DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
Date of interview: 12th March 2020
Number of cases at time of interview: 12462
Number of deaths at time of interview: 827
Population of Italy: 60.5 million people
Italy has had a rough week. Following the first detection of COVID-19 on the 23rd February, the numbers have exponentially grown to now hit over 12,000 confirmed cases and 827 deaths. I messaged Dr Marco Gardini, a friend and colleague from the European young family doctors movement called VdGM, on the 3rd March who lives in Bolzano. On the 3rd March, Italy’s number of confirmed cases hit 1689 people and Marco and I naively exchanged messages having a little joke and a giggle about the one-metre apart rule. I knew something was wrong when I didn’t hear from him after the 5th. I received a message on the 9th just to let me know that he wasn’t ignoring me but he had been exhausted because he was covering a colleague who was in quarantine. On the 9th, there were 7375 cases – in less than six days, the count had quadrupled.
Certainly in the UK, we are watching Italy nervously as we suspect that we are only two weeks behind them. The sense of reality of the epidemic is becoming real because even Italy, with its top-class healthcare system, was being overwhelmed. We couldn’t use excuses such as a “poor infrastructure” or “weak government” to justify the higher numbers and posts by Italian hospital doctors, who were describing the sheer tsunami of sick patients, were trending on social media.
I knew Marco was probably snowed under and exhausted but he kindly agreed to be interviewed on his one afternoon off to share his experiences in this battlefield.
He says that the virus struck the region of Lombardy first, one of the richest areas of Italy with well-equipped hospitals. Heaven knows how the other regions would have coped if they had to manage the first wave of the epidemic when they have so much less capacity. The challenge with North Italy is that it is a tourist hot spot and January and February is the height of the ski season. People would have come in and out in droves and it was the perfect crucible for transmission and spread. Interestingly, despite the contact-tracing, they’ve not been able to identify their patient zero. Marco describes some of the challenges now, since the season was closed prematurely, because workers from surrounding countries need to go home leading to clinical dilemmas. He recently was asked by a Slovenian seasonaire if he could sign his papers because he desperately wanted to return to Slovenia but Marco couldn’t justify signing them. This is interesting because my friend in Romania texted me yesterday to say that that they are bracing themselves for the return of the seasonal workers, which shows how much impact these local economies have on the spread of disease and how, as family doctors at the coal-face, we bear witness to this.
As we have read in the newspapers, Italy is in total lockdown. Schools and universities closed on the 3rd March. Since four days ago, people are not allowed to travel between cities without a signed permit and risk three-months prison or 206 euro fine with a criminal record if found without the necessary papers. Yesterday, all of the bars and restaurants were closed (although delivery is still accepted) and people are encouraged to stay at home except to commute and to buy food and drink. Even the supermarkets are imposing a one-metre apart rule. Workers are expected to take mandatory holiday or work from home or minimise their work hours to avoid commuting in so often. Jogging for exercise and walking the dogs outside is strongly discouraged. I was told by another Italian friend about a man who had a positive test confirming COVID-19 who went to the shops instead of being in isolation. He is apparently facing a 12 year prison sentence for his carelessness. These extreme measures are planned to stay in place for 15 days and Marco says that the Italians are taking it well. In the UK, we are estimated to be lagging behind Italy by two to four weeks and we are at that uncertain stage. Should we be going out? Should we be getting on public transport? Should we be seeing our friends? Who knows? Personally, I wish the British government would just get on with making some clear rules for citizens because the spread of the disease is a social problem whilst we, as doctors, handle the medical. Understandably, the economy will inevitably take a hit with such draconian rules but Italy’s number of confirmed cases appear to be slowing down for the first time. Money is being put aside by the Italian government and the European Union to support the economy but, at the moment, the health and safety of the Italian citizens is paramount.
Like in the UK, there is a specific phone number to call if you think you have COVID-19. If they also think you have it, they will send an ambulance to your house with specially trained staff to take you to hospital. There’s a tent outside the hospital where you check in, get triaged and swabbed before entering the institution. He’s sure there’s regional differences but he says that the protocols are more or less similar as what is being practised across Europe. He hadn’t really heard about the social media frenzy that had whipped round the UK about people being denied ITU beds and orthopaedic doctors being left in charge of non-invasive ventilation. He says that he will make a few enquiries and get back to me and I really hope that this was all just fake news. Initially, family physicians in Italy received their clinical guidance from their medical trade union rather than the government but now they get daily updates. In the community clinics, you try your best to only have one patient in the waiting room at a time and to offer the simple surgical masks if there are more. At the moment, Marco’s colleague is in quarantine so he is covering both his patients as well as his own. In Italy, the patients are registered to the doctor not the clinic like in the UK so, if the doctor is not able to work, provisions need to be made to cover the needs of the patient population in limbo. Italy also has universal health coverage so all the patients are protected.
We talk about the Personal Protection Equipment for staff. It sounds dire. Marco has one disposable mask that he has to reuse. GPs in Italy provide their own equipment normally but there are no private stocks anywhere for love nor money. The equipment provided by the government is limited and the medical trade union are working hard to change this. It’s not clear how the hospitals are doing but we can only hope that they are better stocked. Family physicians are managing by attempting to do the majority of their consultations by phone and avoiding home visits entirely. It’s challenging if, like Marco, you look after a residential home for elderly patients too. I can feel a real weariness when we talk about these shortages. As front-line staff, we know that we cannot just work from home and it would be against everything we believe in not to be doing our bit. Without the appropriate protection, it feels like we’re in the trenches and we barely have a mask each to protect ourselves. It reminds me of a conversation I had with Dr Luke Kane when he was part of the Ebola humanitarian mission in Sierra Leone. I think of all the Sierra Leonean healthcare professionals who treated the first casualties of Ebola, which had a much higher mortality rate, with no equipment knowing full well that they would be next. Were they heroic or where they just resigned to their future? One of Marco’s friends works as a lab-technician (in full gear) in the labs testing for COVID-19. I hadn’t even considered that there was a person shifting through all the swabs but why wouldn’t there be?! Being fairly on the clumsy side, this would be a total death sentence for me but I cannot imagine the sheer stress of doing that job.
Things hit home when Marco talks about a colleague, Dr Roberto Stella, President of the Order of Doctors of the Province of Varese and Director of the Lombardy Medical School and a huge supporter of the Italian young GP movement (Giotto), who passed away recently due to respiratory failure secondary to COVID-19. It was a sombre moment when we paid our respects to our colleagues who work tirelessly and selflessly for the lives of others.
I am definitely feeling more introspective after our conversation despite our best efforts to keep it upbeat and positive. The RCGP motto is Cum Scientia Caritas (Compassion empowered by knowledge) and it is this compassion that I am seeing everywhere. Family medicine is about compassion, community and continuity and I feel truly humbled by our profession who are showing such strength in the face of this pandemic when there is so much uncertainty around our own wellbeing.
Stay well, stay safe x
Since this interview, Marco informs me that he has received FFP2 masks which he will be picking up today!
Also, Italy’s numbers did get better before getting worse again.