Italy is the first country among democratic states to adopt a lockdown restriction. The measure was applied 18 days after the first confirmed case at Codogno, Lombardy. In Italy, 31,213 cases with a death toll2 of ,852 were reported on March 17. The figure is the second largest after China. As the government announced restrictions on all nonessential movement across the country, people are not allowed to move outside their residing area unless for health or work-related reasons. Most shops except for petrol stations, pharmacies and grocery stores, were ordered to close.
"We are besieged here. It is terrifying. We are quarantined at home, and it is difficult to get up the morale to work. This is an unbelievable experience which has never happened in my life. Isolated from friends, family and everything. It is absurd,” Fabrizio Carinci, a biostatistician and a laurea in statistical and economical sciences at the University of Bologna, wrote in the email header for an interview with Sisa IN.
Mr Carinci has over 30 years of experience using biostatistics for public health research. On February 28, the professor sent an editorial titled “COVID-19: preparedness, decentralisation, and the hunt for patient zero,” to the British Medical Journal (BMJ). He analysed the failure of initial containment efforts of the novel coronavirus focusing on decentralised regional traits of Italy and pointed out the importance of data exchange worldwide. The professor gives online lectures from self-isolation at his home in Pescara, Italy. Sisa IN had an interview with him via email three times consecutively.
How do you see the current situation in Italy?
We were all surprised as nobody had expected the outbreak that started in China could spread in this rapid manner. Admittedly, we underestimated the risk of the disease. Everything in Italy is suspended. The frontline health workers are encountering dramatic hardships, working under pressure with a high chance of infection. For sure, people are scared and terrified. The schools, universities and many public offices are closed either partially or totally. Many people might face difficulties in sleeping. Families are divided and isolated. It seems that a nightmare became a reality in a few days.
How do Italians react to the nationwide quarantine?
The people here have reacted in a uniform manner. They are trying to connect by singing on the balconies, doing activities, and such. I don't think depression would be a huge problem here. We can find a way out. They do whatever they can to remain active as they still walk alone, play sports and walk the dogs. Also, the needs of smart working have increased dramatically. The University of Bologna switched nearly 2,500 offline courses with 50,000 students to online learning within a week. We worked hard to make a face-to-face online platform ready with interactive sessions, software demonstrations and final exams as well as theses.
What caused an exponential surge of new cases in Italy?
Although much smaller than China, Italy has a varied territory. Each region is different in their culture, behaviour, socio-economic status, income and infrastructure. Some regions claim expanded autonomy while others require more assistance from and the presence of the central government. In the Centre and the North of Italy, the regional health system is more responsive and efficient, leading to high performance. Consequently, they have shown higher capability in times of crisis and are competent to deal with highly specialised services of intensive care. Paradoxically, the outbreak took place in this well-prepared area. Despite the advanced health system, however, the scale of the threat was unprecedented, hence, overloading. Given that, the Italian government embraced the Hubei strategy of isolation. The extension of this measure seemed to work at the epicentre, the village of Codogno in Lombardy with no new cases reported recently.
The fatality rate of COVID-19 in Italy is over 7%. It’s twice as high as the world average of 3.4% by WHO. What do you think is the reason?
The fatality rate should consider two indicators, a numerator and a denominator, i.e. the number of deaths out of the total confirmed cases. Firstly, the numerator includes all the individuals at higher risk with underlying complications, e.g. chronic diseases. Italy has a higher number of complex case-mixes than many other countries due to its longest life expectancy demonstrated in the world. We should standardise the indicators for a fair comparison. But this is possible only when we have accurate and comparable data from more countries.
Secondly, regarding the denominator, the Italian government has not (yet) undertaken mass testing. The Italian National Institute of Health recommended screening only those with symptoms to local authorities. Followed by the initial phase of mounting cases, the Italian government changed the testing criteria to comply with WHO guidelines and some EU countries. As we believe the actual number of cases is more significant than the reported figure, the current fatality rate is a statistical artefact.
According to a few media, for instance, Politico, Italy has no choice but to give up treating elderly patients.
The report from Politico, as far as I know, is exaggerated and incorrect. Based on the OECD Health at a Glance Report (2019), Italy has reduced the number of hospital beds up to one third since 1990. This was an outcome of policy changes to modernise the hospitals and to make a transition toward a community-centred health system. (On the other hand, South Korea has kept a high number of beds.) The issue is, however, the outbreak in Italy needed double the average numbers of beds in OECD countries. With the growing number of critical cases, some clinical chiefs alerted the authorities that the new cases should be treated based on the chance to recover due to the overwhelmed health services. The government took the alarm very seriously, and that triggered actions to increase the hospital capacity, which has led to averting the worst-case scenario. This is a great lesson for humanity. Austerity plans and cost reduction should not affect health services anymore!
What kinds of measures does Italy implement to reduce the fatality of COVID-19?
Special laws now allow purchasing devices or opening new dedicated hospitals. Some even proposed using cruise vessels as a possible means to reach out to the whole population across the country. However, the main concern lies in intensive care. Fortunately, however, the hard-hit region is one of the rich and entrepreneurial ones and donors have been extremely proactive in coming up with plans and projects to improve the service capacity so that we can cope with the crisis.
How do you see COVID-19 in South Korea?
South Korea is different from Italy in the way that they introduced strict rules. It is encouraging that the current measures South Korea takes demonstrated their effect and can be replicated. I particularly appreciate the Korean approach called “Trace, Test and Treat”. From the epidemiological perspective, this approach allows you to understand the real evolution of the disease. Unfortunately, however, most western countries might find it hard to apply. There are substantial cultural differences in how we balance personal choice with public benefit. Privacy protection legislation, the General Data Protection Regulation (GDPR) is an example. GDPR might hamper the process of “Trace and Test” unless the law is explicitly amended for the case of an epidemic. I guess South Korea has a better understanding of public security to work in the situation of an outbreak.
What strategies are necessary to overcome the pandemic?
That is my central area of interest. We need to identify mechanisms to make rapid discovery possible under this kind of situations. We also need to identify collaborative models from genetic engineering to health policy decisions linking the research on vaccines and treatment with resilient health systems, which can dynamically expand in times of crisis. To that end, we need a multidisciplinary community of scientists, including data scientists, who can work 24/7 on all possible databases linked together in real-time. Besides, we have to stop this extreme nonsense competition between fellow scientists only to gain a reputation with their research result. We should set up networks rather than competing with one another to unveil a breakthrough. All this competition creates nothing but a barrier to knowledge.
You proposed as an alternative, in the editorial, an efficient and borderless exchange of data.
We need disclosed (anonymous) open data of every single patient infected by the novel coronavirus available worldwide in times of crisis. This way, we can work for the benefit of all people in need. We should connect our brains rather than compete only to build our careers. With open linked data presence, I would be able to exchange my ideas and experiences to model data and identify solutions in collaboration with different governments. Any governments would want to untangle issues immediately, and we, scientists, need the data to contribute to it. Otherwise, we would end up placing all the burdens on those heroes in the hospitals and the industry.
translated by Danielle Jang
translation supervised by Franz Maier, Sumi Paik-Maier
