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Northern Italy has one of the best public health systems in the Western world. Its doctors and medical professionals are well-trained. They felt prepared when the coronavirus began to spread through their prosperous, well-educated region.
And they still could do nothing to prevent what happened.
"I have never seen so many people die together before my eyes," said a nurse from one of the main hospitals in Bergamo, a city in northern Italy that is at the center of the worst outbreak in Europe. "It feels like we are crossing in the middle of a battlefield."
More than 2,500 people have died in about four weeks in Italy. With over 31,500 confirmed cases, the country's doctors and nurses — particularly in the hardest-hit cities in the north — are struggling to keep up. They're running out of beds, equipment and even people, particularly as more health care workers catch the virus.
The nurse, who was not authorized to discuss the situation and asked not to be identified, has since had to stop working. Like many of the front-line health care professionals in Italy, the nurse caught the virus that colleagues have been trying to stop.
"We are getting sick one after the other," the nurse said.
In the months since the new pathogen was identified, northern Italy has emerged as a warning about what can happen even in a region that is considered to have one of the most proficient public health care systems in the world, and even after the country took drastic measures to try to contain the virus' spread.
Milan and Bergamo have been especially devastated. Bergamo alone has had nearly 3,800 confirmed cases.
The huge number of infections has overwhelmed hospitals in the wealthy region of Lombardy, where both cities are, even as officials went to great lengths to prepare facilities by converting some wards into makeshift intensive care units and adding extra beds wherever possible.
Dr. Lorenzo D'Antiga, director of the pediatric department at Hospital Papa Giovanni XXIII in Bergamo, said he and his colleagues are operating in a region with some of the highest incidences of new coronavirus cases.
"We are really in the eye of the cyclone," he said.
In early March, as deaths from the virus spiked and the number of confirmed cases swelled, Italy's government needed to take decisive steps to slow the lightning-fast rate of infection.
On March 8, Prime Minister Giuseppe Conte issued a lockdown of Italy's Lombardy region, effectively quarantining about 16 million people in the north. Two days later, Conte expanded the quarantine order to include the entire country. The decrees came just over a month after similar quarantines went into effect in parts of China where the virus first emerged.
Overnight, the normally bustling streets of cities like Milan and Venice were deserted, their sprawling piazzas and picturesque walkways silent and devoid of people.
But this tranquility betrayed a very different reality for Italians at the front lines of the pandemic.
"It seems relaxed because everyone is staying inside and people are cooking and looking at old photos and doing work at home," said Francesco Longo, director of the Centre for Research on Health and Social Care Management at Bocconi University in Milan. "But in the hospitals, it's like a war."
D'Antiga said that at his hospital, almost half of the 1,000 beds are dedicated to treating patients with COVID-19, the disease caused by the coronavirus. Most other operations at the hospital have scaled back significantly or ground to a halt.
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"In the gastroenterology ward, internal medicine and other wards, they have to send away patients and only admit those with COVID-19 — even in the neurology ward," D'Antiga said. "We have 20 to 30 patients coming in every day requiring admission, but we've run out of beds. It's a really difficult situation."
What makes the situation even worse is that some of the beds are being used to treat medical personnel themselves.
"Here, probably 20 to 30 percent of health care professionals got infected," D'Antiga said. "In my department, I have 25 pediatricians, and currently 10 are off sick. This is the same in other departments, and it's a major challenge."
Although the majority of those who have tested positive so far have experienced mild symptoms, the most serious cases can result in respiratory failure. Nearly 13,000 of Italy's coronavirus patients are hospitalized with symptoms, and of those, more than 2,000 are under intensive medical care, straining hospitals' resources.
D'Antiga said 80 of the 100 beds in his hospital's intensive care unit are occupied by coronavirus patients hooked up to ventilators, but hospitals are rapidly running out of beds and the equipment needed to keep patients alive.
The limited resources are forcing doctors to make excruciating decisions about whom to treat — and who may be beyond help.
Although cases vary, doctors typically take into account a patient's age and condition, which is standard practice even without being in the midst of a pandemic, according to D'Antiga. So far, he said, doctors are mostly heeding the same criteria when they do have to make tough choices.
"Outside of an epidemic, if a 90-year-old person comes in with severe pneumonia, we likely wouldn't admit the patient into intensive care and intubate them," D'Antiga said. "We do have to select, unfortunately, but at the moment, at least we don't have to select among those who would have been treated in normal times."
But that could change, he added. And as the virus spreads, the heart-wrenching situation in Lombardy could be intensified in other regions of Italy and in other countries.
"What we're seeing in Italy is what we're likely to start seeing in hospitals around the world in the coming weeks and months," said Yascha Mounk, a political scientist at Johns Hopkins University in Baltimore. "One of the characteristics of this disease is it has a very long incubation period. It takes a long time for it to start overburdening the health care system, but once it starts, the increase is very rapid."
In Venice, a doctor in the region's main hospital who spoke on the condition of anonymity said that she and her colleagues are already treating 92 coronavirus patients but that they are anticipating an onslaught still to come.
"We are struggling, but we know we are not in the worst moment of the outbreak," she said. "To work in these conditions is really exhausting. Everyone is feeling mentally exhausted."
Her hospital has already created improvised ICUs, and doctors and nurses across the northeast are being deployed to vulnerable areas. Resources in and around Venice, which has had even more time to prepare than Lombardy, are already becoming strained.
"At the moment, we are in good condition, but if the emergency keeps going on for weeks and weeks, I don't know how well we can react," she said.
Some doctors and experts in Italy have been outspoken in hope that other counties will learn from their experience.
Longo said one crucial takeaway is that early actions can make a big difference.
"The quicker you close a country and reduce social contact the better," he said. "The only effective mechanism is to introduce a constraint to make people stay home. This is not just the lesson from Italy. It's also the lesson from China."
D'Antiga added that Italy's experiences could also provide stark warnings about what can happen even in a country with a well-regarded health care system that provides universal coverage to its residents. In countries where that's not the case, such as in the U.S., doctors could be under more stress and face additional challenges. There are already concerns, for example, that hospitals in the U.S. could face a shortage of ventilators.
"We have a system in Italy where everybody has access, so we can make decisions based only on medical factors," he said. "In the U.S., that will be much more challenging, and the choices will be very different from an ethical point of view."
Still, Longo said that as Italians approach the end of their second full week under quarantine, people have found ways to remain hopeful.
"There's really a sense of solidarity, of belonging to the same community," he said. "Everyone feels that we can only rescue ourselves if we stick together."