The COVID-19 Crisis In Health Systems & Prospects For Recovery – The View From Italy Inside View 27/03/2020 • Nicoletta Dentico Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to print (Opens in new window) Health workers in Lecco, Lombardy, Italy in full protective gear. No illusion. COVID-19 is closer to us than we may imagine. And getting closer day by day. Around the world, in big cities and small centres alike, people are heading deeper into a sort of dystopian fiction, as if empty streets, latex gloves, face masks and self isolation were the new normal. Some 1.3 billion Indians have been asked to stay home to fight the spread of the disease. One third of humanity is under Coronavirus lockdown. Never before has a virus stopped the entire world’s gears quite like this. The media of the entire planet is gripped by this new coronavirus, spreading a global panic – although we are also beginning to see governments step up response and engineer mass planning for worst-case scenarios. As it should be. The repercussions, however, are also moving the global health sphere into business and politics. The COVID-19 shockwave will end, at one point. Meanwhile, it is forcing a Copernican re-thinking of the interconnected global economy we have had in place for over three decades. COVID-19 is not the first wake-up call for the world of the 21st century. The first seismic shock came with the terrorist attack of 9/11, followed by a global financial crisis which boiled over in 2008, with the collapse of Lehman Brothers. Yet again, this invisible and silent virus – a minuscule RNA packet enveloped in a protein capsule – has shaped up to be an enormous stress test for globalization, shaking up all our institutional certainties as well as our individual lives. We are re-discovering just how vulnerable nations and people are. Just how fragile the globalized economy is, with its productive arrangements. In his latest book on inequalities, Walter Scheidel reminds us that epidemics are one of the most transformative events in human history. Nothing new under the sun, basically, except that we don’t seem to learn the cogent lessons that the past, including the recent past, offers us. Since the start of the millennium we’ve seen a number of coronavirus species make the leap from animals to humans. The first occurred in China with SARS in 2002-2003, then in 2012 with MERS in Saudi Arabia and Jordan. Other virus specie leaps hae occurred with swine flu (H1N1) in 2009, bird flu in 2013 and 2017 (H7N9), as well as other pathogens such as Zika and Ebola (still active in Africa). For decades, experts from the science community have warned about the need to prepare for another pandemic like the 1918 Spanish flu (“the Great Influenza”), which killed at least 50 million people worldwide, but their premonitions went unheeded. Now that we are in it, SARS-CoV2 looks pretty much like the pathogen for which scientists had been waiting. It kills healthy adults as well as elderly people. Covid-19’s global fatality rate doubled over the past two months – up from 2.1% as of 20th January to 4.4% as of 23rd March, according to data of the World Health Organization (WHO). That is is much higher than 2% of the Spanish flu pandemic, although clearly, we still lack reliable evidence on how many people have been infected. The WHO recommendation (“Test, test, test”) has been key to the success in countries like South Korea, Singapore, Honk Kong and Iceland, which implemented widespread initiatives to test thousands of their inhabitants a day, early into the outbreak, thereby keeping numbers under control. Overall, Europe’s variety of approaches, largely dependent on test kit availability or shortages as well as the limits of national health system capacity. This, in turn, has been a significant factor in the epidemiological tracking of the disease, as well as where it hit the hardest. Making testing quickly available has formed the basis of Germany’s strategy to combat the virus; COVID-19 tests have been available through the country’s statutory healthcare since January. Expansion of testing in France occurred only after lockdown, as the death toll increased. The same trend became apparent in Spain, where the death toll last week was doubling every three days. Italy, the first country in Europe to experience a serious domestic surge of COVID-19 cases, and still the region’s major epicentre, has had to negotiate across a variety of sub-national approaches to testing, which make today’s estimates of the national mortality rate quite unreliable, as many mild or asymptomatic cases go uncounted. The lessons from Italy’s COVID-19 mistakes need to be shared widely. However, differences in the number of people who are tested for the coronavirus and how deaths are recorded, limit the comparability of published data across even European countries to a large extent. What we certainly know by now is that the virus has an exponential transmission rate: one affected person may pass it on to 2-3 people, 10 people if the vector is a doctor or a nurse. The efficiency of the contagion is also apparent among symptomless and pre-symptomatic individuals, or people with few symptoms This means that COVID-19 is much harder to contain than SARS, which had a slower transmission rate, and only through symptomatic people. COVID-19 has already caused 10 times more cases than SARS, in just one-quarter of the time. When the emergency ebbs, we shall no longer recognize the landscape. Yet, in the reflections that accompany the spread of COVID-19 we may find it useful to explore several political hypotheses, which take us from globalization to its direct effects at home. Let’s try a few. Washing hands (Photo: Fabio Fadeli) The Sad Geopolitics of the Crisis Let’s start with the uncomfortable truth. While geared to prepare for war, the world is amazingly unprepared to fight viruses. NATO, for example, has a rapid reaction force (NRF) which regularly carries out months’ long exercise programs in order to integrate and standardize all operational aspects – logistics, food and fuel provision, operational language, radio waves, etc. – across national contingents. Nothing, nothing like that exists in the domain of health emergency and pandemic containment. The last serious simulation of a pandemic catastrophe in the US, the Dark Winter Exercise, took place in 2001. European countries are in even a worse condition. Europe doesn’t have a shred of a common health policy, so there is no joint program for tackling a health emergency. In addition, all of WHO emergency preparedness structures for identifying risks, issuing a global alert and coordinating immediate responses are, unlike NATO’s , short of funding and poorly-staffed. The unbelievable fact is that, while the first virus outbreak was wreaking havoc in Wuhan, European countries kept looking at China from a distance, and even with a certain degree of prejudice, cherishing the conviction that the epidemic would never really reach the Western world – no one seems to know why. Had government decision-makers seriously studied the data shared by China after WHO officially declared an international health emergency, they would have understood that the entire world was likely to have to deal with COVID-19 at different stages of the viral evolution. After several geopolitical slaloms and visible resistance, the WHO finally declared a COVID-19 pandemic on 11th March. Pandemic means sustained and continuous transmission of the disease, simultaneously in more than three different geographical regions. The threshold had been met, according to public health experts, weeks before the announcement. The trajectory of the disease meant that the SARS-CoV2 virus had gained a foothold across the globe and multiplied quickly even in countries with relatively strong health systems. While some analysts connect the WHO delay with the World Bank’s pandemic bonds mechanism, the highly due signal came in the end to rebuke and shake governments, mostly in the industrialized West, for their “alarming level of inaction”, in the words of the WHO Director General, Tedros Adhanom Ghebreyesus. Whether because the pandemic can rattle markets and lead to more drastic travel and trade restrictions, or out of a dubious sense of political opportunism, a number of world leaders until very recently have either kept hiding or underrating the spreading capacity of COVID-19. In any case, they have delayed and still are delaying any serious containment measure. The WHO Director General’s preoccupation with the lack of cooperation among member states, voiced in late January on the eve of the WHO Executive Board session (February 3-8), was confirmed, two months into the global spread of COVID-19. Contrary to the obligations provided by the WHO International Health Regulations (adopted in 2005, in the wake of the SARS epidemic to improve global capacity to prevent and control diseases), inter-governmental cooperation was rapidly supplanted by a viral health sovranism in dealing with the developing pandemic. That’s what we have seen happen in Europe, the cradle of the most violent COVID-19 outbreak, worldwide. Only a couple of weeks ago, most European countries were still indulging in inertia at home on how to face the disease, pretending that not much was happening. Buying time, somewhat in a state of denial. Italy – the First Democratic Laboratory for COVID-19 Management Donning the protective suit (Photo: Fabio Fadeli) But time and trust are essential to good epidemic management. When Italy, the epicentre of the pandemic in Europe and the first democratic laboratory for COVID-19 management, asked for urgent medical supplies under a special European crisis mechanism, no European Union country responded. On the contrary, Germany, issued a decree to block exports of medical masks and other protective gear to Italian healthcare facilities. France, for its part, confiscated all available medical supplies by national order. Another slap in the face came from the European Central Bank (ECB) president Christine Lagarde, whose declaration implied that it was no longer ECB’s job to preserve Italy in the Euro zone. The result was the collapse of the Italian stock market, the loss of €68 billion of savings in one day, and the renewed kindling of financial malaise, alongside the viral. The impending question is whether Europe’s post-war institutional setup, grounded upon principles of solidarity and cooperation, will survive the COVID-19 pandemic. COVID-19 is a groundbreaking test for European unity, a few weeks post Brexit. After the initial dormancy, draconian measures never before seen in peacetime Europe are forcing dramatic changes on daily life. More than 250 million people are in total or partial lockdown in the EU as Belgium and Germany have decided to follow Italy, Spain and France in closing schools and urging, or asking, people not to leave their homes. Only around mid-March, over two months after the Chinese declared their emergency outbreak in Wuhan (January 7th ), did Europe start to grasp the dimensions of the challenge. It took the European Central Bank heated internal debates before adopting a stimulus of €750 billion bond buybacks for the Eurozone to combat the economic and financial spillover unleashed by coronavirus. A much needed amount indeed, but still quite feeble if compared to Germany’s € 550 billion financial aid package and to the Trump administration’s US$ 2 trillion stimulus to support the economy and the American families (9.5% of the national GDP). It has faced harsh criticism for its inactivity, but finally the European Commission found its footing and announced the suspension of the Stability Pact last week, much advocated for by the Italian government as coronavirus stretched the country’s defences, as well as Europe’s. Proposals asking for seizing this historical moment and launch new Covid19 credit lines, or very long maturity Eurobonds, are being voiced. Europe urgently needs a new catastrophe relief plan. “We’ll take the right steps, at the right time”, and “we can turn the tide of this disease in 12 weeks”, says Prime Minister Boris Johnson, with an apparent U turn from his initial – and quite controversial – strategy in the virus management. The UK government, which had sought to pursue business as usual, is moving towards more mass testing, social distancing and some school closures – shortly before Johnson himself confirmed that he had COVID-19. The SARS-CoV2 pandemic “could not have occurred at a worse time for the UK and its citizens” writes Prof. Martin Mckee of the London School of Hygiene and Tropical Medicines, referring to the Brexit negotiations. Instead of doing everything possible to preserve the areas of relevant collaboration with the EU, such as health, “the UK has decided to isolate itself from European systems that have been built up over the past decade, many as a result of problems exposed by the 2009 swine flu pandemic“. The country is now outside of the European Medicines Agency (EMA) rapid authorization mechanism for pandemic vaccines and medicines, which entails that the UK has to wait longer for these health tools then the EU member states. To worsen the picture, the UK has also withdrawn from the EU’s emergency bulk purchase mechanism for vaccines and medicines. This lever allows EU governments to enhance their market power and speed up access to vaccines and medicines during an emergency situation. Ultimately, as humans we are a limitless pastureland for the virus but we are, above all, a very disordered, unprepared, and yet arrogant herd. The result is considerable governance failure so far, while the WHO Director General implores us: “do not let the fire burn”. More of this is to be seen if we open a broader view beyond the borders of Europe. What will happen, now that SARS-CoV2 creeps steadily into most African countries? The geopolitical implications may not come secondary to matters of health and safety. Selfie in full protective gear. Tension between Health and the Economy One of the reasons why the right to health is subject to so many violations lies in the fact that health cannot live in isolation. The right to health drags along with it other social and economic rights, which exist in a constant friction with economic rules and financial profits. On the other hand, disease spread implies economic losses. That’s what makes health and the economy so intertwined. With astonishing foresight, 2019 report of the World Bank Global Preparedness Monitoring Board pointed out the “very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen” which could wipe out nearly 5% of the world’s economy. Now, with the coronavirus outbreak a reality, the OECD has warned that it could halve global economic growth this year to 1.5%, the slowest rate since 2009. It has cut its 2020 growth forecast for China to a 30-year low of 4.9%, down from 5.7% in November. Even as China slowly goes back to work, the virus continues to cause massive economic disruption. The virtual shutdown of China’s ‘factory of the world’, decreased the supply of products and spare parts, disrupting production the world over. Low and middle income countries, especially those dependent on commodity exports and global supply chains, are particularly vulnerable in this economic havoc. In Italy, we have been confronted far too many times over the past years with the dilemma between health and the economy (and employment) across the country. These same tensions led to the flagrant missteps in the country’s early management of COVID-19S, particularly at the regional level. No need to lecture: things are complex, and policy decisions not easy. Yet, right from the start, the highly productive valleys of Lombardy got engaged in arm wrestling with local entrepreneurs over the need to recognize and curb the contagion with rigorous public health measures and resistance to a contraction in economic activity that a health lockdown would create. Local authorities hesitated, as the contagion kept surging, and central government likewise fluctuated at the end of February. After initial containment measures, contradictory messages aimed to reassure the North’s economic exuberance (“Milano non si ferma”, Milan doesn’t stop), ended up legitimizing baseless patterns of behaviour that favoured the virus spread. Two different strategic approaches in tackling COVID-19 may be identified so far: Firstly, there is combat of virus spread through mass testing and social distancing measures, including the extraordinary forced isolation of communities in the Chinese and Italian model. Secondly, and arguably the flimsier approach to the contagion, places an exclusive focus on testing and treating the most affected people (the English, German, Dutch and partly French model). Of course, the containment option entails economic costs but, as Roberto Buffagni highlights, it is rooted in the legacy of ancient cultural and political values that apparently keep inspiring the decision-making style in those countries, if only by instinct. On the other hand the laissez faire strategy, still the norm in some parts of Europe, has its roots in a pragmatic analysis which bears some sinister social selection implications. In the case of COVID-19, the more at-risk population is largely made up of elderly people, or people with other forms of chronic disease. Their loss, however painful, does not pose a threat to the functionality of the economic system, the laissez-faire theory goes. Rather the reverse. In fact, it operates with somewhat re-generational leverage, insofar as it alleviates the pension system costs alongside the costs of other social welfare structures in the country. The resulting dynamic therefore triggers off an economically expansive process “due to the legacies that, as in the great past epidemics, will enhance the liquidity and assets capacity of new generations who have a higher inclination to investments and consumption than their elders”, says Roberto Buffagni. By so doing, a government increases its economic and political operability, when compared to countries that choose the costly lockdown route. However, as Italians know only too well now, another critical element in the policy puzzle in either scenario, is the functionality of the health system in terms of its ability to prevent disease, treat and manage those who become ill. And when health services are overwhelemed, an unchecked viral outbreak will ultimately lead to massive economic deaths, a toll linked also to the exasperating epidemic of precarious labour conditions, even in highly successful national economic sectors like tourism. COVID-19 has thus brought to the surface the many hidden pathologies lingering in the economic fabric of the country, untreated for too long. If the virus marks a watershed in our history, and in the history of Europe as a whole, we need to go beyond the immediate COVID-19 emergency response to advance the urgent political and economic regeneration we have long wanted to see. It’s time to work for a systemic reframing of our attitudes about health systems and services, in a post-virus world, to prompt positive changes in line with our constitutional rights. Health as a Common Good & the Role of the Public Health System We needed the SARS-CoV2 shockwave to convince Italian public opinion about the value of the national health system (Servizio Sanitario Nazionale,1978), as the main tool that secures communities and grants individuals protection from catastrophic life events. After two world wars, national health systems were gradually introduced in Europe as the most effective institutional mechanisms for sealing societies’ democratic pacts. In Italy, the universal public health system has been instrumental in the social and economic development of the country and still today accounts for its high population life expectancy, according to Bloomberg. The renewed awareness of the difference that a universal, free public health institution can make, is vividly present in the hardest hit countries now. Initiatives such as Spain’s to place all private hospitals under state control indefinitely should spread internationally like the virus, and generate a strong global consensus around a rights-based vision of health systems and services, which goes beyond issues of financial resources. I consider it the political point-of-no-return of the current viral crisis. In fact, this is the coronavirtue that we must seize and preserve, if we are serious about universal health coverage and sustainable development for all. In the name of neoliberal ideologies, and often in the name of odious debt service repayment, the development of solid health systems in the global South has been stubbornly opposed for decades, with a huge toll in the health and lives of billions of people. Most low and middle income countries are therefore now facing the coronavirus bare-handed. Years of spending cuts due to fiscal austerity policies also have undermined public health provisioning in developed economies, so that health systems have been dismantled and broken to pieces in Europe, as well. As for Italy, debt reduction and spending reviews have shrunk investments – health expenditure increased by 14.8% from 2001 to 2008, by a meagre 0.6% from 2009 to 2017. Despite the aging of Italian society, the national health budget was trimmed by €25 billion between 2010 and 2012, local health units were dismantled (contracting from 642 in the 1980s to 101 in 2017), and 175 hospitals were closed down. Repeated rounds of devolution and privatization have dismembered the Italian national health system to the advantage of private insurance schemes. Nowhere has this trend of public health system dismemberment been more apparent than in Lombardy, which has been the hardest hit by the pandemic, despite being the wealthiest region of the country. The compelling title of the 2018 Censis-Rbm report – Resentment Healthcare, Resentment for Healthcare: Scenes from an Unequal Country – illustrates the disquieting portrait of an out of control “out-of-pocket-society”. Private spending on health services increased by 9.6% from 2013 to 2017, forcing over 7 million people into debt, or into selling their properties (2.8 million people) to access their right to healthcare. A perfect crime against common sense. Confronted with SARS-CoV2, Italy has today less than half the number of intensive care beds than Germany, or France. Building on Covid19’s Lessons: Policies for the Future Health workers in Lecco, Lombardy, Italy in full protective gear. The devastation is under our eyes. Italy’s death toll has overtaken China, with 4% of China’s population. The immediate reduction of the virus spread is no doubt the most urgent priority now to avoid the collapse of the health system, with all its implications. At the same time, we need to start planning now for the necessary policy changes that should be undertaken post-emergency, across the social and economic spectrum. Health-wise, more adequate financial and human resources will have to be injected into the universal health system. We need to undo the damage caused to public services in the past and we need to revise the balance of power and the rules of engagement for the private sector, including in the area of scientific and medical research. There are no reasons why health should be allowed to assert itself as a profit-extracting mechanism. A new governance for health will have to be set in place in Italy. National Health Services means national, i.e. centralized, and not splintered into a variety of regional strategies more or less ancillary to the temptations of the private sector. Health devolution, introduced in 2001, has not functioned. Overall, it has resulted in significant health inequalities. A Mirror To The World On a small scale, Italy mirrors the health divide existing between the North and the South of the world. It has produced different and diverging approaches, multiplying inefficiencies and opportunities for corruption (in line with the global empirical evidence), and ultimately increasing costs. As the early stages of the virus outbreak have clearly demonstrated, health devolution responds very poorly to the complexities involved in the production of good health. That is why we need to definitively reverse those national policies that currently tolerate regimes of “differentiated autonomy”, especially in Italy’s northern economic powerhouses (Lombardy and Veneto). Italy is thriving in emergency conditions, for a series of structural reasons. We have the second oldest population in the world after Japan – possibly, the main cause of COVID-19 higher mortality rate in Italy. The country is the hardest hit by climate change in Europe, both for its geographical position and geographic conformation. Above all, Italy bears already a number of serious health crises that need more adequate national policies. Antimicrobial resistance (AMR) is one good example. We are the EU country hosting the highest number incidents of antimicrobial-resistant infections. According to the European Centre for Disease Control (ECDC) and the Istituto Superiore di Sanità (ISS), Italy alone accounts for one third of all the AMR-related deaths in Europe. Renowned virologist Ilaria Capua has aleady hinted at the potential relationship between these higher levels of AMR and higher SARS-CoV2 mortality in the country. Post COVID-19 will be like post-war, with its unpalatable numbers of victims, its rubble, and the need for reconstruction. Nothing will be the same anymore. But new conditions are emerging, a new historic awareness is spreading. This calls upon policymakers to redesign a stronger and better country. A stronger and better Europe. In its tragic manifestation, silent and intrusive Coronavirus is paradoxically our best chance. _______________________________ Nicoletta Dentico Nicoletta Dentico is a journalist and a senior policy analyst, leading the Global Health programme of the Society for International Development (SID, www.sidint.net). She previously was director of Médecins Sans Frontières (MSF) in Italy, and she has also played an active role in the MSF campaign on access to essential medicines as well as consulting for the World Health Organization. Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to print (Opens in new window) Combat the infodemic in health information and support health policy reporting from the global South. 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