Lessons from Italy’s Response to Coronavirus

As policymakers around the world struggle to combat the rapidly escalating Covid-19 pandemic, they find themselves in uncharted territory. Much has been written about the practices and policies used in countries such as China, South Korea, Singapore, and Taiwan to stifle the pandemic. Unfortunately, throughout much of Europe and the United States, it is already too late to contain Covid-19 in its infancy, and policymakers are struggling to keep up with the spreading pandemic. In doing so, however, they are repeating many of the errors made early on in Italy, where the pandemic has turned into a disaster. The purpose of this article is to help U.S. and European policymakers at all levels learn from Italy’s mistakes so they can  recognize and address the unprecedented challenges presented by the rapidly expanding crisis.

In a matter of weeks (from February 21 to March 22), Italy went from the discovery of the first official Covid-19 case to a government decree that essentially prohibited all movements of people within the whole territory, and the closure of all non-essential business activities. Within this very short time period, the country has been hit by nothing short of a tsunami of unprecedented force, punctuated by an incessant stream of deaths. It is unquestionably Italy’s biggest crisis since World War II.

Some aspects of this crisis — starting with its timing — can undoubtedly be attributed to plain and simple sfortuna (“bad luck” in Italian) that were clearly not under the full control of policymakers. Other aspects, however, are emblematic of the profound obstacles that leaders in Italy faced in recognizing the magnitude of the threat posed by Covid-19, organizing a systematic response to it, and learning from early implementation successes — and, most importantly, failures.

It is worth emphasizing that these obstacles emerged even after Covid-19 had already fully impacted in China and some alternative models for the containment of the virus (in China and elsewhere) had already been successfully implemented. What this suggests is a systematic failure to absorb and act upon existing information rapidly and effectively rather than a complete lack of knowledge of what ought to be done.

Here are explanations for that failure — which relate to the difficulties of making decisions in real time, when a crisis is unfolding — and ways to overcome them.

Recognize your cognitive biases. In its early stages, the Covid-19 crisis in Italy looked nothing like a crisis. The initial state-of-emergency declarations were met by skepticism by both the public and many in policy circles — even though several scientists had been warning of the potential for a catastrophe for weeks. Indeed, in late February some notable Italian politicians engaged in public handshaking in Milan to make the point that the economy should not panic and stop because of the virus. (A week later, one of these politicians was diagnosed with Covid-19.)

Similar reactions were repeated across many other countries besides Italy and exemplify what behavioral scientists call confirmation bias — a tendency to seize upon information that confirms our preferred position or initial hypothesis. Threats such as pandemics that evolve in a nonlinear fashion (i.e., they start small but exponentially intensify) are especially tricky to confront because of the challenges of rapidly interpreting what is happening in real time. The most effective time to take strong action is extremely early, when the threat appears to be small — or even before there are any cases. But if the intervention actually works, it will appear in retrospect as if the strong actions were an overreaction. This is a game many politicians don’t want to play.

The systematic inability to listen to experts highlights the trouble that leaders — and people in general — have figuring out how to act in dire, highly complex situations where there’s no easy solution. The desire to act causes leaders to rely on their gut feeling or the opinions of their inner circle. But in a time of uncertainty, it is essential to resist that temptation, and instead take the time to discover, organize, and absorb the partial knowledge that is dispersed across different pockets of expertise.

Avoid partial solutions. A second lesson that can be drawn from the Italian experience is the importance of systematic approaches and the perils of partial solutions. The Italian government dealt with the Covid-19 pandemic by issuing a series of decrees that gradually increased restrictions within lockdown areas (“red zones”), which were then expanded until they ultimately applied to the entire country.

In normal times, this approach would probably be considered prudent and perhaps even wise. In this situation, it backfired for two reasons. First, it was inconsistent with the rapid exponential spread of the virus. The “facts on the ground” at any point in time were simply not predictive of what the situation would be just a few days later. As a result, Italy followed the spread of the virus rather than prevented it. Second, the selective approach might have inadvertently facilitated the spread of the virus. Consider the decision to initially lock down some regions but not others. When the degree announcing the closing of northern Italy became public, it touched off a massive exodus to southern Italy, undoubtedly spreading the virus to regions where it had not been present.

This illustrates is what is now clear to many observers: An effective response to the virus needs to be orchestrated as a coherent system of actions taken simultaneously. The results of the approaches taken in China and South Korea underscore this point. While the public discussion of the policies followed in these countries often focuses on single elements of their models (such as extensive testing), what truly characterizes their effective responses is the multitude of actions that were taken at once. Testing is effective when it’s combined with rigorously contact tracing, and tracing is effective as long as it is combined with an effective communication system that collects and disseminates information on the movements of potentially infected people, and so forth.

These rules also apply to the organization of the health care system itself. Wholesale reorganizations are needed within hospitals (for example, the creation of Covid-19 and non Covid-19 streams of care). In addition, a shift is urgently needed from patient-centered models of care to a community-system approach that offers pandemic solutions for the entire population (with a specific emphasis on home care). The need for coordinated actions is especially acute right now in the United States.

Learning is critical. Finding the right implementation approach requires the ability to quickly learn from both successes and failures and the willingness to change actions accordingly. Certainly, there are valuable lessons to be learned from the approaches of China, South Korea, Taiwan, and Singapore, which were able to contain the contagion fairly early. But sometimes the best practices can be found just next door. Because the Italian health care system is highly decentralized, different regions tried different policy responses. The most notable example is the contrast between the approaches taken by Lombardy and Veneto, two neighboring regions with similar socioeconomic profiles.

Lombardy, one Europe’s wealthiest and most productive areas, has been disproportionately hit by Covid-19. As of March 26, it held the grim record of nearly 35,000 novel coronavirus cases and 5,000 deaths in a population of 10 million. Veneto, by contrast, fared significantly better, with 7,000 cases and 287 deaths in a population of 5 million, despite experiencing sustained community spread early on.

The trajectories of these two regions have been shaped by a multitude of factors outside the control of policymakers, including Lombardy’s greater population density and higher number of cases when the crisis erupted. But it’s becoming increasingly apparent that different public health choices made early in the cycle of the pandemic also had an impact.

Specifically, while Lombardy and Veneto applied similar approaches to social distancing and retail closures, Veneto took a much more proactive tack towards the containment of the virus. Veneto’s strategy was multi-pronged:

  • Extensive testing of symptomatic and asymptomatic cases early on.
  • Proactive tracing of potential positives. If someone tested positive, everyone in that patient’s home as well as their neighbors were tested. If testing kits were unavailable, they were self-quarantined.
  • A strong emphasis on home diagnosis and care. Whenever possible, samples were collected directly from a patient’s home and then processed in regional and local university labs.
  • Specific efforts to monitor and protect health care and other essential workers. They included medical professionals, those in contact with at-risk populations (e.g., caregivers in nursing homes), and workers exposed to the public (e.g., supermarket cashiers, pharmacists, and protective services staff).

Following the guidance from public health authorities in the central government, Lombardy opted instead for a more conservative approach to testing. On a per capita basis, it has so far conducted half of the tests conducted in Veneto and had a much stronger focus only on symptomatic cases — and has so far made limited investments in proactive tracing, home care and monitoring, and protection of health care workers.

The set of policies enacted in Veneto are thought to have considerably reduced the burden on hospitals and minimized the risk of Covid-19 spreading in medical facilities, a problem that has greatly impacted hospitals in Lombardy. The fact that different policies resulted in different outcomes across otherwise similar regions should have been recognized as a powerful learning opportunity from the start. The findings emerging from Veneto could have been used to revisit regional and central policies early on. Yet, it is only in recent days, a full month after the outbreak in Italy, that Lombardy and other regions are taking steps to emulate some of the aspects of the “Veneto approach,” which include pressuring the central government to help them boost their diagnostic capacity.

The difficulty in diffusing newly acquired knowledge is a well-known phenomenon in both private- and the public-sector organizations. But, in our view, accelerating the diffusion of knowledge that is emerging from different policy choices (in Italy and elsewhere) should be considered a top priority at a time when “every country is reinventing the wheel,” as several scientists told us. For that to happen, especially at this time of heightened uncertainty, it is essential to consider different policies as if they were “experiments,” rather than personal or political battles, and to adopt a mindset (as well as systems and processes) that facilitates learning from past and current experiences in dealing with Covid-19 as effectively and rapidly as possible.

It is especially important to understand what does not work. While successes easily surface thanks to leaders eager to publicize progress, problems often are hidden due to fear of retribution, or, when they do emerge, they are interpreted as individual — rather than systemic — failures. For example, it emerged that at the very early onset of the pandemic in Italy (February 25), the contagion in a specific area in Lombardy could have been accelerated through a local hospital, where a Covid-19 patient was not been properly diagnosed and isolated. In talking to the media, the Italian prime minister referred to this incident as evidence of managerial inadequacy at the specific hospital. However, a month later it became clearer that the episode might have been emblematic of a much deeper issue: that hospitals traditionally organized to deliver patient-centric care are ill-equipped to deliver the type of community-focused care needed during a pandemic.

Collecting and disseminating data is important. Italy seems to have suffered from two data-related problems. In the early onset of the pandemic, the problem was data paucity. More specifically, it has been suggested that the widespread and unnoticed diffusion of the virus in the early months of 2020 may have been facilitated by the lack of epidemiological capabilities and the inability to systematically record anomalous infection peaks in some hospitals.

More recently, the problem appears to be one of data precision. In particular, in spite of the remarkable effort that the Italian government has shown in regularly updating statistics relative to the pandemic on a publicly available website, some commentators have advanced the hypothesis that the striking discrepancy in mortality rates between Italy and other countries and within Italian regions may (at least in part) be driven by different testing approaches. These discrepancies complicate the management of the pandemic in significant ways, because in absence of truly comparable data (within and across countries) it is harder to allocate resources and understand what’s working where (for example, what’s inhibiting the effective tracing of the population).

In an ideal scenario, data documenting the spread and effects of the virus should be as standardized as possible across regions and countries and follow the progression of the virus and its containment at both a macro (state) and micro (hospital) level. The need for micro-level data cannot be underestimated. While the discussion of health care quality is often made in terms of macro entities (countries or states), it is well known that health care facilities vary dramatically in terms of the quality and quantity of the services they provide and their managerial capabilities, even within the same states and regions. Rather than hiding these underlying differences, we should be fully aware of them and plan the allocation of our limited resources accordingly. Only by having good data at the right level of analysis can policymakers and health care practitioners draw proper inferences about which approaches are working and which are not.

A Different Decision-Making Approach

There is still tremendous uncertainty on what exactly needs to be done to stop the virus. Several key aspects of the virus are still unknown and hotly debated, and are likely to remain so for a considerable amount of time. Furthermore, significant lags occur between the time of action (or, in many cases, inaction) and outcomes (both infections and mortality). We need to accept that an unequivocal understanding of what solutions work is likely to take several months, if not years.

However, two aspects of this crisis appear to be clear from the Italian experience.

  1. First, there is no time to waste, given the exponential progression of the virus. As the head of the Italian Protezione Civile (the Italian equivalent of FEMA) put it, “The virus is faster than our bureaucracy.”
  2. Second, an effective approach towards Covid-19 will require a war-like mobilization — both in terms of the entity of human and economic resources that will need to be deployed as well as the extreme coordination that will be required across different parts of the health care system (testing facilities, hospitals, primary care physicians, etc.), between different entities in both the public and the private sector, and society at large.

Together, the need for immediate action and for massive mobilization imply that an effective response to this crisis will require a decision-making approach that is far from business as usual. If policymakers want to win the war against Covid-19, it is essential to adopt one that is systemic, prioritizes learning, and is able to quickly scale successful experiments and identify and shut down the ineffective ones. Yes, this a tall order — especially in the midst of such an enormous crisis. But given the stakes, it has to be done.

Maria Butina is just the tip of the Russia iceberg

There is no right to bear arms in Russia, and under this regime there never will be. According to court papers, Butina nevertheless convinced some naive members of the National Rifle Associationthat she was a genuine activist. In doing so, she gained access to their world.

.. They were both seeking to assist political movements they believed to be pro-Kremlin (the Communist Party of the 1930s; the pro-gun wing of the Republican Party of the 2010s). They were both backed by Kremlin money, diverted through cutouts (the Communist International, in the former instance; a couple of Russian oligarchs, allegedly, in the latter).

.. Butina, even if considering only her role as an open, pro-Kremlin activist, also has many counterparts, agents of influence who are openly agitating for Russian interests, now on the far-right edge of Western politics instead of the far-left.

  • Gianluca Savoini, the leader of the enigmatic Lombardy-Russia Cultural Association, seems to perform a similar role in Italian politics, even showing up recently as a member of an official Italian government delegation to Moscow.
  • Bela Kovacs , a Hungarian member of the European Parliament, is on trial in Budapest on a charge of spying on European Union institutions on behalf of Russia.

.. they too are part of a long-term project, though it’s not a proletarian revolution. Instead, it’s a kleptocratic coup d’état: The modern Kremlin project seeks to undermine Western democracies, break up the E.U. and NATO, and put corrupt relationships rather than the rule of law at the center of international commerce.

.. it’s worth remembering why Golos and his network failed. In large part,

  • it was because the center-left — especially the anti-Soviet wing of the American trade union movement — rejected Soviet-style communism in the United States. It’s also because,
  • in the 1940s and 1950s, the American political establishment, Democratic and Republican, unified around the need to defeat Soviet-style communism in Europe. And it’s because,
  • even in the depths of the Depression, the majority of Americans were never beguiled by the appeal of authoritarianism.

.. A wing of the Republican Party is preparing to double down and support the Russian autocracy, which it believes, mistakenly, is “Christian.” 

.. To push back against them, as well as their equivalents from the rest of the autocratic world, we will need not only to catch the odd agent but also to

  • make our political funding systems more transparent, to
  • write new laws banning shell companies and money laundering, and to
  • end the manipulation of social media.

It took more than a generation for Americans to reject the temptations of communist authoritarianism; it will take more than a generation before we have defeated kleptocratic authoritarianism too — if we still can.

 

 

How to Destroy Democracy, the Trump-Putin Way

All around the world, strongmen are seizing power and subverting liberal norms.

fascism came out of particular historical circumstances that do not obtain today—

  • a devastating world war,
  • drastic economic upheaval, the
  • fear of Bolshevism.

.. When Naomi Wolf and others insisted that George W. Bush was taking us down the path of 1930s Germany, I thought they were being histrionic. The essence of fascism after all was the obliteration of democracy. Did anyone seriously believe that Bush would cancel elections and refuse to exit the White House?

.. So maybe fascism isn’t the right term for where we are heading. Fascism, after all, was all about big government—grandiose public works, jobs jobs jobs, state benefits of all kinds, government control of every area of life. It wasn’t just about looting the state on behalf of yourself and your cronies, although there was plenty of that too. Seeing Vladimir Putin and Donald Trump at the press conference following their private meeting in Helsinki, though, I think maybe I’ve been a bit pedantic. Watching those two thuggish, immensely wealthy, corrupt bullies, I felt as if I was glimpsing a new world order—not even at its birth but already in its toddler phase. The two men are different versions of an increasingly common type of leader:

  • elected strongmen ‘who exploit weak spots in procedural democracy to come to power, and
  • once ensconced do everything they can to weaken democracy further,
  • while inflaming powerful popular currents of
    • authoritarianism,
    • racism,
    • nationalism,
    • reactionary religion,
    • misogyny,
    • homophobia, and
    • resentments of all kinds.

.. At the press conference Putin said that associates of the billionaire businessman Bill Browder gave Hillary Clinton’s campaign $400 million, a claim Politifact rates “pants on fire” and about which The New York Times’ Kenneth Vogel tweeted, “it was so completely without evidence that there were no pants to light on fire, so I hereby deem it ‘WITHOUT PANTS.’”

.. A Freudian might say that his obsession with the imaginary sins of Clinton suggests he’s hiding something. Why else, almost two years later, is he still trying to prove he deserved to win? At no point in the press conference did he say or do anything incompatible with the popular theory that he is Putin’s tool and fool.

.. These pantsless overlords are not alone. All over the world, antidemocratic forces are winning elections—sometimes fairly, sometimes not—and then using their power to subvert democratic procedures.

There’s Recep Tayyip Erdoğan in Turkey—remember how when he first took office, back in 2014, he was seen as a harmless moderate, his Justice and Development Party the Muslim equivalent of Germany’s Christian Democrats? Now he’s shackling the press, imprisoning his opponents, trashing the universities, and trying to take away women’s rights and push them into having at least three, and possibly even five, kids because there just aren’t enough Turks.

.. Then there’s Hungary’s Viktor Orbán, who coined the term “illiberal democracy” to describe these elected authoritarian regimes, now busily shaping the government to his own xenophobic ends, and

.. Poland’s Andrzej Duda, doing much the same—packing the courts, banning abortion, promoting the interests of the Catholic church.

Before World War II Poland was a multiethnic country, with large minorities of Jews, Roma, Ukrainians, and other peoples. Now it boasts of its (fictional) ethnic purity and, like Hungary and the Czech Republic, bars the door to Muslim refugees in the name of Christian nationalism.

One could mention

  • Philippine President Rodrigo Duterte,
  • Egyptian President Abdel Fattah el-Sisi,
  • Israel’s Benjamin Netanyahu, and
  • India’s Narendra Modi as well.

Pushed by anti-immigrant feeling, which is promoted by

  • unemployment and
  • austerity,

right-wing “populist” parties are surging in

  • Italy,
  • Greece,
  • the Netherlands,
  • France,
  • Germany,
  • Austria, and even
  • Sweden and
  • Denmark.

And don’t forget Brexit—boosted by pie-in-the-sky lies about the bounty that would flow from leaving the European Union but emotionally fueled by racism, nativism, and sheer stupidity.

.. At home, Donald Trump energizes similarly antidemocratic and nativist forces. Last year, outright neo-Nazis marched in Charlottesville, and Trump called them “very fine people.” This year, Nazis and Holocaust deniers are running in elections as Republicans, and far-right misogynist hate groups like the Proud Boys are meeting in ordinary bars and cafés.

.. The worst of it is that once the leaders get into power, they create their own reality, just as Karl Rove said they would:

  • They control the media,
  • pack the courts
  • .. lay waste to regulatory agencies,
  • “reform” education,
  • abolish long-standing precedents, and
  • use outright cruelty—of which the family separations on the border are just one example—to create fear.

While everybody was fixated on the spectacle in Helsinki, Trump’s IRS announced new rules that let dark-money groups like the National Rifle Association and the Koch brothers’ Americans for Prosperity keep their donors secret. 

.. American democracy might not be in its death throes yet, but every week brings a thousand paper cuts.

.. There’s nothing inevitable about liberal democracy, religious pluralism, acceptance of ethnic diversity, gender and racial equality, and the other elements of what we think of as contemporary progress.

.. He has consolidated a bloc of voters united in their grievances and their fantasies of redress. The

  • fundamentalist stay-home moms, the
  • MAGA-hat wearing toughs, the
  • Fox-addicted retirees, the
  • hedge-fund multimillionaires and the
  • gun nuts have found one another.

.. Why would they retreat and go their separate ways just because they lost an election or even two? Around the world it may be the same story: Democracy is easy to destroy and hard to repair, even if people want to do so, and it’s not so clear that enough of them do.

Why Justin Trudeau Is Able to Stand Up to Donald Trump

I have the immediate urge to praise Canada, set in motion by Justin Trudeau’s recent rebuke of Donald Trump at the G-7 summit. There, Trudeau made it plain that he and his country were not about to be bullied by the American President, not on a question of unilateral tariffs, not about anything. Trump responded with gangster-style threats and sneers, followed by more threats and sneers from his associates.

.. The question worth asking is what it is in the Canadian national character, if I may call it that, that makes Canadians so ready to take on bullies.

Canada has been doing this as long as there has been a Canada. The Mounties wear red coats, we were taught in school, to defy villains by their very presence.

.. Lester Pearson prompted Charles de Gaulle to cut short a visit to the country, in 1967, after he had insulted Canadian sovereignty.

.. When Pierre Trudeau learned that Richard Nixon, in 1971, had called him an “asshole,” he delivered an unforgettable Canadian retort: “I’ve been called worse things by better people.”

.. Famously obliging in attitude—how do you get twenty-five Canadians out of a swimming pool? You say, “Please get out of the swimming pool”—Canadians are also notoriously stubborn of spirit.

.. Canadian democracy is supported by some of the strongest social capital in the world, exceeded only, by most academic measures, by that of Scandinavia and New Zealand.

.. Trust in social institutions, in the honesty of government and the solidarity of citizens, remains strong in Canada, even when its results, as with the election of Doug Ford—the smarter brother of the late Rob Ford, the onetime mayor of Toronto—to the premiership of Ontario, is not what progressive-minded people might like.

.. the United States now ranks below Canada, it still scored high in recent registries. But it once led the world in social capital. Can it do so again?

.. The term seems to have originated, or at least become most closely associated, with the Harvard political scientist Robert Putnam.

.. in northern Italy, where citizens participate actively in sports clubs, literary guilds, service groups, and choral societies, regional governments are “efficient in their internal operation, creative in their policy initiatives and effective in implementing those initiatives.” In southern Italy, by contrast, where patterns of civic engagement are far weaker, regional governments tend to be corrupt and inefficient.

.. If you have experience working outside your immediate clan or cohort, you’re likelier to be able to practice democratic politics.

.. Jürgen Habermas captured in the phrase “the public sphere,” when he showed how essential civic life was to the Enlightenment: a government is only as strong as its cafés.

.. for all the South’s cultural self-proclamation, it was a paralyzed, frozen society, while the North was full of activity. “Our young men are members and managers of reading rooms, public libraries, gymnasiums, game clubs, boat clubs, ball clubs, and all sorts of clubs, Bible classes, debating societies, military companies; they are planting road-side trees, or damming streams for skating ponds, or rigging diving-boards, or getting up fireworks displays, or private theatricals; they are always doing something,”

.. it was the strength of Canada’s commonplace civilization, the knowledge that a huge and hugely variegated country would find bullying unacceptable, that gave Trudeau the nerve to speak

.. his defense of the idea that there is more to politics than the rituals of domination and submission, which are the sum total of Donald Trump’s understanding of society.

.. The bankruptcy of America’s social capital becomes more evident when we see it flourish elsewhere. It’s no accident that Trudeau, in addition to receiving the support of his own Parliament, has received that of what used to be called the free world. The American President, meanwhile, has found himself more at home with the brutal leaders of gangster governments.