A market in Naples, Italy, on June 19. Italians are cautiously optimistic that they have the virus in check. Photo / Gianni Cipriano, The New York Times
After a stumbling start, the country has gone from being a global pariah to a model — however imperfect — of viral containment that holds lessons for its neighbours and for the United States.
When the coronavirus erupted in the West, Italy was the nightmarish epicentre, a place to avoid at all costs and a shorthand in the United States and much of Europe for uncontrolled contagion.
"You look at what's going on with Italy," President Donald Trump told reporters March 17. "We don't want to be in a position like that." Joe Biden, the presumptive Democratic nominee, used Italy's overwhelmed hospitals as evidence for his opposition to "Medicare for All" at a presidential debate. "It is not working in Italy right now," he said.
Fast forward a few months, and the United States has suffered tens of thousands more deaths than any country in the world. European states that once looked smugly at Italy are facing new flare-ups. Some are imposing fresh restrictions and weighing whether to lock down again.
Prime Minister Boris Johnson of Britain on Friday announced a delay to a planned easing of measures in England as the infection rate there rose. Even Germany, lauded for its efficient response and rigorous contact tracing, has warned that lax behaviour is prompting a surge in cases.
And Italy? Its hospitals are basically empty of Covid-19 patients. Daily deaths attributed to the virus in Lombardy, the northern region that bore the brunt of the pandemic, hover around zero. The number of new daily cases has plummeted to "one of the lowest in Europe and the world," said Giovanni Rezza, director of the infective illness department at the National Institute of Health. "We have been very prudent."
And lucky. Today, despite a tiny uptick in cases last week, Italians are cautiously optimistic that they have the virus in check — even as Italy's leading health experts warn that complacency remains the jet fuel of the pandemic. They are aware that the picture can change at any moment.
How Italy has gone from being a global pariah to a model — however imperfect — of viral containment holds fresh lessons for the rest of the world, including the United States, where the virus, never under control, now rages across the country.
After a stumbling start, Italy has consolidated, or at least maintained, the rewards of a tough nationwide lockdown through a mix of vigilance and painfully gained medical expertise.
Its government has been guided by scientific and technical committees. Local doctors, hospitals and health officials collect more than 20 indicators on the virus daily and send them to regional authorities, who then forward them to the National Institute of Health.
The result is a weekly X-ray of the country's health, upon which policy decisions are based. That is a long way from the state of panic and near collapse that hit Italy in March.
Last week, Parliament voted to extend the government's emergency powers through October 15 after Prime Minister Giuseppe Conte argued the nation could not let its guard down "because the virus is still circulating."
Those powers allow the government to keep restrictions in place and respond quickly — including with lockdowns — to any new clusters. The government has already imposed travel restrictions on more than a dozen countries to Italy, as the importation of the virus from countries is now the government's greatest fear.
"There are a lot of situations in France, Spain, the Balkans, which means that the virus is not off at all," said Ranieri Guerra, assistant director general for strategic initiatives at the World Health Organization and an Italian doctor. "It can come back at any time."
There is no doubt that the privations of the lockdown were economically costly. For three months, businesses and restaurants were ordered closed, movement was highly restricted — even between regions, towns and streets — and tourism ground to a halt. Italy is expected to lose about 10% of its gross domestic product this year.
But at a certain point, as the virus threatened to spread uncontrollably, Italian officials decided to put lives ahead of the economy. "The health of the Italian people comes and will always come first," Conte said at the time.
Italian officials now hope that the worst of the cure came in one large dose — the painful lockdown — and that the country is now safe to resume normal life, albeit with limits. They argue that the only way to start up the economy is to keep tamping down the virus, even now.
The strategy of closing down completely invited criticism that the government's excessive caution was paralysing the economy. But it may prove to be more advantageous than trying to reopen the economy while the virus still rages, as is happening in countries like the United States, Brazil and Mexico.
That does not mean that calls for continued vigilance, as elsewhere in the world, have been immune to mockery, resistance and exasperation. In that, Italy is no different.
Masks often are missing or lowered in trains or buses, where they are mandatory. Young people are going out and doing the things young people do — and risk in that way spreading the virus to more susceptible parts of the population. Adults started gathering at the beach and for birthday barbecues. There is still no clear plan for a return to school in September.
There is also a burgeoning and politically motivated anti-mask contingent led by nationalist Matteo Salvini, who July 27 declared that replacing handshakes and hugs with elbow bumps was "the end of the human species."
At his rallies, Salvini, leader of the populist League party, still shakes hands and wears his mask like a chin guard. In July, during a news conference, he accused the Italian government of "importing" infected immigrants to create new clusters and extend the state of emergency.
Last week, Salvini joined other mask sceptics — nicknamed the "negationists" by critics — for a protest in the Senate library, along with special guests such as Italian crooner Andrea Bocelli, who said he did not believe the pandemic was so serious because "I know a lot of people, and I don't know anyone who ended up in an ICU."
But the country's leading health experts said that the lack of severe cases is indicative of a decrease in the volume of infections, as only a small percentage of the infected get very sick. And so far, Italy's malcontents have not been numerous or powerful enough to undermine what has been a hard-won trajectory of success in confronting the virus after a calamitous start.
Italy's initial isolation by European neighbours at the outset of the crisis, when masks and ventilators were hardly pouring in from across the borders, may actually have helped, Guerra, the WHO expert, said.
"There was competition initially; there was no collaboration," Guerra said. "And everyone acknowledged Italy was left alone at that time." As a result, he said, "what they had to do at that time because we were left alone turned out to be more effective than other countries."
Italy first quarantined towns, and then the Lombardy region in the north, and then the entire peninsula and its islands, despite the near absence of the virus in much of central and southern Italy. That not only prevented workers in the industrial north from returning home in the much more vulnerable south, but it also fostered and forced a unified national response.
During the lockdown, movement was strictly limited between regions and towns and even city blocks, and people had to fill in "autocertification" forms to prove that they needed to go outside for work, health or "other necessities." Masks and social distancing regulations were enforced by some regional authorities with steep fines. Generally, if grudgingly, the rules were followed.
As searing scenes of human suffering, empty streets and the heavy toll on an elderly generation of northern Italians spread, the transmission rate of the virus quickly decreased, and the curve flattened, as opposed to other European countries, such as Sweden, which pursued an alternative to locking down.
That the initial outbreak was localised in the overwhelmed hospitals created enormous stress, but it also enabled doctors and nurses to expedite contact tracing.
Then the country reopened, gradually, expanding liberties at two-week intervals to respond to the virus's incubation period.
The lockdown eventually had a secondary effect of decreasing the volume of virus circulating in society, and thus reducing the probability of coming in contact with someone who had it. At the end of the lockdown, the virus circulation had steeply fallen off, and in some central and southern regions, there were hardly any chains of transmission at all.
"It's always a matter of probability with these pathogens," said Guerra, adding that new early alarm systems such as the monitoring of wastewater for traces of virus had lowered the probability of infection even more.
Some Italian doctors said they believe that the virus is now behaving differently in Italy. Matteo Bassetti, an infectious disease doctor in the northwestern city of Genoa, said that during the height of the crisis, his hospital was inundated with 500 Covid-19 cases at one time. Now, he said, his intensive care unit, with 50 beds, has no coronavirus patients, and the 60-bed Covid-19 unit built specially for the crisis is empty.
He said he thought that the virus had weakened — an unproven view, he acknowledged, that has nonetheless found an eager audience in Salvini and other politicians opposed to extending the state of emergency.
Most health experts said that the virus still loomed, and as the government considers a new decree to reopen nightclubs, festivals and cruise ship travel, many of them have implored the country not to let down its guard.
"Even if the situation is better than in other countries, we should continue to be very prudent," said Rezza of the National Institute of Health, adding that he thought the question of what Italy had done right was better posed "at the end of the epidemic."
"We cannot exclude that we will have outbreaks in Italy in the next few days," he said. "Maybe it's just a matter of time."
Written by: Rukmini Callimachi
Photographs by: Gianni Cipriano and Alessandro Grassani
© 2020 THE NEW YORK TIMES
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