Italy worries about high death toll among coronavirus patients

MILAN — As Italians gear up for a COVID-era Christmas, a nagging worry is clouding celebrations: Why, despite the lockdowns and personal sacrifices made, is COVID-19 more lethal in Italy than elsewhere in Europe?

For months now, the evening news has brought death toll numbers that remain stubbornly high: Between 600 and 800 people die every day — numbers that are par with the death toll at the height of the pandemic in March. The stark figures are an unwelcome reminder that, if Italians have largely adapted to life with the virus, something is still seriously wrong. Newspaper headlines are asking: “Why do more people die in Italy?”

In terms of COVID-19 deaths per 100,000 inhabitants, Italy’s numbers are actually in line with those of other hard-hit European countries, such as Spain. But when it comes to the country’s case-fatality ratio — the number of deaths among those who are infected with COVID-19 — the country is faring worse than most.

For every 100 Italians infected, more than 3 people die (3.5 percent). Among the 20 most-affected countries in the world, only Mexico and Iran have higher fatality rates among infected patients (9 percent and 4.7 percent respectively), according to data from Johns Hopkins University.

Italy’s numbers are high in comparison to others in Europe too: In France, the case-fatality rate is 2.4 percent; in Germany it’s 1.6 percent; and hard-hit Spain has a rate of 2.7 percent. Only the United Kingdom, with 3.4 percent, has similarly worrying figures.

There is no easy explanation for the high mortality among infected Italians, according to Enrico Bucci, a biochemist and adjunct professor at Temple University of Philadelphia. Most likely, it is the result of a combination of known factors: the age of Italy’s population, the quality of its health care system, and the choices made by politicians — though it is unclear how much weight each carries, said Bucci.

According to Eurostat data, the median age in Italy is 46.7, compared with an EU average of 43.1, making it one of the oldest in Europe — and that trend is only accelerating. Between 2009 and 2019, the percentage of Italians over 80 went from 5.6 percent to 7.2 percent. By comparison, that figure is 6.5 percent in Germany and 6.4 percent in Portugal.

The equation, then, might seem simple: In a country where a large portion of the population is over 80, COVID-19 will kill more people. But other factors also come into play, including the robustness of the health system.

“Yes, COVID kills the elderly the most, but there is not a day that goes by that I don’t ask myself if everything possible had been done to save my father. Was my country’s health system ready to help him?” said Simona, a teacher from Milan who lost her father in early November.

In Italy, the health emergency laid bare serious shortcomings in hospitals when it comes to staff and equipment. Regional facilities, especially — which for years have faced severe staff cuts and little investment — found themselves unprepared to face the tsunami of COVID-19 cases. 

OECD data shows that between 2000 and 2017, Italy and Belgium were the countries that suffered the biggest cuts to their health systems. Twenty years ago, Italy had 23.3 hospitals for every 1 million inhabitants, today it has 17.5. Similarly, Belgium went from 21.9 to 15.3. As for beds in Italian hospitals, there were 4.7 beds per 1,000 inhabitants in 2000, while in 2017 there were only 3.18. 

Those statistics left health care workers facing an uphill battle during the early months of the pandemic. 

“In the first wave we went to fight this virus with uncovered hands,” said Paola Pedrini, the head of the general practitioners’ union in Lombardy, one of the hardest-hit regions in Italy. “Today it is better, but it is not an optimal situation yet.”

According to Pedrini, lowering the COVID-19 mortality rate will require more support to regional health care facilities and family doctors, both of which are crucial to avoid clogging up hospitals and, in turn, ensuring that those who need intensive care receive the proper treatment that will save their life. 

“Not investing in health means not taking care of citizens, it means not being ready to face emergency situations like this,” said Pedrini. “We hope that our politicians have learned something.”

Health care workers can only do so much — they also rely on politicians to make the right decisions when it comes to ordering lockdowns, carrying out contact tracing and implementing other safeguards to keep the virus under control. 

Some experts blame political infighting for the high death toll in Italy, saying the ongoing conflict between Rome and the regional governments — neither of which wants to be responsible for making unpopular decisions — has cost the country precious time. 

Back in March, it took several days for the government to decide whether or not to enforce a lockdown in the city of Bergamo, one of the hot-spots of the pandemic. As the days passed, the infection rate climbed, as did the number of fatalities. The government, advised by a committee of scientific experts to opt for a total lockdown, was under pressure from business lobbies that wanted factories in the area to remain open. In the ensuing quarrels between Rome and the region, their hesitations and back-and-forths, Bergamo became the hospital — and later the graveyard — of Italy. 

This dynamic is still slowing down decision-making and costing lives, experts say.

“From October 10 to 30, every index suggested taking action, but we had to wait for the official decree on November 4 [for the second national lockdown],” Carlo La Vecchia, a professor of epidemiology in Milan, told Corriere della Sera. “October was like February during the first wave; there were the same signs. We didn’t know then, we didn’t understand. This time we knew that acting immediately was essential.”

Meanwhile, some have sounded a note of caution about Italy’s death rate, suggesting that faulty numbers could be skewing the picture. 

According to immunologist Antonella Viola, the country’s infection tracking systems have not been able to keep up with the rise in cases this fall, because of a lack of testing capacity. This raises the possibility that the rate of deaths per positive cases may be lower than previously thought.

“There are more positives than those we manage to intercept,” said Viola. “This has already happened during the first wave, as demonstrated by serological analysis carried out this summer. This fact alone would blow up all the calculations.” 

Nevertheless, for Italians looking for a sign of hope going into 2021, it is hard not to avoid comparing the death toll in their news bulletins with that of other European countries, such as Germany, where the virus has been far less deadly.

Many of the underlying problems have not been addressed and doing so — if it is done at all — could take years.

“We have fewer doctors and fewer nurses, and local medicine that has been destroyed by cuts to the health care system,” said Viola. “This means that the most fragile people, the elderly, are looked after less in Italy than in Germany. After all, if Germany invests twice as much in the health of its citizens as Italy, it is obvious that the effects can be seen.”