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Italy’s Health Care System Groans Under Coronavirus — a Warning to the World
In less than three weeks, the virus has overloaded hospitals in northern Italy, offering a glimpse of what countries face if they cannot slow the contagion.
ROME — The mayor of one town complained that doctors were forced to decide not to treat the very old, leaving them to die. In another town, patients with coronavirus-caused pneumonia were being sent home. Elsewhere, a nurse collapsed with her mask on, her photograph becoming a symbol of overwhelmed medical staff.
In less than three weeks, the coronavirus has overloaded the health care system all over northern Italy. It has turned the hard hit Lombardy region into a grim glimpse of what awaits countries if they cannot slow the spread of the virus and ‘‘flatten the curve’’ of new cases — allowing the sick to be treated without swamping the capacity of hospitals.
If not, even hospitals in developed countries with the world’s best health care risk becoming triage wards, forcing ordinary doctors and nurses to make extraordinary decisions about who may live and who may die. Wealthy northern Italy is facing a version of that nightmare already.
“This is a war,” said Massimo Puoti, the head of infectious medicine at Milan’s Niguarda hospital, one of the largest in Lombardy, the northern Italian region at the heart of the country’s coronavirus epidemic.
He said the goal was to limit infections, stave off the epidemic and learn more about the nature of the enemy. “We need time.”
This week Italy put in place draconian measures — restricting movement and closing all stores except for pharmacies, groceries and other essential services. But they did not come in time to prevent the surge of cases that has deeply taxed the capacity even of a well-regarded health care system.
Italy’s experience has now underscored the need to act decisively — quickly and early — well before case numbers even appear to reach crisis levels. By that point, it may already be too late to prevent a spike in cases that stretches systems beyond their limits.
With Italy having appeared to pass that threshold, its doctors are finding themselves in an extraordinary position largely unseen by developed European nations with public health care systems since the Second World War.
Regular doctors are suddenly shifting to wartime footing. They face questions of triage as surgeries are canceled, respirators become rare resources, and officials propose converting abandoned exposition spaces into vast intensive care wards.
Hospitals are erecting inflatable, sealed-off infectious disease tents on their grounds. In Brescia, patients are crowded into hallways.
“We live in a system in which we guarantee health and the right of everyone to be cured,” Prime Minister Giuseppe Conte said on Monday as he announced the measures to keep Italians in their homes.
“It’s a foundation, a pillar, and I’d say a characteristic of our system of civilization,” he said. “And thus we can’t allow ourselves to let our guard down.”
For now, Italian public health experts argue that the system, while deeply challenged, is holding, and that all the thousands of people receiving tests, emergency room visits and intensive care, are getting it for free, keeping a central principle of Italian democracy intact.
But before the region of Lombardy centralized its communication on Thursday and seemed to muzzle doctors and nurses who spoke out about the conditions, there emerged troubling pictures of life inside the trenches against the infection.
A photo of one nurse, Elena Pagliarini, who collapsed face down with her mask on in a hospital in the northern town of Cremona after 10 straight hours of work, became a symbol of an overwhelmed system.
“We are on our last legs, physically and physiologically,” Francesca Mangiatordi, a colleague who took the picture said on Italian television on Wednesday, urging people to protect themselves to avoid spreading the virus. “Otherwise the situation will collapse, provided it hasn’t already.”
A doctor in a hospital in Bergamo this week posted on social media a graphic account of the stress on the health system by the overwhelming number of patients.
“The war has literally exploded and battles are uninterrupted day and night,” the doctor, Daniele Macchini wrote, calling the situation an “epidemiological disaster” that has “overwhelmed” the doctors.
Fabiano Di Marco, head of pulmonology at the Papa Giovanni XXIII hospital in Bergamo, where he has taken to sleeping in his office, said Thursday that doctors literally “draw a line on the ground to divide the clean part of the hospital from the dirty one,” where anything they touch is considered contagious.
Listen to ‘The Daily’: ‘It’s Like a War’
We spoke to a doctor triaging care at the heart of the coronavirus crisis in Italy about what may lie ahead for the U.S.transcript
Listen to ‘The Daily’: ‘It’s Like a War’
Hosted by Michael Barbaro, produced by Lynsea Garrison, Annie Brown, Clare Toeniskoetter and Kelly Prime, and edited by Lisa Chow
We spoke to a doctor triaging care at the heart of the coronavirus crisis in Italy about what may lie ahead for the U.S.
- dr. fabiano di marco
Can you see me? No, I think.
- michael barbaro
I cannot see you, but I can hear you. And I think I can hear you — ah, now I can see you.
- dr. fabiano di marco
OK. Sorry for my English. I don’t know if my English will be adequate for a podcast. But then you will decide, OK?
- michael barbaro
It’s exceptional. And I’m really grateful that you’re making time for us.
- dr. fabiano di marco
Thank you. Thank you.
- michael barbaro
So, where are you right now?
- dr. fabiano di marco
Now, I’m at home. After three weeks, today, in the afternoon, I am at home, because I have a big family with three children. And I decide to come back at home one day.
- michael barbaro
So you have not been home in three weeks?
- dr. fabiano di marco
Three weeks, yes. I have been in my hospital every day, start of the crisis, Friday the 21st of February. And since then, it was a total mess. It’s like a war, to be honest.
- michael barbaro
From the New York Times, I’m Michael Barbaro. This is “The Daily.”
- [music]
- archived recording
This is how Italy’s cases have grown now for the last month — slowly at first, but now more rapidly. It’s a textbook epidemic curve.
- michael barbaro
Italy has quickly become the new epicenter of the pandemic, with nearly 30,000 infections and more than 2,000 deaths, numbers that are soaring by the day, even after the government there took extreme measures to lock down much of the country.
- archived recording (dr. jerome adams)
We are at a critical inflection point in this country.
- michael barbaro
On Monday, the U.S. surgeon general warned that the United States is now on a strikingly similar path.
- archived recording (dr. jerome adams)
People, we are where Italy was two weeks ago in terms of our numbers. And we have a choice to make as a nation. Do we want to go the direction of South Korea and really be aggressive and lower our mortality rates? Or do we want to go the direction of Italy?
- michael barbaro
Today, a conversation with a doctor in Bergamo, north of Milan, one of Italy’s hardest hit areas.
- [music]
It’s Tuesday, March 17.
- michael barbaro
Could I just ask you to just say your full name for me?
- dr. fabiano di marco
OK. My name is Fabiano Di Marco. I’m a professor of the University of Milan and the head of the respiratory unit of the Hospital Papa Giovanni XXIII of Bergamo, which is a town close to Milan.
- michael barbaro
Can you give me a sense, and maybe paint the picture, of what it’s like in the hospital right now, what you’re dealing with?
- dr. fabiano di marco
I have now — my ward has been totally transformed. Nothing is as before. I’ve been in my hospital every single day for 14 hours or 15 hours a day —
- michael barbaro
Wow.
- dr. fabiano di marco
— to try to deal with the outbreak of coronavirus infection.
- michael barbaro
What has been the story of what has happened in your hospital these past few weeks? Because I think people in the United States are desperate to understand what you have seen, and what people have said to you, and what it has looked like. You described it as a war. So we want to understand what you mean.
- dr. fabiano di marco
OK. Every day we receive, on average, between 50 to 70 patients with severe respiratory failure due to coronavirus infection. Every single day. And to describe my reality, my hospital is, at least in Europe, a huge hospital with 1,000 beds. But to receive every day between 50 and 70 patients with severe pneumonia due to coronavirus, it’s impossible. You have to change your organization day by day.
- michael barbaro
And tell me what you mean. How do you have to change your organization to deal with people who are in such severe respiratory condition?
- dr. fabiano di marco
So we change it, the normal ward, mainly surgery wards, because the activity of surgery has been reduced off at least 80 percent. And we transform it, so far five wards of surgery for patients with coronavirus. Now we have, between the five wards and the emergency room, at least 350 patients with respiratory failure due to coronavirus infection.
- michael barbaro
Wow.
- dr. fabiano di marco
Today is the first day in which we have more than 50 percent of the hospital dedicated to coronavirus patients. To organize these, we had to teach cardiologists, dermatologists, rheumatologists — specialists of something very different from respiratory failure — how to treat this patient. You try to find a solution. But day by day, it’s no longer enough. So I can tell you that my colleagues, both physicians and nurses, they cry every day.
- michael barbaro
Wow.
- dr. fabiano di marco
I’m 47. I’m not so, so old to be the head of a ward, at least in Italy. But I have with me 20 colleagues who are respiratory physician, with many fellow. They are 27, 30. So for me, it’s a huge responsibility. And I was scared they can be sick. OK? But we cry every day. And now, we have today, 460 nurse at home because they are sick. And I think we have —
- michael barbaro
Wow.
- dr. fabiano di marco
Yes. It’s a very huge number.
- michael barbaro
You have 460 nurses who are in a hospital in the middle of this crisis who are home because they’re sick?
- dr. fabiano di marco
Yeah, today. This is the outcome of today.
- michael barbaro
And is that because they are sick with the coronavirus?
- dr. fabiano di marco
There are some who are sick, some with a total burnout for the situation, and other who are contact of patients, so they stay in quarantine at home.
- michael barbaro
Doctor, you said you are upset, that you maybe even cry every day. And I wonder if there is an experience, maybe one story or one patient, that made you upset?
- dr. fabiano di marco
The main problem for us is to treat our colleagues. As doctor, we are used to treat patients. And for us it’s normal. There is not so emotional, luckily, because we are used to treat other people. But this is difficult when the patient is your colleague. And we have now admitted tens of colleagues or nurse, people who you will meet every day in your life.
- michael barbaro
Your colleagues are now your patients because they have contracted the virus.
- dr. fabiano di marco
Absolutely. For example, yesterday, the chief of my department come to the emergency room to be with a low level of oxygenation. He has a bilateral pneumonia due to coronavirus.
- michael barbaro
Wow. I’m sorry.
- dr. fabiano di marco
Not very severe. But he was someone who tried to organize the hospital to deal with this infection three days ago. And we went to have a dinner with my wife and his wife one week ago.
- michael barbaro
Wow.
- dr. fabiano di marco
I don’t know. We are scared because on Friday, only in my hospital, we had 20 deaths.
- michael barbaro
20 deaths.
- dr. fabiano di marco
Yeah. For coronavirus. In one day.
- michael barbaro
That’s extraordinary.
- dr. fabiano di marco
Yeah. So another important thing, we have not had the opportunity to allow the relative to come to the hospital for two reasons. First, it’s a danger for them and for other people, evidently, because in 80 percent of the cases, they are infected. The second reason, which is not easy to understand if you are not in this situation, is that we do not have enough personal protective equipment — the mask in case of infection, something to cover the shoes, and the gown. It’s impossible to find these now Europe, not only in Italy.
- michael barbaro
So you’re running out of those and you can’t get them anywhere, in the region or anywhere in Europe. You just can’t get them.
- dr. fabiano di marco
Yeah. Impossible to find.
- michael barbaro
Wow.
- dr. fabiano di marco
If I allow one or two relative to come to the hospital, I have to give them these. But we do not have this for us.
- michael barbaro
Right. You need them for doctors.
- dr. fabiano di marco
Yeah. They cannot receive the relative in hospital. So the patients are alone. And they die alone. We — this is difficult for us. We try to call, every day, the relative. But I have to tell you that sometimes, in the confusion of this new organization with a dermatologist who is trying to treat a patient with severe respiratory failure, and probably the doctors cry, and the — no one remember to call the relative. So it’s happened that the relative call the hospital —
- michael barbaro
And the person’s already dead.
- dr. fabiano di marco
Yeah.
- [music]
- michael barbaro
We’ll be right back.
Doctor, you’ve mentioned a lot of the choices that you and your staff have to make now that this is such a terrible situation. And I wonder how you make decisions about who gets which treatment, and who has the best chance to survive. How do you make those decisions?
- dr. fabiano di marco
This is, for us, a crucial point, because we have hundreds of very sick patients. But we have tens of I.C.U. beds.
- michael barbaro
Right.
- dr. fabiano di marco
The problem is that you can find many scores of gravity. But these scores of gravity have been thought for another reason. OK?
- michael barbaro
And when you say score of gravity, you mean, basically, kind of a calculation of who is in greatest need?
- dr. fabiano di marco
Absolutely. So for instance, if you are 80, you have a severe respiratory failure, and I don’t know, you have also renal failure, I have to admit you in the I.C.U. because you are very severe. And you have a probability to die very high. OK. I have to admit you in the I.C.U.. But now we need another score, which is a score which help us to understand your probability to benefit of the I.C.U. bed. And we do not have this score. OK?
- michael barbaro
Because it has not been created.
- dr. fabiano di marco
Absolutely. We are trying to do this now, because for example, the age, for all of the stage of severity, higher is the age, higher is the score. But when you have few beds for many people, the age is absolutely the opposite. If you are 85, I give the bed to another one who is 45.
- michael barbaro
Because 45-year-old is more likely to benefit from the I.C.U. bed than the 80-year-old. So you’re saying all the normal rules have to be thrown out the window.
- dr. fabiano di marco
Absolutely. We need a new tool we do not have, because so far, the difference between the number of patients, number or bed, is something totally new for us. OK? And not only for us, all the country will have to deal with this. But it’s difficult to tell people that if you are 80, you will never have the I.C.U. bed.
- michael barbaro
Of course.
- dr. fabiano di marco
But so far, if you have not the opportunity to build a new hospital with 1,000 bed, such as in China, we need this terrible tool, because this is a tool of selection.
- michael barbaro
Right — of who lives and who dies.
- dr. fabiano di marco
Yeah. And this is why it’s important. If you do not reduce the number of patients who are sick, it’s impossible to deal with this disease. Impossible. You have to reduce the rate of infection. And the only way to reduce the rate of infection is to change totally the life of people. Now, in Italy, everyone is at home. This is a tragedy for economy. No one is working. No one is working. But it’s the only way. There is not something in between.
- michael barbaro
It sounds like you’re saying that once you are in a hospital as a doctor, looking at a room full of people with this virus, overwhelmed, it’s too late. That the role of countries who are not yet at the place Italy is in is to make sure they don’t ever get to that place, don’t ever get to the point that your hospital is at. And to do whatever it takes to not get there.
- dr. fabiano di marco
Absolutely. You have two choices. You decide to not close all the activities, close the people in their home, and you will accept thousand of beds. Or, you have to close all the activity. There is not a choice in between. I know this is difficult to have this approach, because also in Italy, if you speak with my colleague in another town, it’s quite difficult to understand this. Because many people, including many physicians, have not this perception of this. Because in your reality, all is normal. It’s difficult to be scared for something you have not the perception. OK? So I can understand that in other countries, it’s the same. But trust us, or, such as in Bergamo, each family will have a relative or a friend who dies. This is the situation in Bergamo. This is not a disease that you can discuss on TV, or you will have the perception of this in your family, in your relative, in your town. It’s something very aggressive, very aggressive.
- michael barbaro
I wonder, as a doctor, what advice you would give to doctors in the United States who may have to do what you have to do and make the kind of difficult decisions that you have to make now.
- dr. fabiano di marco
I think that the best is to speak with us to analyze the situation of Italy. It could be something important. Because you have to be prepared for this. This is the only thing I would suggest to my colleague. Because also in Italy, I have some colleague in the other part of Italy who are not prepared. And I speak with them. They are doing the same thing we did three weeks ago. This is incredible. This new reality we are living started the 23rd of February, not three years ago. OK? Three weeks ago. After three weeks, we are living in another dimension. For me, it’s difficult to think to my life before this.
No one can be prepared for this — impossible.
- michael barbaro
I wonder, just a final question here. At the beginning of our conversation, you said you were finally home after three weeks. And I wonder what it was like to come home to your family. What are you telling them? And how are you feeling?
- dr. fabiano di marco
My children are at home now for three weeks. The schools are closed. Luckily there are three, so they can stay together. But we try to create a normal situation at home. For me, it’s difficult, because evidently, I have a risk of infection which is higher than compared to other people. So I had to decide what to do at home. If stay with a mask —
sorry. And I decide to stay normal, without the mask.
- michael barbaro
It sounds like this was a tough decision.
- dr. fabiano di marco
Yeah, because I have to find the solution between to protect the best, uh, my wife and do not scare my children. OK? The only good news is that children and young boys or girls are not affected. This is the only consolation for us. And I decide that I changed my approach to my children. OK? I pay attention to my hands. I pay attention to my towel. OK? But I decide to not wear a mask because it will be difficult for them to see the father who is a respiratory physician in Bergamo with those kind of cases, hundreds of that. So also for these, it’s really difficult to decide what is the best. And then I spoke with my wife. And we decided to do this.
- michael barbaro
It sounds like on top of all the difficult decisions you’ve had to make, you had to go home and make one more difficult decision, which was this mask.
- dr. fabiano di marco
Yeah. Absolutely.
- [music]
- michael barbaro
Doctor, I really want to thank you so much for giving us your time. And I want to wish you the best of luck, you and all your colleagues, doctors and nurses at the hospital. We’re going to be thinking about you a lot in the coming days.
- dr. fabiano di marco
Thank you. Thank you. It has been a privilege. I hope, indeed, to be useful for some of my colleagues and for you.
- [music]
- michael barbaro
We’ll be right back.
Here’s what else you need to know today.
- archived recording (donald trump)
This afternoon, we’re announcing new guidelines for every American to follow over the next 15 days. As we combat the virus, each and every one of us has a critical role to play in stopping —
- michael barbaro
On Monday, President Trump issued sweeping new health guidelines for Americans, encouraging them to work from home, avoid restaurants, bars, and food courts, and discretionary travel, and limit gatherings to 10 people or fewer.
- archived recording (donald trump)
If everyone makes this change or these critical changes and sacrifices now, we will rally together as one nation. And we will defeat the virus. And we’re going to have a big celebration all together.
- michael barbaro
But the guidelines are not mandatory. And the president stopped short of explicitly ordering Americans to stay home, as several countries in Europe and a handful of U.S. counties are now doing. On Monday, health officials in the Bay Area of California instructed nearly 7 million people to remain in their homes, with few exceptions, to slow the virus’s spread.
- archived recording
These new orders direct all individuals to shelter at their place of residence and maintain social distancing of at least 6 feet from any other person when outside their residence. We know we need to do this. And we know we need a regional approach.
- michael barbaro
American health officials now predict that the U.S. outbreak is likely to last for months.
That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.
Giorgo Gori, the mayor of Bergamo, said that in some cases in Lombardy the gap between resources and the enormous influx of patients “forced the doctors to decide not to intubate some very old patients,” essentially leaving them to die.
“Were there more intensive care units,” he added, “it would have been possible to save more lives.”
Dr. Di Marco disputed the claim of his mayor, saying that everyone received care, though he added, “it is evident that in this moment, in some cases, it could happen that we have a comparative evaluation between patients.”
On Thursday, Flavia Petrini, the president of the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care, said her group had issued guidelines on what to do in a period that bordered on wartime “catastrophe medicine.”
“In a context of grave shortage of health resources,” the guidelines say, intensive care should be given to “patients with the best chance of success” and those with the “best hope of life” should be prioritized.
The guidelines also say that in “in the interests of maximizing benefits for the largest number,” limits could be put on intensive care units to reserve scarce resources to those who have, first, “greater likelihood of survival and secondly who have more potential years of life.”
“No one is getting kicked out, but we’re offering criteria of priority,” Dr. Petrini said. “These choices are made in normal times, but what’s not normal is when you have to assist 600 people all at once.”
Giulio Gallera, the Lombardy official leading the emergency response, said on Thursday that he hoped the guidelines never needed to be applied.
He also said the region was working with Italy’s civil protection agency to study the possibility of using an exhibition space abandoned by canceled conventions as a 500-bed intensive care ward.
But, he said, the region needed doctors, and respirators.
“The outbreak has put hospitals under a stress that has no precedents since the Second World War,” said Massimo Galli, the director of infectious diseases at Milan’s Sacco University hospital, which is treating many of the coronavirus patients. “If the tide continues to rise, attempts to build dams to retain it will become increasingly difficult.”
Dr. Galli pointed out that while the government’s emergency decrees had sought to boost the hiring of thousands of doctors and health workers — including medical residents in their last years of medical school — it took time to train new doctors, even those transferred from other departments, who had little experience with infectious diseases. Doctors are also highly exposed to contagion.
Matteo Stocco, the director of the San Paolo and San Carlo hospitals in Milan, said 13 members of his staff were home after testing positive for the virus. One of his primary emergency room doctors was also infected, he said, “after three weeks of continuous work, day and night on the field.”
Dr. Puoti, of Niguarda hospital, said the doctors kept distance from one another in the cafeteria, wore masks during staff meetings and avoided gathering in small rooms. Still, he said, some had been infected, which created the risk of greater personnel shortages.
“We’re trying to keep a humanly sustainable level of work,” he said. “Because this thing is going to last.”
He said the hospital was trying to buy more respirators and preparing for the possibility that patients would come not only from the surrounding towns, but because of a wave of infections in Milan.
Dr. Stocco said that moment had already arrived.
Fifty people showed up in the emergency room on Thursday afternoon with respiratory problems, he said. The hospital had already canceled surgeries and diverted beds and respirators to coronavirus patients, and doubled its intensive care capacity.
“The infection is here,” he said.
Carlo Palermo, president of the association representing Italy’s public hospital doctors, said the system had so far held up, despite years of budget cuts. It also helped, he said, that it was a public system. Had it been an insurance-based system, there would have been a “fragmented” response, he said.
He said that since about 50 percent of the people who tested positive for the virus required some form of hospitalization, there was an obvious stress on the system. But the 10 percent needing intensive care, which requires between two and three weeks in the hospital, “can saturate the capacity of response.”
Many experts have noted that if the wealthy and sophisticated northern Italian health care system cannot bear the brunt of the outbreak, it is highly unlikely that the poorer south would be able to cope.
If the virus spread south at the same rate, Dr. Palermo said, “the system won’t hold up, and we won’t be able to assure care.”
Many experts have warned that Italy is about 10 days ahead of other European countries in the development of its outbreak. Chancellor Angela Merkel of Germany has raised the alarm that about 70 percent of Germans could get the virus.
And reports of the overwhelmed Italian system have resonated in the United States, where President Trump closed flights to foreigners coming from Europe on Wednesday night.
“The Italian disease is becoming a European disease and Trump, with his decision, is trying to avoid that this becomes an American disease,” said Romano Prodi, a former Italian prime minister and president of the European Union commission.
“In any case I think that coronavirus is already also an American problem,” he said, adding that, because of the difference in the health care system, “it may be more serious than the European one.”
Elisabetta Povoledo contributed reporting from Rome, Emma Bubola from Verona, Anna Momigliano from Milan, and Barbara Marcolini and Haley Willis from New York.
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