The lessons Italy has learned about its COVID-19 outbreak could help the rest of the world

For the first time sincecoronavirusinfections exploded in the small town ofLodi, Lombardy, the northern Italian region that would become the epicentre of the European outbreak, a remarkable sighthas appeared in the hospital there: a few empty beds.

Health-care workers continue to issue strong warnings that Italy is far from being out of the woods, and on Wednesday morning, Italy's health minister extended the nationwidelockdownto April 13.

But the crushing pressure on northern Italianintensive-careunits seems to be finally easing, providing if not a light at the end of the tunnel deaths in Italy have surpassed13,000and still top700a day thena distant flicker of hope.

Only carefully conducted epidemiological studies will bring to light exactly how and whyCOVID-19 took off in northern Italy with suchspeed. But in the midst of the emergency, experts say there are already lessons to be gleaned from Italy's fatal errors and urgent messages for other parts of the world.

"The biggest mistake we made was to admit patients infected withCOVID-19 into hospitals throughout the region," said CarloBorghetti, the vice-premier of Lombardy,an economically crucial region with a population of 10 million.

"We should have immediately set up separate structures exclusively for people sick withcoronavirus.I recommend the rest of the worlddo this, tonotsendCOVIDpatients into health-care facilities that are still uninfected."

'Like throwing a lit match onto a haystack'

Already, Italian cities in other regions are doing this,as well as field hospitals in Milan andBergamo, Lombardy, which are almost complete.

However,the virus wasnot only spread to "clean" i.e. infection-free hospitals by admitting positive patients. In early March, as the number of infected was doubling every few days, authorities allowed overwhelmed hospitals to transfer those who tested positive but weren't gravely ill into assisted-living facilities for the elderly.

"It was like throwing a lit match onto a haystack," saidBorghetti, who spoke out against the directive at the time. "Some facilities refused to take in the positive patients. For those that did [take them in], it was devastating."

Along with the tragic misstep ofputtinginfected people under the same roof as clusters of the most physically vulnerable,Borghettiand others point to a deeperstructural factor that accelerated the outbreak in northern Italy: a highly centralized health-care system with large hospitals as its focus.

Under normal circumstances, these large hospitals are very effective, with a wide range of expertise under one roof. But as the go-to place for health services, they acted as conductors of infection.

"For the past 20 years, the region invested heavily in hospitals, which are now among the best in Europe,"Borghettisaid. "Unfortunately, we did not make the same investment in local health services: health clinics, rehab facilities, community nursing and family doctors. And as a result, we're drowning [in the epidemic]."

Testing policy 'was wrong'

Epidemiologists estimate the real number of infected in Italy, now officially more than110,000, is likely at least 10 times that number. Affected areas in Italy began vast testing of even asymptomatic people in the last week of February, shortly after Patient One was discovered on Feb. 21. A week later,however,they began to comply with the government's requests tolimit testing only to symptomatic cases.

"That policy of testing was wrong," said GuidoMarinoni, president of the Medical Association ofBergamo, the hardest-hit city. "We should have extended testing to the relatives of positive people and the contacts of those relatives, at the very least."

This same loose grasp on the number of infected also applies to deaths, which researchers and mayors in Italy's north say could be four to six times higher than the official count.

Comparisons between the number of deaths in the four years prior to 2020 with the same period this year show a dramatic spike in mortality that the official death count ofCOVID-19does not seem to adequately account for.

The gap, say experts, is the result of data being collected only on those who are hospitalized or who die in hospital with a positive test. Yet most people die at home.

"Many have died at home with undiagnosedcoronavirusthat exacerbated heart and lung complications," said scientist LucaForesti, CEO of theSantagostinoMedical Centre, Italy's largest out-patient clinic.Forestihas conducted a study on the mortality rate in four different towns in northern Italy:Nembro,Pesaro,CernuscosulNaviglioandBergamo.

"Another factor is thatpeople with other unrelated illnesses, under normal conditions, would call an ambulance and be taken to emergency. But with hospitals overwhelmed, there were no ambulances" or hospital beds available, saidForesti.

He estimates90 per cent of the additional deaths in northern Italyso far this yearare fromcoronavirusand only 10 per cent due to unrelated illnesses.

Theories about spread don't bear out

In the early weeks after the virus took off here, many theorized about what was behind Italy's high case fatality rate (deaths per confirmed infections), a global outlierat a shocking10 per cent.

Among the explanations werethe country's aged population and a cultural propensity to socialize in groups, often cross-generational, as well as showing affection through touch compared to Asia, where mask-wearing and social distancing are common even in non-pandemic times.

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Experts say the full impact of these factors won't be clear until further studies are carried out.

"Luck is a fundamental determinant of contagion [at the beginning]," saidMatteoVilla, a researcher at the Italian Institute for International Political Studies. "A virus can be introduced to a person who has little contact with others, ortoa super spreader," which was the case withItaly'sPatient One.

After it starts to take off, however, it follows the same exponential pattern.

The biggest takeaway from Italy, experts say, is that what happened here can happen anywhere.