Lentis/The 2020 Pandemic Response in Italy
Italy was among the first countries to be affected by COVID-19 and responsible for accelerating the spread of the disease throughout Europe and other Western countries. When the outbreak began in February 2020, the Coronavirus had not yet exploded across the globe. Italy faced the novel threat alone, without a clear strategy to defeat the virus. Despite efforts, the death toll in Italy has risen to almost 60,000. As Italy combats a resurgence in coronavirus cases, this chapter investigates the initial responses from the Italian government and healthcare officials, as well as social and cultural factors that transformed Italy into Europe’s epicenter.
Italian Government's MismanagementEdit
The Italian government’s mismanagement of the COVID-19 pandemic originates from its response to the H1N1 outbreak in 2009. Italians criticize the government for overreacting and purchasing millions of later unused vaccines, causing distrust and skepticism of the Italian government.  Therefore during the early stages of the COVID-19 outbreak, Italians were reluctant to heed warnings and restrictions, citing Italy’s previous mishandling of viral outbreaks.
Skepticism grew as several prominent Italian politicians were seen shaking hands at a public event in Milan, only weeks before Italy’s lockdown.  Inconsistent guidelines and unclear policy further increased widespread distrust among Italians, accelerating the transmission of the virus. On February 23, a first Decree Law was introduced and identified 12 municipalities in northern Italy as ‘red zones,’ or hotspots of the outbreak.  However, on February 26, Rome’s scientific committee said there was no evidence indicating the need for a lockdown, with the Mayor of a north Italian town publicly stating, “Don’t worry. There is no redzone foreseen”.  This statement was later proven false, and on March 9, the Italian government placed the entire country under one protection zone. 
Gradual lockdowns failed to contain the virus, as the severity in Italy worsened as more cities and towns closed. Moreover, Italians disregarded lockdowns in their home municipalities by traveling to southern regions that remained opened. Despite the announcement of a final decree on March 22 prohibiting movement of citizens between municipalities, it was too late to control the already exploding outbreak.
Italian Health Care System’s Response:Edit
Beyond the Italian government mishandling the initial response, the healthcare system also proved unprepared. Servizio Sanitario Nazionale (SSN) is a regionally-based national health service. Although universal coverage is provided to citizens largely free of charge, the quality of healthcare provided varies depending on the region. Northern Italy is known for its economic prosperity and higher quality of healthcare compared to its southern counterpart. 
However, almost immediately, the virus appeared to affect northern regions disproportionately, particularly in Lombardy and Veneto where the outbreaks began. The influx of patients requiring intensive care quickly oversaturated northern hospitals, and the shortage of hospital beds, ventilators, and healthcare professionals became a serious threat.  Furthermore, adequate personal protection equipment was not properly distributed to health workers. Before the end of March, healthcare workers accounted for 9% of the total cases, and by May 4, 154 doctors had died from COVID-19 infection.  On the local level, efforts were made to contain the virus and care for the increasing number of sick patients: new healthcare workers with specialized training were hired, new hospitals were built, and old hospitals were converted into COVID-19 centers with the help of thousands of volunteers. However, the lack of a centralized response from the national government caused each area to act independently, and therefore each had a different outcome.
For example, Lombardy and Veneto had significantly different infection and mortality rates despite similar economic and social determinants. Lombardy’s hospital-centered approach proved to be lacking compared to Veneto’s community-based approach, prioritizing extensive contact tracing and rapid testing. By April 1, the mortality rates were 7.5 times higher in Lombardy than in Veneto. Veneto took specific actions that may have contributed to this outcome: independently producing chemical reagents needed to process swabs, adopting a bio-surveillance system allowing the integration of data from different sources, and proactively tracing potentially infected community members. 
A key factor in Italy’s national response was the Ministry of Health’s introduction of Special Continuity Assistance Units (SPCU). These healthcare workers offer quick, at-home specialized treatment for patients with no severe symptoms, helping to prevent infected patients from going to the hospital when it is too late to recover. The integration of these units with community nurses and social workers helped build confidence and connected communities, as a joint effort to improve health and reduce inequalities. 
Italian Culture & the COVID-19 ResponseEdit
Italy has one of the world’s oldest populations, with 23% of the population 65 or older.  The higher mortality rate among the elderly population along with the Italian culture’s reverence for the elderly created complications while trying to slow the spread of COVID among the elderly. Flamboyant Italian culture, such as kisses on the cheek when greeting, caused an initial disregard for social distancing and quarantine measures, further accelerating the spread of COVID.  Lastly, Italy’s multigenerational household made it extremely difficult for infected citizens to isolate themselves from the older, at-risk members of their family.  Italians eventually made purposeful cultural changes to protect their elderly population, but only after the first wave of cases devastated the country.
Conclusion: Lessons from ItalyEdit
The coronavirus pandemic is the most challenging health crisis in 100 years. Italy’s efforts serve as a case study for combatting various sociotechnical emergencies, not only public health crises. Disasters intensified by climate change such as hurricanes, droughts, and forest fires all require similar strategies as viral outbreaks. Successful responses to unexpected disasters vary in approach, but the most important factor to prevent and reduce the impact of catastrophes is preparation. 
The Global Preparedness Monitoring Board (GPMB), co-created by the World Health Organization (WHO) and the World Bank, released their annual report in 2019, warning of “a rapidly spreading pandemic due to a lethal respiratory pathogen” which could kill millions and devastate the world’s economy.  Despite similar pleas to strengthen global healthcare systems in previous reports, few countries took the threat seriously, resulting in the Coronavirus pandemic experts warned was imminent.
From 2014 to 2018, changes in Italian healthcare policy decreased the number of hospital beds and hospitals despite the increasing use of hospital services.  By February 2020, half of the hospital beds in northern Italy were designated for intubated patients, stretching the resources of an already depleted healthcare system.  Although WHO applauded Italian health officials for their initial efforts, lack of preparation doomed Italy from the start. The Italian government hesitated to enforce lockdowns after it was clear the pathogen had not been successfully contained, citing financial concerns and mass panic. Ineffective distribution of protective equipment to doctors and nurses, under-testing the population, and fear of repeating the mistakes of the H1N1 outbreak highlight Italy’s failure to prepare for and contain the disease. 
The 2019 Global Climate Report from the World Meteorological Organization (WMO) urged countries to drastically reduce CO2 emissions under the threat of “unprecedented floods and droughts” risking millions of lives and costing trillions of dollars.  Unlike pandemic warnings, many countries have taken important steps to reduce carbon emissions and seek alternative energy solutions, such as Chile’s new climate initiative.  Although the World should try everything to prevent rising temperatures from reaching irreversible levels, it should expect the worst. World leaders need to treat threats of unparalleled natural disasters due to climate changes as they should have treated threats of a pandemic, not as possible but as inevitable. We recommend future researchers investigate initial responses from other countries during Italy’s outbreak to identify successful global cooperation strategies that can be broadly applied to various public safety emergencies.
- Sanfelici, M. (2020). The Italian Response to the COVID-19 Crisis: Lessons Learned and Future Direction in Social Development. The International Journal of Community and Social Development, 2(2), 191–210. https://doi.org/10.1177/2516602620936037
- Pisano, G. P., Sadun, R., & Zanini, M. (2020, March 27). Lessons from Italy’s Response to Coronavirus. Harvard Business Review. https://hbr.org/2020/03/lessons-from-italys-response-to-coronavirus
- Horowitz, J., & Bucciarelli, F. (2020, December 6). The Lost Days That Made Bergamo a Coronavirus Tragedy. The New York Times. https://www.nytimes.com/2020/11/29/world/europe/coronavirus-bergamo-italy.html?action=click&module=RelatedLinks&pgtype=Article
- Statista Research Department. (2020, September). Topic: Healthcare system in Italy. Retrieved December 08, 2020, from https://www.statista.com/topics/6349/healthcare-system-in-italy/
- Nacoti, M., Ciocca, A., Giupponi, A., Brambillasca, P., Lussana, F., & Pisano, M. (2020). At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Innovations in Care Delivery, 1(6).
- Binkin, N., Michieletto, F., Salmaso, S., & Russo, F. (2020). Protecting our health care workers while protecting our communities during the COVID-19 pandemic: A comparison of approaches and early outcomes in two Italian regions. MedRxiv. doi:10.1101/2020.04.10.20060707
- Horowitz, J. (2020a, March 4). Italy’s Elderly Suffer Heavy Toll as Coronavirus Spreads. The New York Times. https://www.nytimes.com/2020/03/04/world/europe/coronavirus-italy-elderly.html
- Daughen, V. (2020). Culture and COVID-19 Observations From an Italian American Nurse. Holistic Nursing Practice, 34(4), 196–198. https://doi.org/10.1097/HNP.0000000000000395
- Nations, M. (2020, August 26). Coffee Culture and Coronavirus: Why Italy’s Pandemic Response is Unique. Glimpse from the Globe. https://www.glimpsefromtheglobe.com/regions/europe-regions/coffee-culture-and-coronavirus-why-italys-pandemic-response-is-unique/
- FEMA. (2004, August). Are You Ready? An In-depth Guide to Citizen Preparedness. https://www.fema.gov/pdf/areyouready/areyouready_full.pdf
- GPMB. (2019, September). A World at Risk: Annual report on preparedness global health emergencies. https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdf
- Statista. (2020, November 16). Number of hospital beds in Italy 2014-2018. https://www.statista.com/statistics/557293/hospital-beds-in-italy/#:%7E:text=Between%202014%20and%202018%2C%20the,during%20the%20same%20time%20range.
- Fasanotti, F. S. (2020, March 27). Knowledge is power: Lessons learned from Italy’s coronavirus outbreak. Brookings. https://www.brookings.edu/blog/order-from-chaos/2020/03/09/knowledge-is-power-lessons-learned-from-italys-coronavirus-outbreak/
- Horowitz, J. (2020b, March 5). Italy, Mired in Politics Over Virus, Asks How Much Testing Is Too Much. The New York Times. https://www.nytimes.com/2020/02/27/world/europe/italy-coronavirus.html
- WMO. (2020, March). WMO Statement on the State of the Global Climate in 2019. https://library.wmo.int/doc_num.php?explnum_id=10211
- Leprince-Ringuet, N. (2020, October 14). Chile’s Enhanced Climate Plan Sets an Example for Other Countries. World Resources Institute. https://www.wri.org/blog/2020/07/chiles-enhanced-climate-plan-sets-example-other-countries#:%7E:text=Chile’s%20Enhanced%20Climate%20Plan%20Sets%20an%20Example%20for%20Other%20Countries,-by%20No%C3%ABmie%20Leprince&text=Chile’s%20new%20climate%20plan%20sets,bolder%20ambition%20in%20the%20future.&text=With%20this%20commitment%2C%20Chile%20further,recent%20UN%20climate%20negotiations%2C%20COP25