ROME—Italy, the first non-Asian country hit by the coronavirus pandemic early this year, once again is struggling with one of the world’s deadliest outbreaks.
Around 680 people are dying of Covid-19 in Italy on an average day, on par with Brazil and behind only the U.S. This year Italy has recorded about 67,900 confirmed deaths from the virus, the highest total in Europe, and fifth in the world after the U.S., Brazil, India and Mexico—which all have much bigger populations.
Once again, Italians are asking themselves: Why is Covid-19 killing more people here than almost anywhere else?
The answer lies partly in demographics, public health experts say. Italy has one of the world’s oldest populations, second only to Japan. Nearly one in four Italians is over 65, an age group much more likely to succumb to the disease.
Another factor: Multigenerational homes are especially common in Italy, potentially exposing older people to infection from their younger relatives.
Since the pandemic began, 95% of those killed by the virus in Italy have been over 60, and 86% over 70. Deaths in many other countries have also been concentrated among older people, but there are proportionately more of them in Italy.
Italy’s death toll also looks bad on a per capita basis. The country has recorded 15.9 coronavirus deaths for every 100,000 residents over the past two weeks, compared with 6.3 in Spain, 6.9 in Germany and 8.3 in France, according to the European Center for Disease Prevention and Control.
In March, images of army trucks carrying the bodies of Covid-19 victims out of the overwhelmed city of Bergamo became a symbol of Italy’s tragedy—and a warning for the rest of the world.
After Italy suppressed the first wave with help from a long and stringent lockdown, few Italians thought the high death toll would repeat itself. Virus infections slowed to a trickle in the summer. Millions of Italians adopted mask-wearing. Hospitals and the government appeared better prepared.
Italy’s infections remained modest even in early fall, when a second wave of contagion swept over Spain, France and the U.K. But as winter begins, Italy is back where it was in March: the worst-hit place in Europe.
On Friday, the Italian government announced another lockdown, over the Christmas and New Year holidays, for fear that hospitals could overflow and deaths rise even higher in January.
From Dec. 24 to Jan. 6, bars and restaurants will have to close and there will be travel and movement restrictions across the country. On specific days, such as on Christmas Eve and weekends, most stores must stay shut, too.
“Among our experts there are strong fears the curve of infections could surge during the Christmas holidays,” Italian Prime Minister Giuseppe Conte said Friday in explaining the new rules.
Despite policies aimed at sheltering older people, the virus has again spread in nursing homes and hospitals, affecting numerous people over 65.
Yet age alone doesn’t explain Italy’s grim tally. A national health-care system that was overstretched and understaffed before the pandemic is also to blame, said Antonella Viola, a professor of pathology at the University of Padua.
“Yes, the population is old and frail, and there are pre-existing conditions. But that can’t be that different from the rest of Europe,” said Dr. Viola. “There is a clear problem in the way that local health care is organized. There are too few doctors. GPs have too many patients to properly care for each of them.”
In the spring, hospitals in badly hit parts of northern Italy didn’t have enough beds to treat all severely ill Covid-19 patients. To avoid a repeat, the government sought to increase the number of intensive-care beds across the country.
But many hospitals have struggled with the influx of Covid-19 patients this fall anyway because they didn’t have enough doctors and nurses to care for them, partly a consequence of decades of spending cuts.
And little has been done to improve care outside hospitals. Many Italian regions have long neglected local health-care networks, including family doctors, public health experts say. Thus, many Covid-19 patients who stay at home have received little or no support. Many severely ill people come to the hospital too late, if they make it at all.
Even in the wealthy northern region of Lombardy, which has some of Europe’s best hospitals, the local network of physicians and smaller clinics is poorly equipped to care for Covid-19 patients who remain at home, especially in remote rural or mountainous areas.
“It’s a system that prioritizes hospital care. We have excellent specialized care, such as ICUs and transplant units,” said Guido Marinoni, a Lombardy representative for the Italian doctors association. “But everything that has to do with local medicine and prevention was put in second place. That’s become clear.”
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Since the start of the pandemic, around 3.5% of Italians who tested positive for the virus have died, according to official data collated by Our World in Data, a nonprofit research project based at the University of Oxford—a higher percentage than in any other major European country. In Germany, around 1.7% of those who tested positive succumbed.
The true rate of fatalities among infected people is significantly lower, experts say, because many virus-carriers are never tested.
While Italy spent $3,650 on health care per inhabitant in 2019, Germany spent $6,650, according to data from the Organization for Economic Cooperation and Development. Average spending among OECD nations was $4,224 per person.
“Germany is better equipped and better prepared in general,” said Luciano Gattinoni, an Italian professor of anesthesiology and intensive care who currently teaches at Germany’s University of Göttingen.
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