Why was Lombardy hit harder than Italy's other regions?

On 20 January, a 64-year-old woman visited Irven Mussi, a GP in Milan, suffering from flu-like symptoms that wouldn’t let up. It was three days before two Chinese tourists landed at Milan’s Malpensa airport and 11 days before they tested positive for Covid-19 in Rome, becoming Italy’s first confirmed cases.

Mussi was not the only doctor in Lombardy to notice a “strange pneumonia” in patients around the same period, with some of his colleagues citing anomalies in both adults and children in late December.

“We had cases of atypical bronchial pneumonia that didn’t respond to treatment,” Mussi told the Guardian. “When the illness didn’t pass we started to wonder whether it might be connected to coronavirus.”

His 64-year-old patient was hospitalised on 14 February, but it was only after Italy’s first locally transmitted case was confirmed in the Lombardy town of Codogno on 21 February that she was tested and found to have Covid-19.

“I fought for a long time to get her tested,” said Mussi. “One of the most serious errors made was to only test those who had been in China or who had contact with Chinese people.”

Covid-19’s unfettered spread in Lombardy weeks before the first official case was confirmed, with the early suspicions from GPs allegedly ignored or dismissed by regional health authorities, is one explanation for the region becoming Italy’s ground zero.

Coronavirus has killed almost 16,000 people in Lombardy and infected more than 87,000 – the highest number per capita in Italy. By comparison, just next door in Piedmont and Veneto, the disease has killed 3,838 and 1,898 people, respectively, as of Thursday. Even as the number of deaths and infections subside, Lombardy still glaringly stands out from the other 19 Italian regions in the daily figures. For this reason, it will probably have to keep its borders closed as the rest of the country opens up for inter-regional travel from 3 June.

But the question of why the virus has been so lethal in Italy’s richest region while leaving others relatively unscathed is yet to yield any concrete answers. Other theories include Lombardy’s close trade ties with China and the rest of the world, population density (the region has the largest number of residents in Italy), and high levels of pollution.

However, Michele Usuelli, a doctor and regional councillor for the small, leftwing party, Più Europa, pins much of the blame on politics and healthcare mismanagement. He said Lombardy’s fate began to be charted out in the late 1990s when the Italian government decentralised healthcare, giving regions more autonomy.

At the same time, the privatisation of healthcare became more prevalent. Although other regions continued to mostly maintain the public health system, a succession of Lombardy governors, including Silvio Berlusconi’s Forza Italia between 1995 and 2013, and Matteo Salvini’s far-right League since then, allowed the private and public systems to compete for funds based on efficiency.

Even though Lombardy developed one of the most enviable healthcare systems in Italy, the strategy left private firms free to invest in areas of care that made more money, inevitably leading to a reduction of beds in the public system and leaving the region less equipped to meet all types of health needs.

“For example, over the last 25 years there has been a reduction in the number of hospital departments dealing with infectious diseases,” said Usuelli. “There has also been a fall in the number of doctors entering specialist schools for infectious diseases.”

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With the enormity of what the region has endured in recent months starting to sink in, anger has been mounting towards the League’s regional president, Attilio Fontana, so much so he said he now needed a police escort. Fontana and Giulio Gallera, Lombardy’s health councillor, are to be questioned by prosecutors in Bergamo, the Italian province worst affected by the virus, amid an investigation into criminal negligence that focuses in particular on the failure to immediately close a hospital where an outbreak occurred and care home deaths.

A commission led by Patrizia Baffi, a councillor with an opposition party, Italia Viva, has been established to scrutinise what went wrong in Lombardy. Usuelli said a crucial area that the commission must consider is failure to pick up on early warnings from GPs.

“For sure, some GPs tried to signal this strange pneumonia to the relevant authorities, so either there was an interruption in communication or nobody cared,” he said.

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The region’s response to the outbreak offers some additional insight. Codogno was immediately quarantined along with nine other nearby towns after the sudden outbreak. Vò Euganeo, a town in Veneto where the first person in Italy died of Covid-19, was also quarantined. But unlike Lombardy, Veneto quickly controlled the contagion by mass testing its population.

Lombardy authorities also delayed closing Bergamo, partly because they were under pressure by business associations to keep things going. “Across Lombardy, production never completely stopped,” said Arnaldo Caruso, a professor at Brescia University and president of the Italian Society for Virology. “People continued to work during the lockdown and without all the precautions that came later.”

A Champions League football match in Milan on 19 February attended by 40,000 Atalanta fans from Bergamo and the transfer of hospital patients to care homes in order to alleviate the pressure on wards were also believed to have contributed to the high death and contagion rate.

Some studies have pointed to Lombardy’s high pollution. However, research comparing pollution levels in Bergamo and Brescia, another badly hit Lombardy province, with the closely located Verona, a city in Veneto, between the beginning of December and end of February, paints a different picture.

“We were surprised to find that PM10 was more or less the same in Brescia and Verona, yet Verona got off lightly,” said Gianenrico Senna, the president of the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC), who led the research. “Levels in Bergamo were also lower than in Verona.”

Senna’s team identified population density as a more plausible explanation.

“In Bergamo there are more or less 300 people for every square kilometre, for Brescia it’s 200 and for Verona it’s 100,” he said. “This seemed to make the difference between areas that are closely located.”