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Why Covid caused such suffering in the richest region of Italy

LONDON – Dr. Chiara Lepora never imagined being located in her native Italy. As a doctor for the international aid agency Doctors Without Borders, she was accustomed to caring for people in countries like Yemen and South Sudan amid extreme poverty and war.

But earlier this year, as the new coronavirus spread from Asia to Europe, Dr. Lepora found himself under pressure in the northern Italian province of Lombardy, one of the richest places on earth.

Anchored in Milan, the financial and fashion capital of Italy, Lombardy boasts a sophisticated industry and world-class medical facilities. Yet it was crushed by the first wave of the global pandemic, forcing doctors to standardize ventilators and hospital beds, while having to decide who lived and who died.

The disaster in Italy’s richest region is partly due to the entrustment of much of the public health system to profitable private companies, failing to coordinate their services. In the previous quarter of a century, significant investments were made in lucrative specialties such as cardiac surgery and oncology. Areas on the front lines of the pandemic, such as family medicine and public health, have been neglected, leaving people over-relying on hospitals for care.

“If you think profit is the ultimate game of healthcare, not health, some people will be missed,” said Dr. Lepora. The pandemic reveals all these weaknesses.

Unlike the United States, where more than 30 million people do not have health insurance, Europe remains a country of public, state-sponsored health care, including Italy. Yet in Lombardy, the worst-hit region, a pandemic has uncovered the traps of a poorly executed push to open the system to private providers.

“Specializations such as hygiene and prevention, primary health care, outpatient clinics, infectious diseases and epidemiology are considered non-strategic assets, not sexy enough,” said Michele Usuelli, a neonatologist in Milan who has a seat in the regional assembly representing the center-left Più Europa. .

“That’s why we have a health system that is very well prepared to treat the most complex diseases, but completely unprepared to fight something like a pandemic,” added Dr. Usueli.

The same could be said for many rich countries, including the United States and Britain, where modern medical care does not provide immunity against the pandemic. Only a few places – including Taiwan, South Korea and New Zealand – stand out with their effective responses to the pandemic.

But Lombardy claims to be one of the worst affected areas on earth. According to the World Health Organization, Italy has suffered more than 760 deaths per million people, more than the United States and almost as many as Britain. Half of the approximately 17,000 deaths in Italy occurred in Lombardy.

The roots of the change in Lombardy date back to 1995, when a lavish politician named Roberto Formigoni became regional governor. He advocated legislation that allows private providers to serve patients while collecting payments from the taxpayer-funded regional health system.

Many saw the change as an innovation that brought competition, forcing public hospitals and clinics to improve. But privatization was riddled with corruption.

Mr Formigoni will serve more than five years in prison for a scheme that accepts yacht trips, vacations in lavish Caribbean resorts and various gifts from a lobbyist for private medical providers in exchange for running the region’s business on his way.

The scandal was less of a diversion than an indication of the forces driving privatization, a reality that continued even after Mr Formigoni left in 2013, experts say.

Many argue that the problems plaguing the regional health care system are not an indictment of privatization, but of the failure of local government leaders to ensure that private companies provide the necessary services.

“The problem is in the management of hospitals and clinics,” said Francesco Paolucci, a professor of health economics and politics at the University of Bologna.

Regional officials could condition their willingness to pay for treatment in modern oncology centers with promises that private providers would provide less lucrative services such as geriatric care. But this thinking was invented from the profits that had to be realized.

“They have given permission to the private sector to open more or less what they want,” Dr. Usueli said. “It was a completely missed opportunity to make private companies responsible for their social responsibility.”

The focus on profitable specialties creates incentives for doctors to look for work in these fields while abandoning general medicine.

In 2016, in Lombardy, home to more than 10 million people, only 90 medical school graduates continued to pursue specialized training to become general practitioners. They receive annual scholarships of 11,000 euros (nearly $ 13,000), less than half of those provided by people preparing for majors such as cardiology. Their numbers have risen in recent years, but are not enough to replace retired general practitioners, medical associations say.

With the best medical minds focused on advanced treatments, Lombardy’s ability to provide basic medical care and protect public health is gradually deteriorating. Over the last decade, total health care spending in Lombardy has increased by 11%, while support for primary care has been reduced by 3%, according to official data analyzed by Dr Usueli.

Lombardy appears to have complicated its problems with a 2015 law that centralizes services for chronic diseases such as hypertension in hospitals, further reducing the role of GPs in helping patients stay healthy.

“It was about cost rationalization and waste avoidance,” said Marco Cambeli, a gastroenterologist who heads an association of doctors and dentists in the city of Varese. “But this has led to a loss of connection between patients and their GPs.”

In the neighboring region of Veneto, the health care system, centered on so-called community care – in which family doctors and nurses make home visits for prevention – is doing far better. There, primary care physicians and an effective contact tracking effort prevented an influx of people from reaching hospitals.

“Family doctors are worth it,” said Filippo Anelli, president of the National Federation of Doctors and Dentists. “If the mentality is that you have to make money from health care, investing in public medicine seems obviously less rewarding.”

When the first wave hit, Milan, a city of more than 1.3 million people, had only five doctors, public health and hygiene experts, said Roberto Carlo Rossi, president of the Milan Guild of Doctors and Dentists. They were responsible for setting up a mode for testing and tracking contacts.

The region has since hired more. However, last month, Lombardy’s health department informed doctors that the agency “could no longer conduct a timely epidemiological investigation.” The announcement was as untimely as it was disturbing: Covid’s daily deaths in Italy have tripled in almost the past two weeks, with Lombardy once again leading the trend.

Dr. Lepora, Doctors Without Borders, was on her way to her base in Dubai in February, returning from a trip to the United States when she stopped to visit her family in the northern Italian region of Piedmont. The pandemic closed airports, leaving it looted.

Two dozen other Italians working with Doctors Without Borders remained the same. They set up a support unit at a state hospital in the town of Lodi.

Doctors have had experience in disaster areas and are amazed to see that Italy has become one. Their Italian colleagues entered intensive care units full of Covid patients without appropriate protective clothing.

Dr. Lepora tried to introduce a rationing system by limiting the number of people entering the hospital. But she said the plan clashes with private companies that provide catering and cleaning services. They refused to limit their visits, worried they could be accused of violating their contracts.

By the time he returned to the Middle East in June, Dr. Lepora had diagnosed an anxiety problem. “The service, not the patient, was the focus,” she said.

In Milan, 35-year-old Erica Conforti opened her own practice as a family doctor in February, just in time for the pandemic. She had taken a practice from a retired doctor, working from a private office in an apartment building.

According to the rules governing the Lombardy health system, general practitioners were to be responsible for no more than 1,500 patients, but Dr. Conforti initially inherited 1,800, including 500 elderly people.

She was drawn to the common practice by the desire to help people with everyday illnesses. “I like talking to patients,” she said.

As the pandemic spread, she found herself working 12 hours a day and still unable to handle the series of calls and emails. She struggled to visit patients affected by the coronavirus. The regional system lacked protective clothing such as masks and gloves, so she bought it herself.

As the second wave gains strength, Dr. Conforti worries that the same suffering is at work. Hospital beds have been added to the region, but nurses and anesthesiologists are missing.

“If there are not enough people who know how to work in a hospital setting, then increasing the number of beds is pointless,” she said.

In her own practice, 30 of her patients tested positive for Covid-19 on the last day, while more than 50 were quarantined pending tests that took five and six days to give results.

“I wish I could connect with positive Covid patients at least once a day, but I just don’t have the time,” said Dr. Conforti. “I’m worried that every little distraction I have has very serious consequences. I’m scared while I’m working. “

Gaia Pianigiani contributed with reports from Italy.

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