ROME: As Italy prepares to emerge from the West’s first and most extensive coronavirus lockdown, it is increasingly clear that something went terribly wrong in Lombardy, the hardest-hit region in Europe’s hardest-hit country.

Italy had the bad luck of being the first Western nation to be slammed by the outbreak, and its official total of 26,000 fatalities lags behind only the US in the global death toll. Italy’s first homegrown case was recorded Feb 21, at a time when the World Health Organisation was still insisting the virus was containable and not nearly as infectious as the flu.

But there is also evidence that demographics and health care deficiencies collided with political and business interests to expose the 10 million people in the northern Italian region of Lombardy to Covid-19 in ways unseen anywhere else, particularly the most vulnerable in nursing homes.

Virologists and epidemiologists say what went wrong there will be studied for years, given how the outbreak overwhelmed a medical system long considered one of Europe’s best, while in the neighboring Veneto region, the impact was significantly more controlled.

Prosecutors, meanwhile, are deciding whether to lay any criminal blame for the hundreds of dead in nursing homes, many of whom don’t even figure into Lombardy’s official death toll of 13,269, half of Italy’s total.

By contrast, Lombardy’s front-line doctors and nurses are being hailed as heroes for risking their lives to treat the sick under extraordinary levels of stress, exhaustion, isolation and fear. One WHO official said it was a miracle they saved as many as they did.

Here’s a look at the perfect storm of what went wrong in Lombardy, based on interviews and briefings with doctors, union representatives, mayors and virologists, as well as reports from Italy’s Superior Institute of Health, national statistics agency ISTAT and the Organisation for Economic Cooperation and Development, which advises developed economies on policy.

Italy was the first European country to halt all air traffic with China on Jan 31, and even put scanners in airports to check arrivals for fever. But by Jan 31, it was already too late. Epidemiologists now say the virus had been circulating widely in Lombardy since early January, if not before.

Doctors treating pneumonia in January and February didn’t know it was the coronavirus, since the symptoms were so similar and the virus was still believed to be largely confined to China. Even after Italy registered its Feb 21 case, doctors didn’t understand the unusual way Covid-19 could present itself, with some patients experiencing a rapid decline in their ability to breathe.

After a phase of stabilisation, many deteriorated quickly. This was clinical information we didn’t have, said Dr Maurizio Marvisi, a pneumologist at a private clinic in hard-hit Cremona. There was practically nothing in the medical literature.

Because Lombardy’s intensive care units were already filling up within days of Italy’s first cases, many primary care physicians tried to treat and monitor patients at home. Some put them on supplemental oxygen, commonly used for home cases in Italy.

That strategy proved deadly, and many died at home or soon after hospitalisation, having waited too long to call an ambulance.

Reliance on home care will probably be the determining factor of why we have such a high mortality rate in Italy,” Marivi said.

Published in Dawn, April 27th, 2020