ROME – “As in any war, we have to choose who to treat and who not.”
That was a headline on March 9 in Il Corriere della Sera, a leading newspaper in Italy, that informed us that hospitals in Italy’s north, the epicenter of the coronavirus outbreak in our country, were being stretched thin and the health care system was on the brink of collapse.
An anesthesiologist at a hospital in Bergamo, one of the cities with the most cases of Covid-19, the illness caused by the new coronavirus, told the paper that the intensive care unit was already at capacity, and doctors were being forced to start making difficult triage decisions, admitting people who desperately need mechanical ventilation based on age, life expectancy, and other factors. Just like in wartime. The article was inexplicably placed on page 15, while the main headline on the newspaper’s front page relayed the political quarrels over the measures to curb the contagion.
The hospital in Bergamo was not the only hospital in the area dealing with a lack of capacity and rationing of care. The same day, I heard from a manager in the Lombardy health care system, among the most advanced and well-funded in Europe, that he saw anesthesiologists weeping in the hospital hallways because of the choices they are going to have to make.
In the days since, overwhelmed hospitals have set up tents as makeshift hospital wards, and cargo containers have been placed at the entrances of medical centers to sort out patients coming at an increasing pace. Some of the people who can’t get medical care are dying in their homes.
As more medical professionals started to describe similar situations on social media and in interviews, the Italian society of anesthesiologists published extraordinary new guidelines to help doctors facing ethical dilemmas, making clear that the “first come, first served” criterion that had been used among patients with the same illnesses and level of risk in ordinary times was not appropriate in dealing with the current emergency.
Until last week, the Italian public health care system had the capacity to care for everyone. Our country has universal health care, so patients aren’t turned away from hospitals here. But in a matter of days, the system was being felled by a virus that I, and many other Italians, had failed to take seriously.
The inability of the medical system to deal with the flow of patients in critical condition is not one of the problems of this complex medical emergency. It is the problem. I shouldn’t have been surprised. As a journalist, I had read, heard, and spoken to several experts explaining that the most immediate threat of Covid-19 was the hospital system becoming overwhelmed, and therefore the most pressing need was to avoid too many people getting sick at the same time, as resources are limited. (It’s what’s called “flattening the curve.”)
But that information was somehow stored in some remote interstice of my mind, covered by an incessant flow of bits and charts on the mortality rate of the elderly, political mismanagement, quarrels over under-testing and over-testing, market collapses, projections on the economic impact of the epidemic, and so on. All of this is, of course, extremely relevant — but at the same time feels totally irrelevant when lives are being lost in a situation that was preventable. As of Friday night, 1,266 people have died in Italy due to the outbreak.
So here’s my warning for the United States: It didn’t have to come to this.
We of course couldn’t stop the emergence of a previously unknown and deadly virus. But we could have mitigated the situation we are now in, in which people who could have been saved are dying. I, and too many others, could have taken a simple yet morally loaded action: We could have stayed home.
What has happened in Italy shows that less-than-urgent appeals to the public by the government to slightly change habits regarding social interactions aren’t enough when the terrible outcomes they are designed to prevent are not yet apparent; when they become evident, it’s generally too late to act. I and many other Italians just didn’t see the need to change our routines for a threat we could not see.
Italy has now been in lockdown since March 9; it took weeks after the virus first appeared here to realize that severe measures were absolutely necessary.
According to several data scientists, Italy is about 10 days ahead of Spain, Germany, and France in the epidemic progression, and 13 to 16 days ahead of the United Kingdom and the United States. That means those countries have the opportunity to take measures that today may look excessive and disproportionate, yet from the future, where I am now, are perfectly rational in order to avoid a health care system collapse. The United States has some 45,000 ICU beds, and even in a moderate outbreak scenario, some 200,000 Americans will need intensive care.
Before the outbreak hit my country, I thought I was acting rationally because I screened and processed a lot of information about the epidemic. But my being well-informed didn’t make me any more rational. I lacked what you might call “moral knowledge” of the problem. I knew about the virus, but the issue was not affecting me in a significant, personal way. It took the terrible ethical dilemma that doctors face in Lombardy to wake me up.
I put myself in their shoes, and realized that everything should be done in order to avoid those ethically devastating choices: How do we decide who gets an ICU bed and who doesn’t? Age? Life expectancy? How many kids they have? Their special abilities? Is the patient’s profession a relevant factor? Is it right to save a middle-aged doctor who will save more lives if he survives as opposed to a younger person who’s been unemployed for the last 12 months? These are the kind of theoretical questions you are asked to weigh in leadership classes at business school. But this is not a personality test. It’s real lives.
The way to avoid or mitigate all this in the United States and elsewhere is to do something similar to what Italy, Denmark, and Finland are doing now, but without wasting the few, messy weeks in which we thought a few local lockdowns, canceling public gatherings, and warmly encouraging working from home would be enough stop the spread of the virus. We now know that wasn’t nearly enough.
On Wednesday, Prime Minister Giuseppe Conte announced the latest step in a process that has progressively turned Italy into a fully quarantined country. Shops are mandated to be closed at all times, with the exception of pharmacies, food stores, and newsstands, as the government wisely considers information a primary need. All non-essential jobs have been temporarily stopped. People who still go to the office are requested to prove the absolute necessity to do so by signing a certificate that must be submitted and vetted by the police. Transgressors face up to three months in jail and a fine. Going out for physical activity is permitted, provided it’s short and solitary. Schools and universities — which have been shut down since March 4 — will be closed at least until April 3, but the date will likely be extended.
Life in lockdown is hard, but it is also an exercise in humility. Our collective well-being makes our little individual wishes look a bit whimsical and small-minded. My wife and I work from home, or at least we try to. We help the kids with their homework, following the instructions their teachers send every morning via voice messages and video, in a moving attempt to keep alive their relationships with their students.
So far, my two young sons are less bored than we’d thought they’d be, and are coping well. And thank God for our small shared rooftop where they can run for a little while in the afternoon, at least until the woman on the 5th floor complains about the noise during her nap time. Either I or my wife goes out once a day to take a short walk and get some food when we need it. Despite cops being stationed on the street to dissuade everyone from leaving their homes, we both think there are still too many people out and about. We read. We pray. We play soccer in the hallway. It’s a time of reflection and silence, a moment in which some big questions emerge — like why, exactly, we decided not to have a TV.
Strangely, it’s also a moment in which our usual individualistic, self-centered outlook is waning a bit. In the end, each of us is giving up our individual freedom in order to protect everybody, especially the sick and the elderly. When everybody’s health is at stake, true freedom is to follow instructions.
Mattia Ferraresi is a writer for the Italian newspaper Il Foglio.