Italy now has the highest number of deaths from COVID-19 outside of mainland China. On January 31, when the Italian government announced the suspension of all direct flights to and from China amid the outbreak of COVID-19, Italy had only two cases of coronavirus. Today, a month after the suspension of direct flights with China, COVID-19 cases have surged dramatically, reaching up to more than cases 6077 as of March 24.

What actually caused this massive outbreak in Italy? Why is Italy the most affected country outside the Asian continent?

As a signatory of the Schengen Agreement, Italy has no border control with most European countries. Banning direct China flights unilaterally was not a rational and well-thought-out choice and just caused serious troubles and anxieties for the thousands of Italian and Chinese passengers who had to return home.

Furthermore, even if Italy suspends all China flights, passengers departing from China can still choose to come through stopovers in third destinations. The problem is fundamentally neither the flights from China nor people coming from China, but rather how Schengen area countries have not jointly implemented stricter health controls at international airports, if compared to what China did.

Moreover, there is no habit of wearing face masks in Italy even when you catch a cold and are sick. If a person wears a face mask on the street, he may be regarded as someone with cancer or having other serious health issues. Differently from many Asian societies where wearing a face mask is normal, this is rare in Italy.

The fact that there are so many cases of COVID-19  involving people who have never been to China or had contact with someone from China, means that COVID-19 could have been circulating in northern Italy for many weeks before it was detected because people simply thought they had a common cold.

These are several reasons to explain why Italy has become the most affected country outside Asia. At the current stage, if Italian politicians do not take immediate measures to curb COVID-19’s wide spread in the country and across Europe and beyond, the situation will only get worse. Some Italians have also started to blame and even harass physically and verbally the overseas Chinese communities in Italy.

Days ago, Luca Zaia, governor of the Italian northwestern region of Veneto, said that COVID-19 was caused by Chinese people because they had bad hygiene and the cultural practices of eating live mice. Such fake and racist statements offend all Chinese people and cannot be forgiven.

One factor affecting the country’s death rate may be the age of its population — Italy has the oldest population in Europe, with about 23% of residents 65 or older, according to The New York Times. The median age in the country is 47.3, compared with 38.3 in the United States, the Times reported. Many of Italy’s deaths have been among people in their 80s, and 90s, a population known to be more susceptible to severe complications from COVID-19, according to The Local.

“Italy is a country of old people,” said Prof Massimo Galli, the director of infectious diseases at Sacco hospital in Milan. “The elderly with previous pathologies are notoriously numerous here. I think this could explain why we are seeing more serious cases of coronavirus here, which I repeat, in the vast majority of cases start mildly and cause few problems, especially in young people and certainly in children.

“Our life expectancy is among the highest in the world. But unfortunately, in a situation like this, old people are more at risk of a serious outcome.”

The overall mortality rate is always going to depend on the demographics of a population, said Aubree Gordon, an associate professor of epidemiology at the University of Michigan. In this case, the reported mortality rate is not “age standardized,” which is a way to adjust for the underlying demographics of a population, she said.

Given Italy’s older population, “you would expect their mortality rate to be higher on average, all else being held equal,” compared with a country with a younger population, Gordon told Live Science.

In addition, as people age, the chances of developing at least one condition that weakens their immune system — such as cancer or diabetes — increases, said Krys Johnson, an epidemiologist at the Temple University College of Public Health. Such conditions also make people more susceptible to severe illness from coronavirus, she said.

Another serious issue may be the number of people in a given area who require medical care — having a lot of severely ill people in a single region could potentially overwhelm the medical system, Gordon said. She noted that this was likely the case in Wuhan, China, where the coronavirus outbreak began and which saw the majority of COVID-19 cases in China. A recent report from WHO found that the fatality rate was 5.8% in Wuhan, compared with 0.7% in the rest of the country, Live Science previously reported.

“We probably don’t know how many people have actually become infected,” Johnson said. People with more mild symptoms, or those who are younger, may not be going to get tested, she said. Johnson suspects that the true fatality rate in Italy is closer to the global fatality rate of 3.4%.

Italy has conducted a substantial number of tests — more than 42,000 as of Saturday (March 7), according to Al Jazeera. However there is likely “quite a sizeable outbreak” in the area, which would need even more testing to identify, Gordon said.

According to a hospital administrator in the area, Dr. Lorenzo Casani, “We know that Patient 1 went in and out at least three or four times from the emergency room, so he spread the virus to other patients and also to the health-care workers.”

The virus spread quickly from the smaller towns in the north to the big city of Milan. Then it exploded

“Well, you know, because we were watching it on TV from China, we saw them building up two hospitals in a week and I said, ‘Well this is crazy,'” said Dr. Giacomo Grasselli, who leads Milan’s COVID-19 task force.

“Now, I completely understand why they did that. “Grasselli briefly untied the surgical mask he’s been wearing nearly constantly in the hospital as he spoke to CBC News about what it’s been like to work in Italy’s hospitals during the outbreak.

“It’s like a bomb of patients that blows and you just come out every day from 50, 60, 70 new patients and it’s a challenge of how to find a place for each one of them. So it’s incredible what’s happening and it’s a very bad experience, very bad experience,” he added.

All the hospitals in northern Italy are stretched to the breaking point. Health-care workers are totally exhausted, themselves terrified of contracting the virus and passing it on to their own families. Ventilators are the only thing that will keep the sickest patients alive, and there may not be enough to go around. Doctors have been put in the agonizing position of deciding who lives and who dies.

The elderly, and those with complicating medical conditions, might be sacrificed.

“If you have to choose between a 75-year-old person and a 20-year-old person, who are you going to choose? Obviously, it’s the person with the higher expectation of life,” Casani said.

“So there will be a moment that an anesthesiologist will have to take off the respirator from this 75-year-old guy and give it to the 20-year-old. And this will be a horrible choice for the doctors, but obviously necessary.”

Effectively that means that some people are being left to die because it’s not possible to treat everybody,” said Prof. Yascha Mounk of Johns Hopkins University in Washington, D.C.

He has studied the ethical dilemmas of what used to be considered “battlefield medicine.”

“I mean, I can only imagine how psychologically devastating it must be for the doctors and nurses involved. They are already at great danger to themselves, working around the clock, in an extreme situation, seeing many people die and now you add on top of that the psychological stress of having to look at a patient and say, ‘I’m not going to be able to do anything for you.’ It’s hard to fathom.”

While some people point to the average age of the population, the oldest in Europe the others point to the bad air pollution in the northern industrial areas that has caused widespread lung disease.

“In the northern region we have the most polluted air in … Europe, and this is linked with viral infection, pneumonia infections,” Casani said.

As to why COVID-19 spread so quickly once it arrived, he said, “We do not have emergency plans for pandemics. We have it for natural disasters. And, also we were the first, so we were totally unprepared.”

Mounk sees this differently. “I think the question of ‘Why Italy?’ is the most important question and it has a simple answer: No reason at all. The only thing that makes Italy different is that the first couple of [community-transmitted] cases arrived in Italy about 10 days before they arrived in Germany, the United States or Canada. So if other countries aren’t going to react in an extreme way right now, they’re going to become Italy.”




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