From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Bergamo’s Response to the Coronavirus Pandemic – Update (May 2020)

Matteo M Galizzi (LSE) and Simone Ghislandi (University Bocconi)

Below is an updated timeline regarding the Covid-19 pandemic in Bergamo.

Early April 2020: Evidence emerged that, already from 8^th March 2020, the Lombardy region allowed Covid-19 patients in non-critical conditions to be transferred from hospitals to some of its nursing homes (RSA). The Italian Higher Health Institute seemed to be unaware of this. The mayors of Bergamo, Brescia, Cremona, Lecco, Mantova, Milano, and Varese write to the Lombardy region asking for clarity about the RSA, the lack of PPE for healthcare professionals, and the low rates of testing. A total of 1,310 out of 6,500 residents in the RSA in the Bergamo province have died of Covid-19, a quarter of the residents in some of the RSA (e.g. the RSA of Clusone, Val Seriana).

9^th April 2020: After having prioritised testing and PPE for hospitals, the Lombardy region local health authority (ATS) Bergamo – responsible for the hospitals and care homes (RSA) – starts testing symptomatic residents and healthcare professionals in its RSA. However, initially there are only 50 tests for 65 RSA. The Bergamo province reports 10,043 confirmed Covid-19 cases.

17^th April 2020: The head of the Lombardy region dismisses the accusations of having authorized the transfer of Covid-19 patients from hospitals to RSA, blaming that decision on the single local ATS, which, however, are controlled by the Region. On the non-governmental side, the #CommissariateLaLombardia hashtag goes viral with a petition asking the government to put the Lombardy region under special administration. Confirmed Covid-19 cases in the Bergamo province: 10,590.

23^rd April 2020: The Lombardy region studies the possibility of setting up specialised RSA dedicated to Covid-19 elderly patients in order to minimise infections in RSA. Evidence emerges that in many RSA in the Lombardy region (and beyond) PPE were lacking for healthcare professionals: the first substantial provision of PPE to many RSA arrived only on 1^st April 2020. Evidence also emerges that relatives were able to regularly visit elderly residents in RSA, often without restrictions or PPE. About 40% of the 6,773 deaths in the Italian RSA since 1^st February 2020 could be attributable to Covid-19, says the ISS: 2,724 cases, of which more than 1,600 in the Lombardy region only. Covid-19 cases: 10,946.

26^th April 2020: The Papa Giovanni XXIII hospital in Bergamo, that was the epicentre of local response to the outbreak, slowly returns to normality, removing the red lines stickers to separate the contaminated areas within the hospital. Covid-19 cases: 11,113.

28^th April 2020: The Italian Prime Minister visits Bergamo where he is asked by journalists about the government’s inaction in locking down Alzano and Nembro, and in allowing hundreds of thousands in the Bergamo province to go back to work without any systematic testing. Covid-19 cases: 11,196.

30^th April 2020: The former Prime Minister and leader of the Democratic Party Matteo Renzi lobbies in the Senate in favour of reopening business activities, claiming that, if they were able to talk, reopening would be the request of the people who have died in Bergamo and Brescia. The director of the Mario Negri institute says GPs should temporarily move directly under the National Health System (instead of depending on the single regions), be provided with PPE, and be the first on the frontline to treat Covid-19 patients directly in their homes, together with special mobile units with oxygen and diagnostics, whereas severe Covid-19 patients should be hospitalised in special dedicated hospitals. Covid-19 cases: 11,313.

1^st May 2020: the head of the infectious diseases unit of the Bergamo hospital says that there are currently 200 Covid-19 patients in the Bergamo province hospitals (including the new field hospital) against an average of around 550 hospitalised patients (of which 92 are in ICUs and 142 on ventilators) at the peak of the crisis. Covid-19 cases: 11,360.

4^th March 2020: ‘phase 2’ starts in Italy: while schools remain closed, businesses are allowed to re-open and some movement restrictions are eased. There are no special restrictions for the Bergamo province. The medical doctors’ society in Lombardy reports that a total of 155 doctors (and 30 nurses) have died of Covid-19 in Italy. Covid-19 cases: 11,538.

5^th May 2020: ISTAT releases the official statistics about the number of deaths in each province: compared to the monthly average in the 2015-2019 years, in March 2020 the number of deaths in the Bergamo province has increased by 568%, the highest increase in Italy. A recent study based on ISTAT data estimates that the excess number of deaths between 1^st January and 4^th April 2020 – 5,700 deaths – translates in a reduction of life expectancy of almost 8 years for men and 6.5 years for women in the Bergamo province: the loss of life years associated to the Covid-19 pandemic is the most shocking event in the province since World War II. Covid-19 cases: 11,550.

Bergamo’s Response to the Coronavirus Pandemic – Original post (April 2020)

Matteo M Galizzi (LSE) and Simone Ghislandi (University Bocconi)

Bergamo, in the Italian Lombardy region, has been the epicentre of the Covid-19 epidemic in Europe. With 10,472 people infected to date and 2,060 people dead (as of 31^st March) due to Covid-19, Bergamo has been the hardest hit province in Italy. Below are the timeline and some key facts about the Covid-19 outbreak in Bergamo.

January-February 2020: Covid-19 arrives in Lombardy, one of the most economically active regions in Europe, probably in early January. The virus spreads undetected before the first confirmed case in Lombardy on the 20^th February. Several doctors and nurses in the Bergamo province notice cases of ‘weird’ pneumonia which, on hindsight, could be attributable to Covid-19.

19^th February 2020: Champions League football match Atalanta-Valencia in Milan: about 45,000 Atalanta supporters move from Bergamo province to Milan to watch the match.

20^th February 2020: Covid-19 Italian patient 1 is admitted to a hospital ICU in Codogno, in the Lodi province (Lombardy).

21^st February 2020: the two regions of Lombardy and Veneto start tracing Covid-19 patients, testing both symptomatic and asymptomatic people.

23^rd February 2020: the Lombardy region sets up its first ‘red zone’ in Codogno. All schools and universities in Lombardy and Veneto are closed. There are also restrictions on bars, restaurants, and other public spaces. The first Covid-19 death is recorded in the Bergamo province: in the Pesenti Fenaroli hospital in Alzano Lombardo, Val Seriana a woman dies of Covid-19 after been originally hospitalised for a heart problem. The hospital is closed and re-opened on the same day. It is unclear whether, and to what extent, the hospital has been sanitised before re-opening, and whether the patients and healthcare staff in the hospital are tested or isolated before re-opening.

26^th February 2020: the Lombardy region start testing only the symptomatic cases.

27^th – 28^th February 2020: several national politicians dismiss the risks of Covid-19 and the need for restrictive measures. Confindustria Bergamo (Bergamo’s Confederation of Business Industries) posts a video on its social media to reassure the international business community that ‘Bergamo is running’ as usual. Even the mayor of Bergamo, who later changes his mind, initially posts about this. There are 103 confirmed Covid-19 cases in the Bergamo province.

1^st March 2020: More than 300 retired and trainee doctors and 500 nurses are called on duty in Lombardy on a voluntary basis. Covid-19 cases: 209.

3^rd March 2020: the Lombardy region requests the institution of a ‘red zone’ for Alzano and Nembro. The Italian Higher Health Institute (ISS) scientific committee advises in favour of the red zone. Covid-19 cases: 372.

4^th– 7^th March 2020: the Italian Government closes all the schools in the country and sends the army to Bergamo and Val Seriana to set up a red zone. Covid-19 cases: 761.

8^th March 2020: the Italian government sets up an ‘orange zone’ for the whole of Lombardy. There is no red zone or special restriction for Alzano, Nembro, or the Bergamo province. As a result, most business activities and manufacturing companies are working as usual until 23^rd March. Covid-19 cases: 997.

9^th March 2020: the Lombardy ‘orange zone’ applies to the whole country. Covid-19 cases: 1,245.

11^th March 2020: the restrictions are tightened. Covid-19 cases: 1,815.

14^th March 2020: all the ICU beds in the Bergamo hospital are at full capacity. Covid-19 cases: 2,864.

17^th March 2020: more than half of the beds in the Bergamo hospital are for Covid-19 patients. The New York Times posts its interview of the head of the respiratory unit at the Bergamo hospital: ‘it’s like a war’ he says. Covid-19 cases: 3,993.

23^rd March 2020: the Italian government closes all business activities which are not essential. Covid-19 cases: 6,471.

26^th March 2020: the Lombardy region starts testing only the mono-symptomatic cases (before two or more symptoms were needed). Healthcare professionals from Albania, Cuba, Poland, Russia, and the US arrive in Lombardy to help. Covid-19 cases: 7,458.

1^st April 2020: the local CESVI NGO delivers 670,000 personal protective equipment (PPE) items and ICU equipment devices to healthcare staff in Bergamo hospital. Covid-19 cases: 9,039.

6^th April 2020: the ANA and Emergency NGOs and local volunteers open a new field hospital with 72 ICU beds and 72 sub-intensive care beds, set up in record time of 7 days. Covid-19 cases: 9,815.

The timeline described above draws quite a mixed picture about the response in Bergamo.

Recent evidence shows that Covid-19 arrived in Lombardy no later than early January, before the WHO declared human-to-human transmission. This would explain such an explosion of cases a few weeks later. The Atalanta-Valencia match on 19^th February has been blamed in hindsight for having contributed to the spread of the virus among supporters going to Milan for the match. Given that the first official cases in Lombardy and Bergamo were recorded only on 20^th and 23^rd February, respectively, the evidence on the earlier presence of Covid-19 in Lombardy would also provide support for such a possibility.

In any case, at the beginning of the crisis decision-makers seemed to underestimate the virulence, spread and impact of the new disease, and to lack a systematic plan on how to respond to it. This underestimation and unpreparedness – together with the dismissive views by national politicians and the local confederation of business industries – may have contributed to the initial uncontrollable spread the virus. The differences in how the Lombardy and Veneto regions have tested and traced Covid-19 cases at the beginning have been discussed elsewhere. Next there is the delay in the response about locking down Alzano, Nembro and the whole Bergamo province. The Italian government and the Lombardy region blame each other for such inaction. Another delay that is difficult to justify concerns the business activities there, which continued to work for the two weeks between the beginning of the ‘orange zone’ on 8^th March and the lockdown of all non-essential activities on 23^rd March, during which the cases grew from 997 to 6,471 in the province. Some local leading public health experts indeed warned that the Val Seriana should have been locked down earlier, and that such inaction would end up harming healthcare staff and workers. Finally, a judicial investigation is under way in Bergamo to understand whether the response in the Alzano hospital was appropriate after the first Covid-19 death was recorded there.

On the other hand, Bergamo’s later response to the emergency has been extraordinary, with healthcare staff in hospitals strenuously working around the clock to cope with the overwhelming emergency, and rapidly reorganising the Bergamo hospital to use 60% of its entire capacity for Covid-19 patients; with retired and trainee doctors and nurses volunteering to help; with local people and NGOs donating millions of euros to support with PPE the healthcare staff on the frontline, and the setting up in a record week of a new field hospital with 72 ICU beds.

On balance, Bergamo has attracted attention across the world for the devastating effects that Covid-19 has had on hospitals, human lives, and the social fabric. Bergamo’s unprecedented experience with Covid-19 has made dramatically vivid the role of the ‘curve’ and has highlighted the key importance of ICU facilities as the real bottlenecks in the health system in such an outbreak. Quickly reaching capacity in the 48 ICU beds and ventilators in the brand-new state-of-the-art Papa Giovanni XXIII hospital in Bergamo has overloaded the hospital and led the whole local healthcare system to the brink of a collapse. Similar to what could have happened in Alzano, this may have turned the hospital into a highly contaminated place, infecting not only other patients but also many doctors and nurses: a total of 109 doctors and 26 nurses have died of Covid-19 in Italy, and more than 10,000 of them have been infected. The professional society of the medical doctors in Lombardy (FROMCeO) has blamed the Lombardy region for a series of mistakes in the emergency, from the lack of testing and PPE for the healthcare staff, to the poor management of the care homes (RSA) where 600 out of 6,000 residents have died in the Bergamo province only.

The official death toll (2,060) is a tragedy for the Bergamo province. The world has watched in shock as the deaths in Bergamo became so many that military trucks had to carry the coffins for cremation to other provinces – an unprecedented scene in peace time. Yet the official figure for the deaths claimed by Covid-19 underestimates the true figure, because it only counts the number of patients who died in hospitals, but does not include the many people dying at home or in care homes. Estimates based on the number of obituaries, on the number of deaths released in early April by the Italian Statistical Office (ISTAT), and on other official statistics suggest that, in some municipalities in the Bergamo province, the number of deaths increased by up to 400% compared to analogous figures for 2019, and that the real number of deaths attributable to Covid-19 is between 4,500 and up to four times the initial official figure.

Describing the key facts and the dramatic timeline of what has happened in Bergamo can hopefully help inform the discussion there and elsewhere on how next to respond to the Covid-19 pandemic, including whether and how to ease the current restrictions.

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