing huge numbers now would only help to find hundreds of thousands of infected people, but it would have enormous costs and would no longer make sense. We must intervene in the places where the virus is most present – the hospital facilities – and reduce the exposure of health workers.”
Civil liberties vs containment
Italy, although late, has chosen the path of social distancing to combat the pandemic, later followed by other southern European countries. Decree after decree, Italians have increasingly seen their freedom shrinking in terms of movement in an attempt to contain the epidemic.
After the first week of lockdown, the hashtag #iorestoacasa (I stay at home) became a catchphrase and while the there are no signs of it slowing down, boredom and collective hysteria targeted joggers and runners, who are held up as the new plague-spreaders. They have become the new target of collective hate.
On the other hand, it was only two days ago that many non-essential factories were closed down in the last draconian clampdown by PM Giuseppe Conte.
Last week, the European Union launched a 164 million euro ($177 million) call for innovative technological solutions to help curb the coronavirus outbreak. And while Italian police forces will now be allowed to use drones in an attempt to crack down on people’s movement, the fear is that these containment measures could be followed by some form of surveillance of infected people, like in China, jeopardising the professed principles that characterise contemporary Western democracies.
“The use of digital technologies, especially those conveyed by smartphones, are increasingly used to combat the expansion of the new coronavirus,” Dr Denis Roio of Dyne.org, a Europe-based foundation that promotes digital rights and democracy, tells TRT World.
“In fact, these technologies allow movement control in a precise way, when using GPS, or in a less-precise but still significant way when Bluetooth, Wi-Fi or GPM are used. In terms of social control also metadata are useful, which contain information like with whom an individual has been in contact, how many times, how long for and their physical proximity.”
Yet this mass of data can also interfere with people’s individual and social rights. Technologies associated with fitness tracker devices such as smartwatches are capable of controlling body temperature, heart rate and storing information.
“Valuable data for credit institutes and insurance companies, for example, or for employers to check on the physical conditions of workers or for governments facing tensions over shrinking democratic guarantees,” says Roio.
In considering the many factors that have contributed to curbing the coronavirus outbreak in China and South Korea, including culture and lifestyle, Roio warns, “the use of digital technology for social control to fight the coronavirus and similar epidemics will increase the fragility of a significant sphere of rights of numerous categories of people: we must stay vigilant.”
scritto con Maria Tavernini per TRT World il 24/2/2020
Italy could be facing a significant loss of jobs, business closures and international isolation.
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.