THE SECOND ROUND

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.

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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.

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.

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.

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.

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.

… 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.

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.

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 … 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. 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.” 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.