This week, doctors in Italy have been forced to make choices that no one, least of all people who have taken an oath to protect lives, should face: Who lives and who dies?
As the country’s coronavirus caseload has skyrocketed – more than 15,000 people have been infected and at least 1,000 have died – healthcare workers on the front lines are confronting a worst-case confluence of a contagious new virus, an aging population, and shortage of hospital beds.
Doctors are now prioritizing young and mostly healthy COVID-19 patients because their chances of survival eclipse those of the elderly.
“We do not have free beds in intensive care units,” Lorenzo Casani, the health director of a clinic for elderly people in Lombardy, told Time. Doctors, he added, must “make this horrible choice and decide who is going to survive and who is not going to survive … who is going to get a monitor, a respirator, and the attention they need.”
The tragic triage is reminiscent of the choices made on a battlefield, and indeed, Italy is now at war.
The country reported its first coronavirus case less than four weeks ago, on February 20. Now the scale of the country’s outbreak is second only to China’s.
In response, Italian officials seem to have tried everything: They shut down schools, ordered shops to close, emptied the country’s wildly popular tourist destinations, quarantined dozens of cities, and then expanded that “red zone” to lock down the entire country of 60 million people.
“We all must give something up for the good of Italy. There is no more time,” Prime Minister Giuseppe Conte said in a televised address.
‘From one day to another, it was empty’
Isabella Castoldi, a 25-year-old resident of Florence, told Business Insider that when news of the coronavirus emerged in Italy, few people she knew took the threat very seriously.
“We underestimated the coronavirus,” Castoldi said.
Because the illness originated in China, she added, it seemed “very, very far away.”
Castoldi even went to Milan to get a tattoo on February 28. The coronavirus had breached northern Italy by that point – hundreds were sick. After returning from her trip, she went to work at a popular ice cream store steps from the city center.
“We usually have a very, very long queue that extends outside the door,” Castoldi said. “Then, from one day to another, it was empty.”
As she and a co-worker counted the shop’s daily earnings, she said, realized they’d made “thousands of euros” less than normal.
“That’s when we started to realize that maybe this is more serious than we thought,” Castoldi said.
A series of lockdowns
On February 23, the Italian government put almost a dozen towns – those in which the most coronavirus cases were reported – on lockdown. About 50,000 people were affected. Major landmarks were closed, the annual Venice Carnival was canceled, Giorgio Armani held its runway show at Milan Fashion Week in an empty theater.
By February 26, less than a week after the first reported case, 12 people had died.
Castoldi said she began to notice “overflowing” supermarkets as people panic-bought toilet paper, meat, and pasta.
A week-and-a-half later, on March 8, Conte cordoned off an area of the country containing 16 million people. The quarantine came as Italy’s coronavirus case total approached 6,000; its death toll had surpassed 230.
But news of the impending closure leaked ahead of time, prompting thousands of people to flee parts of northern Italy the day before it went into effect.
Roberto Burioni, a professor of virology at Milan’s Vita-Salute San Raffaele University, told The Guardian that the leak triggered unnecessary travel as people rushed south.
“Unfortunately some of those who fled will be infected with the disease,” he said.
Because Castoldi had been in Milan, which was part of the closed-off region, she reached out to her doctor and was instructed to self-quarantine. She shut herself in her bedroom, venturing out for just a few minutes each day with a mask on, since she lives with her father and brother. Her cat, Bilbo, hung by her side.
On Monday, Conte announced an unprecedented nationwide lockdown.
“All the measure of the red zones are now extended to all of the national territory,” Conte said at a press conference. He announced a “stay at home” policy, a 6 p.m. curfew, and a ban on public gatherings.
By that point, over 9,000 people had contracted the coronavirus and over 460 were dead.
‘We do not have enough doctors’
On Tuesday, the first day of Italy’s nationwide lockdown, Italy recorded its highest leap in fatalities in a single day: 168 new coronavirus deaths were reported. Conte announced that most shops, save for pharmacies and grocery stores, would close.
As of Friday, the country’s coronavirus death toll – a basic calculation that divides the number of deaths by the total number of cases – was at about 7%. It’s a grim reflection of Italy’s struggles, given that the global death rate has been hovering around 3.4% for weeks.
“We were not prepared. We do not have enough doctors for the people. We do not have an organized plan for pandemics,” Casani told Time.
Italy’s investments in its national health service, Servizio Sanitario Nazionale, amount to 6.8% of its gross domestic product, according to Time.
“The continuous cuts – to care and to research – are obviously a problem right now,” Casani told the magazine.
Another reason Italy’s healthcare system appears to be so overwhelmed is that the country’s population, on average, is the second-oldest in the world, after only Japan. The coronavirus is far more deadly to older people – a study from the Chinese CDC found that the death rate among those above 80 years old was nearly 15%.
Italy’s National Institute of Health has estimated that 58% of patients who have died so far were over 80 and another 31% were in their 70s, according to Reuters.
‘An age limit for access to intensive care’
Given the lack of resources and strains on Italy’s hospitals, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care has given nurses and doctors “catastrophe medicine” guidelines to follow as they navigate the deteriorating situation.
“It may become necessary to establish an age limit for access to intensive care,” the document says, according to a translation in the Atlantic.
It adds: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”
In other words, older people are now a lower priority for treatment in Italy, since their chances of survival are slimmer. The guidelines also suggest doctors and nurses de-prioritize patients with underlying health conditions, since the coronavirus is more fatal for those groups, too.
“We decide based on age, and on health conditions,” anesthesiologist Christian Salaroli told Italian daily Corriere della Sera on Monday, “just like all war situations.”
‘The war has literally exploded’
Dr. Daniele Macchini, who works at the Humanitas Gavazzeni Hospital in Bergamo, penned an anguished Facebook post earlier this week, calling the coronavirus a “tsunami that has swept us all.” His thoughts, shared in Italian, were translated by Dr. Silvia Stringhini, an epidemiologist at Geneva University, the New York Post reported.
“The war has literally exploded and battles are uninterrupted, day and night,” Macchini wrote.
Doctors are no longer known for their specialties as “surgeons, urologists, orthopedists,” he added. They are all trying to treat the same illness, and the testing swabs just keep coming back “positive, positive, positive.”
Macchini said he has seen medical staff with “tears in their eyes because we can’t save everyone.”
“We no longer see our families for fear of infecting them. Some of us have already become infected despite the protocols,” he wrote.
On Tuesday, Italy’s medical community took another blow: Roberto Stella, the 67-year-old president of the Medical Guild of Varese, died in Como from respiratory failure caused by COVID-19, CNN reported.
“His death represents the outcry of all colleagues who still today are not equipped with the proper individual protection needed,” Italy’s National Federation of Doctors and General Practitioners said in a statement.
Roberta Re, a nurse at Piacenza hospital in Emilia-Romagna, told the Guardian that she also lost a colleague: a 59-year-old doctor who she considered a good friend.
“It’s an experience I would compare to a world war,” Re said. “But it’s a war that isn’t fightable with traditional arms – as we don’t yet know who the enemy is and so it’s difficult to fight. The only weapon we do have to avoid things getting even worse is to stay at home and to respect the rules, to do what they did in China.”
In Venice, that’s what Castoldi is now trying to do. Her self-quarantine has ended, so she can now roam the house and spend time with her family inside. She remains symptom-free. From her room, Castoldi has posted several warnings on social media, discouraging influencers and others around the world from spreading coronavirus jokes and memes.
“Unless an outbreak like this affects us directly, it’s easy to believe it never will,” she said.