A tsunami of coronavirus victims that is overwhelming health systems in Italy offers a frightening preview of what could lie ahead for the United States as case counts grow and hospitals run out of space and equipment to treat those with severe symptoms.
The strain is so great in Italy that the nation’s doctors have begun rationing care, making heart-wrenching decisions about who gets treatment and who is left to die. Obituary pages in local newspapers are running dozens of pages. Piles of coffins are stacked in parking lots.
“Too many for [the] crematory to burn,” Raffaele De Francesco, a microbiologist at the University of Milan, said in an email.
Just over a month after the hardest-hit Lombardy region confirmed its first case of the coronavirus, almost 64,000 Italians have been diagnosed with COVID-19 — or about .1 percent of the total population in a nation of 60 million. Of those, 6,077 have died, according to the European Center for Disease Prevention and Control.
That case fatality rate, nearly 10 percent, though inflated because the true number of infected victims is not known, is the highest reported in the world. It is a direct result of a health system stretched far beyond its capacity, and the need to deny care to the elderly and those who are already sick.
The Italian outbreak started sometime in February, even before a man in Lombardy was diagnosed with COVID-19. That man did not have any recent history of traveling abroad, and he had not had contact with Italy's first cases of the virus, two Chinese tourists in Rome.
But he had come into contact with hundreds of others in the days before he fell ill. Within 24 hours, Italy had recorded three dozen cases.
“Basically, overnight they went from three cases to dozens and hundreds,” said Cristiana Salvi, a World Health Organization spokeswoman who deployed to her native country in the first days of the outbreak. “They basically had a very narrow window for containment.”
Italy's epidemic was especially severe because of the nation's aging population. As of March 15, the Journal of the American Medical Association reported the median COVID-19 victim was 64 years old, though the youngest person who had died was in their 30s.
Two and a half weeks after the initial outbreak, Prime Minister Giuseppe Conte ordered a lockdown in the northern provinces hardest hit by the disease, followed by a national lockdown a day later.
Even under the lockdown, case counts continued to balloon. Only in recent days has the number of new cases begun to slow, a function of a virus that can incubate for up to two weeks before someone shows symptoms. Italy has reported fewer new cases in both of the last two days, an indicator that officials are watching with cautious optimism.
“We are starting now to see some effects of [the lockdown], but of course it takes more time to see a big decline,” Salvi said. “We cannot drop the guard.”
The new cases in the last few days still number in the thousands, a stark reminder that an out-of-control epidemic can take weeks to corral.
Public health officials in the United States and around the world are now warning that what has happened in Italy is just a preview of what may happen here, as the number of cases in America balloon out of control.
“In some countries the situation will get worse before it gets better,” Maria Van Kerkhove, head of emerging diseases and zoonosis at the World Health Organization (WHO), told reporters on Monday. The WHO has warned that the United States is at risk of becoming the next epicenter of the sprawling pandemic.
Governors of at least 17 states have ordered residents to stay at home, but President TrumpDonald TrumpFormer New York Assembly Speaker Sheldon Silver dead at 77 Biden, Democrats losing ground with independent and suburban voters: poll Bipartisan Senate group discusses changes to election law MORE has not issued a similar dictum to the Italian lockdown. Trump on Tuesday signaled for a second day in a row that the United States will have to open for business, a signal he wants to relax policies that have kept people at home. Trump said shutting the nation's economy for months would cost even more lives.
But the prospect of relaxing social distancing rules and reopening parts of the economy would almost certainly lead to a coronavirus case curve that would grow, rather than flatten.
Trump’s comments, and scenes like packed spring break beaches and bustling farmer's markets, reflect a broader concern in the public health community — that Americans have yet to grasp just how serious the pandemic has become.
“Somehow people are not processing the gravity of the situation, and that is what happened in Italy,” said Janet Baseman, an epidemiologist at the University of Washington.
In Italy, Salvi said Conte's government had quickly heeded the advice of public health experts.
“The government, the decisionmakers are really listening to the scientists. The measures they are putting in place are responding to scientific evidence,” Salvi said.
Even then, the grim statistics in Italy are directly analogous to what is already happening in the United States, and what the nation's next few weeks and months could look like.
America is actually adding cases at a faster pace than Italy did in the first days of its outbreak: It took 16 days for the number of cases in America to grow from 100 to 10,000, a day faster than Italy recorded the same growth. As that growth continues, hospital systems in the United States will become overwhelmed, potentially more quickly than in Italy: Italy has more hospital beds per capita, at 3.2 per thousand residents, than the United States, which has 2.8 beds per thousand, according to the Organization for Economic Cooperation and Development. World Bank statistics show Italy also has more health care workers per capita than the United States.
The coronavirus is spreading unevenly throughout the United States, as it did in Italy. What began as an epidemic in the Seattle area has now become a crisis in the New York City metropolitan area, where officials say the attack rate — or the percentage of the population who have contracted the disease — has grown to about one in a thousand people.
That figure will rise in the coming days and weeks, even without strict interventions, because of the incubation period between when someone is infected and when they begin to show symptoms. But drastic steps can still help bend the curve lower, experts said.
Asked what lessons Americans should take from Italians, De Francesco, the Italian microbiologist, was blunt.
“Lockdown, lockdown, lockdown,” he wrote. “Totally. Everywhere. The sooner the better.”
Correction: An earlier version of this story misstated the percentage of Italy’s population that has tested positive for the coronavirus.