Build a Welfare State During Ordinary Times to Survive Pandemic Times: Lessons from Italy

By Nanditha Mathew

The COVID tragedy in Italy

Italy had the bad luck of being the first European nation where the COVID-19 outbreak erupted, currently with 235,763 documented cases and 34,114 deaths, as I write this article. This high number of infected and deaths is despite the country having one of the best health systems in the world. There could be several factors that caused such vast spread and high death rates in Italy, such as the demographic nature of the population, densely populated cities, organization of the health system, ill-timed public gatherings, timing of the lockdown etc. While factors like the demographic structure of the population are unchangeable, some other factors could likely have been different which might have led to different outcomes. Understanding these factors is useful for other nations to learn, adapt and take timely actions.

A major factor behind the high death rates is the demographic nature of the population. Italy has one of the oldest populations in the world. The share of the population above the age of 65 years is currently around 23%, which makes it a high-risk country since COVID-19 mortality increases exponentially with age. Italy also features a social structure with high social inter-connectivity between generations. For many Italians, extended families form the basis of their social circles. It is very common for the extended family to be deeply involved in each other’s daily lives, a case in point being grandparents (people who are at the highest risk from COVID-19) taking care of grandchildren. They might be even living together since social structures and the poor economic climate results in Italians staying at home for years into their adulthood. Such inter-generational co-residence patterns might have played an important role in increasing infections among the older generation. Inter-generational social contacts are quite high in Italy: contacts that a person belonging to the age category 65-70 years has with younger age groups is high in Italy compared to other countries in Europe.¹ A study² estimates that the combination of aged population with inter-generational residence leads to high death rates due to COVID-19 in countries like Italy and Spain.

Italy being the first country in Europe to witness the outbreak was not aware of the spread of infections when several public gatherings took place. A big public event, cited as the ‘biological bomb’ was the champions league match between Atalanta and Valencia when a third of the population of Bergamo with 1,20,000 inhabitants went to Milan to support their team for the biggest game in the team’s history. One can imagine the virus doing a hop-on hop-off tour when Atalanta supporters hugged and kissed each other for all of the four goals that they scored. Bergamo, consequently, turned out to be one of the worst-hit provinces of Italy.

Italy’s response

It was only after three weeks from the time Italy discovered its first corona-virus case on Feb 21 that it closed down all non-essential businesses and implemented a national ban of unnecessary movements by the public. The question is if the government had acted before, would it have saved lives? A study³ shows that earlier interventions, even small differences in timing would have prevented the exponential growth in cases. Indeed, scientists warned leaders with their early projections in mid-February, but these were not taken seriously. To quote Dr Alessandro Vespignani, Director, Network Science Institute at North-eastern University, Boston: ‘We were talking to officials here, and it was the same reaction we got in Italy, in the U.K., in Spain,’ Dr Vespignani said. ‘They told me, “OK, that’s happening on your computer, not in reality” ‘Look,’ he added, ‘No one’s going to shut down a country based on a model.’⁴

Evidently, Italian politicians did not miss overconfidence on the control of the situation. The Mayor of Milan unveiled a campaign, ‘Milan Doesn’t Stop,’ allowing bars in Milan, Italy’s economic hub, to remain open in the evenings.

Italy is a decentralized country, with significant power vested with local governments, which in the case of its health system, results in differences in health care policies across regions. As I am writing this article, Italy’s wealthy region Lombardy has a shocking record of 90,680 confirmed cases and 16,351 deaths in a population of 10 million while its neighbouring region Veneto fares better with 19,194 cases and 1,951 deaths in a population of about 5 million. The ‘Veneto model’, which emerges as a relative success story, took a comprehensive approach, with extensive testing of both symptomatic and asymptomatic cases, tracing of possible positives and a strong emphasis on home diagnosis and care, which likely reduced the hospitals’ burden.

Experts in Italy claim that the increased burden on hospitals have been a consequence of some strategic mistakes in choosing whom to hospitalize. Several patients with mild symptoms were admitted leading to limited space by the time more patients with severe symptoms arrived.⁵ This has to be viewed in the context of the already low ICU capacity of Italian hospitals – after several years of budget cut, Italy went down to 8.6 ICU beds per 100,000 people, below the average of 15.9 within the developed countries of the OECD.

Italian life involves extended social mingling and gatherings. Apparently, people found it difficult to go on without social activities outside their homes, which is evident by the number of police cases registered for not obeying lockdown rules.⁶ The viral videos of Italian mayors yelling at citizens for not adhering to lockdown measures made rounds on social media. From launching insult-armed drones to going in disguise, mayors had to somehow restrict people who disregarded the nationwide lockdown by going jogging, playing ping pong and taking ‘exhausted dogs’ for long walks.

Though late, with lockdown and several measures in place, Italy witnessed a slowdown and now the country is beginning to open up the economy. It is extremely difficult to effectively estimate the contribution of different causes and preventive measures since many of these were happening and being executed at the same time and this we leave to virologists and epidemiologists to be studied in the coming years.

Lessons for India

In the short-term
Similar to Italy, India has some inherent characteristics that put it at high risk – the density of population, multi-generational co-residence etc. Research⁷ shows that the presence of multi-generational families in India leads to a high frequency of contact among all age groups, especially between the elderly (60 years or older) and young children. Therefore, preventing within-household transmission of the virus becomes particularly challenging. India is, however, not only at high risk due to its high density of population, but also because of its highly vulnerable categories of people – slum-dwellers, migrant workers and the homeless. Existing chronic health conditions make them further susceptible to infection. The dismal living conditions of slum residents — lack of basic facilities, like personal toilets, clean water etc — further contribute to the spread. There should be immediate intervention from the government with policies at local levels, in partnership with NGOs and other organizations that work closely with such vulnerable sections of the society. To add to this, most of these vulnerable groups are part of the informal economy which shut down due to the lockdown leaving several unemployed. Italy introduced a cash transfer programme, the REM (reddito di emergenza), a transfer of ‘emergency income’ to the low-income sections of society. India should undertake such programmes since it is in the immediate responsibility of the government to support the vulnerable in meeting their basic necessities.

In the short-term, we have seen several countries following the policy of lockdown with different levels of intensity. As predicted by scientific models⁸, travel restrictions, lockdown and ‘stay at home’ measures did work in slowing down the pace of COVID-19 infections and thereby, preventing excess burden on hospitals.

A hypothesis that gives some good news is that there is more than one genotype of the virus⁹ and it is the severe genotypes of the virus that cause serious infections leading to hospitalization of the infected people. Isolation of hospitalized patients blocking human-to-human transmission, in other words, isolation of the severe virus genotypes leads to a ‘selective pressure’ on the virus. This could imply that the strain of the virus that will be out around would be a ‘weak’ one and the next level infections would not have as many seriously infected patients as before, causing much less burden on the healthcare system. This, if true, is positive news, but one still needs a minimum level of health infrastructure to accommodate the first round of patients infected with the strong strain of the virus. In addition, it is important that the severely affected seek hospital help. At an early stage, the lockdown certainly helps to reduce the spread of this tough strain of the virus.

Another lesson that India can learn in order manage with less hospital use is not to overburden hospitals with patients with less severe symptoms, since this might lead to running out of space when more serious cases arrive. As discussed before, in the beginning, one of the strategic mistakes that scientists cite with reference to Italy was on the choice of whom to be admitted. At a later stage, the rule followed in Italy was to admit patients with respiratory distress.¹⁰ When the crisis turned serious, the Government regained control of crucial decisions, such as the coordination of intensive care unit availability. The successful ‘Veneto model’ shows that to keep the disease at a level that  does not exceed the capacity of the health system, the policy should be scaling up testing, contact-tracing, household quarantine, providing enough protective equipment to hospital staff and acting immediately in case of exposures of medical staff to avoid loss of personnel capacity.

In all these policies to fight COVID-19, there should be a strong involvement from scientists, especially epidemiologists and virologists in the decision-making process along with politicians, where the latter take a passive role. Politicians do have an important role, but this should be confined to addressing facts, making timely decisions based on science and helping the vulnerable while scientists and health professionals do their job. During the lockdown, in several countries, the head of the state regularly addressed the public, at times, along with scientists, which helps build public trust and compliance to guidelines. A factual ministerial address with legitimate details would seem more credible than overconfident claims like ‘the Mahabharata battle was won in 18 days but the COVID one would take 21 days’¹¹ to which, likely no epidemiologists would have agreed to. A Google search of the word ‘atmanirbharta’, from the Indian Prime minister’s speech,¹² suggests ‘self-reliance’, which, based on the way things stand, might suggest that ‘you are on your own in this’. Irrespective of what the Prime Minister meant, a public understanding that one has to take care of oneself during these times is worthwhile.

Italy, like some other countries, is following the principle of helping the society adapt to the ‘new normal’ while trying to keep it as close as possible to the ‘old normal’. Allowing people to go back to normal life and preventing social gatherings does not go together, but, also for India, adapting to a locally suited ‘new normal’ will be one way forward given the long-expected time to find a vaccine. A hopeful feature of the Italian case is that irrespective of the new relaxation on mobility restrictions of people and even without much contact tracing and testing to replace the relaxation measures, the numbers of both ICU patients and deaths in all Italian regions seem to be improving steadily. Even though it is difficult to understand the causal effect behind the numbers we observe, a moderate guess would be that people likely changed their high-risk behaviour and routines, like touching face frequently, close physical contact in closed spaces etc. New routines of maintaining social distance, wearing masks, avoiding crowding indoors, washing hands frequently etc should come into place. Masks should be compulsory; several countries¹³ have done it following recent scientific studies that show the effectiveness of masks in preventing the transmission.¹⁴

Public awareness regarding the mechanisms of the spread of the virus and building practices and behaviours that put people at low risk is crucial. A clear lack of awareness among the public was more than evident with ‘corona festivals’¹⁵ and group rallies to show support for healthcare professionals, breaking all rules of social distancing, the very reason government opted for a lockdown. Sadly, some of these measures, like social distancing are practically impossible for many living in slums and small apartments.

Easing of lockdown should be carefully planned and should consider country-specific details. For Italy, it was relatively easier to move to online education than for India, where several students lack basic digital infrastructure. The opening of non-essential services like religious places of worship is highly debatable. Given the overall lack of health infrastructure, one way to smoothen the reopening will be to ease the lockdown at different times in different states so that extra resources from one state can be used to help another. This could even be done at a more decentralized level, across different districts within states. A similar strategy was followed in Italy –patients needing ICU for non-COVID-19 diseases were transferred to the regions in Central and southern Italy.

In the long-term
In light of these discussions, what is evident is that the short-term policies are very much linked with long-term policies, in particular, in a strong social welfare state with a very inclusive public healthcare system. Let us turn back to the tale of two Italian regions, the successful Veneto vs tragic Lombardy. One important difference between these two regions is worth mentioning: Lombardy has a system of public-private partnership in healthcare, unlike Veneto.¹⁶ Lombardy’s private hospitals with the ‘patient-focused’ system have been criticised for ‘bad’ profit incentives. An article in an Italian newspaper Il Fatto Quotidiano¹⁷ criticized Lombardy’s healthcare system as ‘concerned only with individual care and profit over prevention’, an approach which ‘transformed health into a commodity, ignoring prevention because it does not produce profits’.

During this pandemic time, one realizes the importance of a social welfare state where no section of society is left behind, especially when it comes to access to health care. According to reports, private hospitals in India have been charging high prices for isolation wards and patients are even asked to pay for personal protective equipment (PPE) used by doctors and other staff.¹⁸There are reports of inefficient service rendered by government hospitals in many states¹⁹ which gives a competitive edge to private hospitals allowing them to charge exorbitant prices for treatment.²⁰ An inclusive public health system turns out to be a necessity, especially for the vulnerable section of the population with health preconditions who are in greatest need for healthcare and those left out of the system. India has historically always spent less on health; it was 3.6% of the GDP (2018), the least among the BRIC countries. Brazil spends the most (9.2%), followed by South Africa (8.1%), Russia (5.3%), China (5%). Economic growth and development do not materialize in the long run without a healthy society, which can only be realized through universal healthcare by massive public investment.

To sum up, in the short-term, we can rely on adapting policies and immediate recovery plans that the situation demands, but for the long-term, the only way is to build a welfare state that includes every section of the society so that no one is left behind.

A Precautionary note on interpreting COVID-19 data

While it is useful to understand the factors behind the cause of spread and which actions led to the reduction of the same, one should be careful in interpreting the numbers we observe. The data available on Worldometers is based on positive tests and on not on those actually infected. We should understand the denominator better to calculate the case-fatality rate properly. Another difficulty lies in differentiating between deaths with COVID-19 infection and deaths caused by COVID-19 infection because, likely, the vast majority of patients who have died had one or more pre-health conditions that led to their death. In addition to these, there might even be unreported deaths, that is, deaths that are due to COVID-19 but not recognized or reported.

One way to reach an estimate of this will be to calculate the ‘excess mortality’,²¹ number of deaths above and beyond what we would have expected to see under ‘normal’ conditions. However, this should be carefully calculated since there are too many factors at play at the same time, for example, the lockdown might have reduced deaths by road accidents to a large extent. To add to the complications, there could be regional variations in reporting and measurement. Even in the developed world, there  are country-level (and sometimes even regional-level) differences in recording deaths: France only records COVID-19 fatalities in hospitals; Spain does not include unconfirmed cases in nursing homes; the Netherlands only tests hospitalized patients; and, Sweden records death from nursing homes as well. It is difficult to comment on India because of the lack of detailed information on how reporting actually is carried out in different states. Indian Council of Medical Research, in an attempt to create robust data, recently provided guidelines on reporting deaths.²²

To properly document COVID-19 and related deaths, is a very complicated task, both in theory and in practice. For instance, to which category does the migrant workers who died out of exhaustion walking home during the lockdown belong? According to WHO guidelines, these are not COVID-19 deaths, but to get a more comprehensive picture of the impact of this crisis it is crucial to document these deaths. These are issues to be thought about and researched since cleaner numbers help us not only in evaluating the situation better but also in making better policies.

AUTHOR
Nanditha Mathew, Researcher, UNU-MERIT, Maastricht, Netherlands

Disclaimer: The views and opinions expressed are those of the author and do not reflect the official policy or position of the United Nations University – Maastricht Economic and Social Research Institute on Innovation and Technology.

Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.