Governments around the world are fighting the rapidly evolving Covid-19 pandemic, and for them, this battlefield has become uncharted territory. Much has been written about the practices and tactics used to suppress a pandemic in China, South Korea, Singapore, and Taiwan. Unfortunately, for most of Europe and the United States, it’s too late to try to keep Covid-19 at an early stage, and the authorities are trying to at least keep up with the spread of the pandemic. They repeat many of the mistakes that were made at the very beginning of the outbreak of coronavirus in Italy, where the pandemic turned into a catastrophe. The purpose of this article is to help American and European authorities at all levels learn from Italy’s mistakes so that they can recognize and deal with the unprecedented challenges posed by the rapidly unfolding crisis.
Within a few weeks (from February 21 to March 22), Italy went from finding the first official case of Covid-19 infection to a government decree that essentially prohibits any movement of people across the country, and to stop any commercial activity of paramount importance. For this very short period of time, the country suffered an unprecedented blow in force with an incessant stream of deaths. Without a doubt, this is the biggest crisis in Italy since World War II.
Some aspects of this crisis, starting with its timing, can certainly be attributed to the banal factor “sfortuna” (translated from Italian as “bad luck”). He clearly could not be under the full control of the authorities. However, other aspects point out the serious problems that the Italian authorities faced in recognizing the extent of the Covid-19 threat, in organizing a systematic response to it and in trying to learn from the success of timely measures and (more importantly) from mistakes and failures .
It is worth emphasizing that Italy faced these problems after the outbreak of Covid-19 completely hit China, and after some alternative virus containment models (in China and other countries) were already successfully implemented. This indicates a systematic inability to quickly and efficiently process existing information and take appropriate measures, and not a complete lack of knowledge about what needs to be done.
Below are the reasons for this fiasco related to the difficulties of making decisions in real time against the background of the unfolding crisis, and ways to overcome them.
Become aware of your cognitive bias. In the early stages, the Covid-19 crisis in Italy did not at all look like a crisis. Initial announcements of the state of emergency were met with skepticism both by the public and by many representatives of political circles, although some scholars had warned of a possible disaster a few weeks before. Indeed, at the end of February in Milan, some well-known Italian politicians publicly shook hands to emphasize that the economy should not panic and stop due to the virus. (A week later, one of these politicians was diagnosed with Covid-19.)
The same attitude towards the virus has been repeated in many other countries, and serves as an example of what scientists studying behavior problems call perception bias: people often use only information that confirms their preferred position or their initial hypothesis. Threats such as a pandemic that develop in a non-linear fashion (that is, they start small, but grow exponentially) are especially difficult to counter because of problems with quick interpretation of what is happening in real time. The most effective time for decisive action is at extremely early stages, when the threat seems small, or even before the first cases appear. But if the operational measures are indeed effective, then after some time such decisive actions will seem to be too exaggerated.
A systematic inability to hear experts becomes a problem in situations where authorities and ordinary people try to figure out how to act in difficult, extremely difficult situations. But a simple solution in such situations simply does not exist. The desire to act makes leaders rely on their inner instincts or on the opinion of their closest associates. In times of uncertainty, it is important to confront this temptation and instead devote time to searching, organizing and assimilating knowledge that is dispersed across different areas of professional competence.
Avoid incomplete solutions. The second lesson that can be learned from the Italian experience is the importance of a systematic approach and the dangers of solutions that help only partially. The Italian government fought the Covid-19 pandemic by issuing a series of orders. The authorities gradually increased restrictions in quarantine zones (“red zones”), and then distributed them until they were finally applied to the entire territory of the country.
In normal times, such an approach would probably be considered reasonable and perhaps even wise. In the current situation, he led to the opposite consequences for two reasons. First, it did not match the rapid exponential spread of the virus. The “real state of affairs” at any current point in time simply did not allow us to understand what the situation would be in just a few days. As a result, Italy followed the spread of the virus, but did not prevent it. Secondly, a selective approach could inadvertently contribute to the spread of the virus. Consider the initial decision to introduce quarantine in certain regions of the country. The announcement of the decree declaring quarantine in northern Italy triggered mass migrations of people to southern Italy, which undoubtedly contributed to the spread of the virus in regions where it was not originally there.
This illustrates what has now become clear to many observers: an effective response to the virus should be organized as a coordinated system of actions taken simultaneously. The results of the approaches used in China and South Korea confirm this view. Although public discussion of the tactics used in these countries often focuses on individual elements of their models (such as large-scale testing), in fact, the effectiveness of the measures taken is associated with many actions that were taken simultaneously. Testing is effective in combination with careful tracking of patient contacts, and tracking is effective if it is combined with an effective communication system that collects and disseminates information about the movements of potentially infected people, etc.
These rules should also apply to the organization of the health system. In hospitals, total reorganizations are necessary (for example, differentiating patient flows into patients with Covid-19 and all others). In addition, there is an urgent need for a transition from patient-centered models of care to a mass-service-oriented system that offers pandemic solutions for the entire population (with a special emphasis on home-based care). The need for coordinated action is particularly acute now in the United States.
Learning is crucial. Finding the right response approach requires the ability to learn quickly from both success and failure, as well as the willingness to change tactics accordingly. Of course, valuable lessons can be drawn from the response from China, South Korea, Taiwan, and Singapore, which helped to contain the spread of the virus fairly quickly. But sometimes the best solutions can be found very close by. Since the Italian health care system is highly decentralized, different regions have tried different responses. The most striking example is the contrast between the approaches of Lombardy and Veneto, two neighboring regions with similar socio-economic characteristics.
Lombardy, one of Europe’s richest and most productive regions, has been disproportionately affected by the Covid-19 coronavirus. As of March 26, almost 35 thousand cases of infection and 5 thousand deaths were recorded in Lombardy with a population of 10 million people. The Veneto region, on the contrary, showed significantly better results, despite the continuous spread of the virus at an early stage: 7 thousand infected and 287 deaths in a population of 5 million people.
The trajectories of the change in the situation in these two regions were formed by many factors independent of the authorities, including a higher population density of Lombardy and a greater number of cases of infection at the time the crisis began. But it is becoming increasingly apparent that the various decisions made regarding public health at the very beginning of the pandemic also proved to be important.
In particular, while Lombardy and Veneto took similar measures to socially isolate and curtail retail trade, the Veneto region initiated much more proactive actions to curb the spread of the virus. Veneto’s strategy was multifaceted:
• Large-scale testing of patients with typical symptoms and asymptomatic patients at an early stage.
• Proactive tracking of potential infected. If a person was diagnosed with coronavirus, then all the households of this patient and his neighbors also underwent testing. If test kits were not available, people were quarantined.
• Particular attention was paid to diagnosis and home care. Whenever possible, samples were taken directly from the patient’s house and then processed in regional and local university laboratories.
• Special efforts were aimed at monitoring the health status and protection of health workers and representatives of other fundamentally significant professions: medical workers, people in contact with risk groups (for example, specialists in caring for patients in nursing homes), as well as people working with the public ( for example, cashiers at supermarkets, pharmacists, and social security staff).
Following the directions of the central government public health authorities, Lombardy has chosen a more conservative approach to testing. In terms of per capita, currently in the region only half of the number of tests conducted in Veneto has been carried out, and they pay much more attention to cases with typical symptoms. In addition, the region’s authorities are investing very limited resources in preventative tracking, home care and monitoring and the protection of health workers.
It is believed that the set of measures adopted in Veneto has significantly reduced the burden on hospitals and minimized the risk of the spread of Covid-19 in medical facilities, which has become a separate problem for hospitals in Lombardy. The fact that different tactics led to different results in similar regions in the rest, from the very beginning should have been recognized as a promising educational opportunity. The results obtained in Veneto could be used to review regional and central policies in the early stages of the crisis. However, only in recent days, a month after the outbreak of coronavirus in Italy, did Lombardy and other regions take steps to mimic some aspects of the Veneto approach, which includes pressure on the central government to increase the scope of diagnosis.
The problem of disseminating freshly acquired knowledge is characteristic of both the private and public sectors. But, in our opinion, accelerating the dissemination of knowledge arising from various political decisions (in Italy and in other countries) should be considered a priority. Meanwhile, according to several scholars, “every country reinvents the wheel.” In a situation of heightened uncertainty, it is important to consider various tactics as “experiments,” rather than thinking about personal or political interests. It is necessary to apply a way of thinking that facilitates the assimilation of past and current experience and allows you to deal with Covid-19 as efficiently and quickly as possible.
It is especially important to understand what measures do not work.Success is easily revealed thanks to leaders seeking to report on progress. Problems because of fear of consequences are often hidden. When they appear, they are interpreted as individual cases, not systemic failures. For example, it turned out that at the very beginning of a pandemic in Italy (February 25), the spread of infection in one area of Lombardy could be accelerated due to a local hospital where the patient with Covid-19 was misdiagnosed and not isolated. Speaking to the media, the Italian Prime Minister referred to this incident as evidence of managerial incompetence in a particular hospital. However, after a month it became clear that this episode could be an indicator of a much deeper problem: hospitals, traditionally organized to provide patient-oriented care,
The collection and dissemination of data is very important . Italy seems to be suffering from two data-related problems. At the start of the pandemic, the problem was lack of data. In particular, it was suggested that the widespread and inconspicuous spread of the virus in the first months of 2020 may have been due to the lack of epidemiological capabilities and the inability of some hospitals to systematically record abnormal peaks of infection.
The problem of data accuracy is acute. In particular, despite the impressive efforts made by the Italian government to regularly update pandemic statistics on the public website, some commentators have hypothesized that striking differences in mortality rates between Italy and other countries and within the regions of Italy itself may be due to (at least in part) by different testing approaches. These discrepancies greatly complicate the management of the pandemic, since in the absence of truly comparable data (within the country and between countries) it is more difficult to allocate resources and understand what measures worked where (for example, identify obstacles to effectively track population movements).
In an ideal scenario, the data documenting the spread and impact of the virus should be as standardized as possible by region and country so that the spread of the virus and measures to contain it can be monitored both at the macro level (at the regional level) and at the micro level (at the hospital level). Do not underestimate the need for data at the micro level. Although the discussion of the quality of medical care is often held from the point of view of macro units (countries or regions), it is well known that medical institutions vary greatly in terms of the quality and quantity of services they provide, as well as their managerial capabilities, even within the same district or region . Instead of hiding these fundamental differences, we must be fully aware of them and plan accordingly the distribution of our limited resources. Only with reliable data at the right level of analysis can governments and healthcare professionals make the right conclusions about which approaches to containing the spread of coronavirus work and which don’t.
A different approach to decision making
There is still enormous uncertainty about what exactly needs to be done to stop the virus. Some key aspects of the virus are still unknown and hotly debated, and are likely to remain so for a considerable time. In addition, significant time intervals arise between action (or in many cases inaction) and results (infection or mortality). We must recognize that a clear understanding of which solutions work can take months, if not years.
Nevertheless, the Italian experience allows us to clearly speak about two aspects of the current crisis. First, given the exponential development of the virus, time cannot be wasted. According to the head of the Italian Protezione Civile (Federal Emergency Management Agency), the virus is “faster than our bureaucracy.” Secondly, an effective approach to combating Covid-19 will require literally military mobilization, both in terms of the totality of human and economic resources that will need to be deployed, and in terms of the unprecedented coordination that will be required to manage various parts of the health system (diagnostic equipment, hospitals, primary care doctors, etc.), as well as various structures of the public and private sectors, and society as a whole.
Taken together, the need for immediate action and mass mobilization means that an effective response to this crisis will require a decision-making approach that is far from ordinary business. If governments want to win the war against Covid-19, it’s important to adopt a systematic approach, make training a priority, and help scale up successful experiments quickly and identify and minimize ineffective ones. Yes, this is a difficult task — especially at the height of such a terrifying crisis. But the stakes in this game are too high, which means this task must be completed.