Davos Man, page 26
But Lepora was not accustomed to thinking of her home country of Italy as a disaster zone. Her assignment in the spring of 2020 was both bewildering and unexpected. She found herself stationed at a public hospital in the north of Italy, overseeing a team of doctors that was providing support to a medical system overwhelmed by the pandemic.
Lepora had been en route to her base in Dubai, returning from a trip to the United States, when she stopped to visit her family in the Italian region of Piedmont. The pandemic all but shut down air travel, leaving her stranded. Two dozen Italian colleagues were similarly stuck. So they formed their unit at the hospital in the city of Lodi, the epicenter of the initial outbreak.
Doctors and nurses were working without enough protective gear, contracting and spreading the virus as they tended to an intensive care unit full of COVID-19 patients. The beds in the unit were full, even as more patients arrived by the day, forcing doctors to decide who lived and who died.
In the four months that Lepora remained in Lodi, she came to understand that the grim shortages around her went beyond the alarming presence of the novel coronavirus.
Profit-minded interests had turned the health care system in the region of Lombardy—Italy’s wealthiest—into something more like a business than a public enterprise organized to protect lives. Over decades, opportunists had privatized the system, yielding lucrative opportunities for themselves, while weakening its capacity to furnish basic medical care.
Across much of Europe, Davos Man’s success in prioritizing his own financial interests over public health helped explain how the pandemic proved so deadly. Davos Man would also help himself to the European rescue funds.
In Britain, a decade of austerity weakened the vaunted National Health Service, leaving it unable to cope with COVID-19 along with the everyday medical needs of the nation.
In Sweden, years of diminished care in nursing homes—the result of a safety net weakened by tax cuts for Davos Man—condemned the elderly to a wave of death. Resources were so scarce that doctors administered comfort care, merely softening the deaths of nursing home residents, as soon as they displayed COVID-19 symptoms.
Unlike in the United States, where the vulnerabilities of a world-class medical system could be pinned directly on monied interests, Europe’s tragedy was the result of a host of overlapping elements and policy decisions, with the blame less easily affixed to individuals.
Throughout Europe, national health care systems were the rule, ensuring that anyone could access medical care—a stark contrast to the United States. But the common backdrop was scarcity, the result of Davos Man’s success in limiting his tax burden, combined with the injection of the profit motive.
This was the reality that Lepora absorbed in Lodi.
Desperate to economize the hospital’s limited stocks of protective gear, she tried to institute a system to limit its use. The key was restricting the numbers of people entering the hospital. But that plan collided with the operations of private companies that had gained contracts to provide meals and cleaning services. They refused to limit their visits, concerned that they could be accused of breaching their contracts.
Lepora worked with the provincial health service to expand a telemedicine initiative aimed at reducing the influx of patients. Eight companies had a piece of the system, and no one was fully in charge. Some COVID-19 patients were receiving three calls a day; some were hearing from no one.
“The service rather than the patient had been put at the center of attention,” Lepora told me. “If you consider profit to be the endgame of health care instead of health, some people are going to be left out.”
The death rate in Europe told the story of which countries had continued to invest in public health, and which had allowed their medical systems to take a back seat to other considerations.
In Germany, the government had resisted the urging of international consultants to shrink its number of hospitals. Germany’s death rate, while considerable, was less than half that in Britain and the United States during the first year of the pandemic.
In the early months of 2020, Italy was Europe’s bleeding edge—the country the rest of the continent watched with a mixture of incredulity and horror, recognizing a preview of what was headed their way.
The northern Italian region of Lombardy was the hardest hit of all. Anchored by Milan, the nation’s fashion and financial capital, it boasted sophisticated manufacturing along with world-class medical care. Yet its hospitals and family medical clinics were overwhelmed—the result of decades of investment that had tilted heavily toward lucrative specialties and away from primary health care.
It was a story that began in the middle of the 1990s, when the presidency of the Lombardy region was claimed by a flamboyant local politician named Roberto Formigoni.
Known widely by the moniker “Il Celeste”—the heavenly—Formigoni was a majordomo in the Fraternity of Communion and Liberation, a Catholic movement that twinned pious social conservatism with prodigious moneymaking. The organization captured interests in major hospitals throughout Lombardy, wielding its influence to restrict the availability of abortions.
Formigoni’s organization was able to take control of hospitals by dint of a privatization law that he had pushed through the regional assembly. It enabled public money to be spent on private companies that provided medical care through the regional health care system. In the quarter century after the passage of the law, private hospitals seized control of 40 percent of the Lombardy market1.
Privatization was sold as the means of injecting greater efficiency into the health care system as it contended with declining levels of financial support. Battered by the global financial crisis, and forced by European rules to shrink its enormous debts, Italy cut spending on medical care, after accounting for inflation, even as its population aged.
By the time the pandemic arrived, Italy was spending far less on health care2 than many other European countries—8.7 percent of its annual economic output, as compared to 11.7 percent in Germany, 11.2 percent in France, and 10.3 percent in Britain.
The impact on intensive care units3 was especially stark, with beds in such facilities dropping from 12.5 per 100,000 inhabitants in 2012 to only 8.6 on the eve of the pandemic, as compared to 29.2 in Germany.
But not every part of health care was shrinking in Lombardy. The privatization scheme triggered a surge of investment into rewarding specialties like oncology and cardiac surgery, while forsaking traditional family medicine.
At Milan’s San Raffaele Hospital4—one of the finest facilities in Italy—booking an appointment as a regular user of the regional health system required calling in and sitting on hold for nearly forty minutes, while those who paid for VIP service secured slots in forty seconds.
Among the direct beneficiaries of the marketization of regional health care was the man who had set it in motion—Formigoni.
Gossip magazines stalked him on lavish holidays, discovering that he was enjoying jaunts on a yacht owned by his friend Pierangelo Daccò, a lobbyist and consultant for medical facilities in Lombardy. Over a decade, according to an eventual criminal prosecution, Daccò supplied Formigoni with gifts and vacations at exclusive Caribbean resorts5, where he was lodged in private villas with personal chefs, at prices reaching 80,000 euros a week. All told, the lobbyist demonstrated his appreciation for Formigoni’s governance with 6.5 million euros’ worth of treats. In exchange, the governor had steered public spending on health care toward Daccò’s clients.
Daccò was ultimately implicated in a complex con involving other politicians and administrators through which he raked off much of the money and stashed it overseas. Prosecutors found that he had bilked the regional health care system of 70 million euros6. They seized his yacht, a massive wine cellar, several houses, and more than three dozen bank accounts.7
When this tawdry dealing burst into public view in the fall of 2012, the ensuing outrage ended Formigoni’s reign as Lombardy’s governor—though not, remarkably, his political career. Even as he was being probed for corruption, Formigoni was elected to the Senate as a member of Silvio Berlusconi’s party.
Formigoni eventually spent more than five years in prison. Daccò, who pleaded guilty to a reduced charge, served two and a half years. The hospitals at the center of the scandal passed into new hands. In 2012, the San Donato Group, the largest hospital chain in Italy, purchased the San Raffaele Group.
In the years leading up to the pandemic, officials in Lombardy sought cost savings, giving hospital managers incentive to cut stocks on items like test tubes and chemical reagents—a decision that limited the capacity for mass testing for COVID-19 when the pandemic arrived.
The managers found their own ways to profit. According to an eventual complaint from prosecutors in Milan, executives at the San Donato Group connived with their counterparts at major pharmaceutical companies8, including Novartis, Eli Lilly, and Bayer, to swindle the Lombardy system through price gouging on drugs. The hospitals received the drugs at a discount, and the executives pocketed the difference—some 10 million euros—while taxpayers reimbursed the hospitals at inflated prices.
These shenanigans were not outliers, but indicators of the mindset that was driving privatization. Regional leaders were operating more like venture capitalists than public servants.
“Specializations such as hygiene and prevention, primary health care, outpatient clinics, infectious diseases and epidemiology have been considered not strategic assets, not sexy enough,” said Michele Usuelli, a neonatologist in Milan who held a seat on the regional assembly, representing the center-left Più Europa Party. “That is why we have a health system very well prepared to treat the most complicated diseases, but completely unprepared to fight something like a pandemic.”
Regional officials failed to use their authority to ensure that the public gained needed care. In exchange for agreeing to pay for expensive cancer treatments at newly constructed oncology centers, they could have demanded that the private owners also furnish less lucrative services like geriatric and pediatric care.
“They gave permission to the private sector to more or less open whatever they wanted,” said Usuelli. “It was a complete missed opportunity to hold private companies accountable to their social responsibility.”
As the first cases of COVID-19 were diagnosed in February 2020, Italy’s most influential business lobby9, Confindustria, urged the government to allow the factories of Lombardy to continue operating to avoid economic damage, preventing a swifter lockdown that might have limited the spread of the virus. This was especially reckless, given the links between the industrial zones of northern Italy and factories in China. Many people transited between the two countries, a vector for transmission.
Milan was a city of more than 1.3 million people. When the first wave hit, it had only five doctors expert in public health and hygiene. They were responsible for setting up a testing and contact tracing regimen. As the second wave gathered force, Lombardy’s health department notified doctors that it could “no longer conduct prompt epidemiological investigations.”
“Family doctors are a cost,”10 said Filippo Anelli, president of the national federation of doctors and dentists. “If the mentality is that you need to make money from health care, the investment in community medicine looks clearly less remunerative.”
Erika Conforti began her career as a family doctor in early February 2020, just in time for the pandemic. In her midthirties, fresh from residency, she had taken over a practice from a retired doctor, working out of a private office in a Milan apartment building.
She had been drawn to general practice out of a desire to help people with everyday ailments. “I love to speak with patients,” she told me. “I love to spend time with them.”
But as the pandemic spread, Conforti was working twelve hours a day, and still failing to keep up with the barrage of calls and emails from patients suffering COVID-19 symptoms.
As the second wave mounted in late 2020, the region had added hospital beds, but lacked nurses and anesthesiologists. “If there’s not enough people who know how to work in the hospital setting, then increasing the number of beds is pointless,” Conforti said.
At her own practice, thirty patients had just tested positive for COVID-19 in a single day, while fifty more were quarantined, awaiting tests that took six days to yield results.
“I’d like to be able to contact positive COVID-19 patients at least once a day, but I just don’t have the time,” she said. “I’m worried that every minor distraction that I have has very serious consequences.”
In Britain, Boris Johnson’s administration was intent on avoiding Italy’s fate. As the virus spread in the spring of 2020, the government prevented hospitals from being overrun, but at a grim cost. To free up capacity, the National Health Service diverted thousands of elderly people from hospitals to nursing homes—many of them privately run, lightly regulated, and woefully unprepared for the unfolding disaster.
Within three months of the pandemic’s arrival, nursing homes in England and Wales alone had seen twenty thousand more deaths11 than usual.
Britain focused all resources on battling COVID-19, effectively shutting down the rest of the health care system. The resulting scarcity revealed how weak the system was before the pandemic.
In Liverpool, Simon Bowers—the doctor who had bemoaned austerity—complained that his patients with other ailments were waiting weeks and even months for treatments and tests that typically required days.
“I’ve written death certificates for two patients in the last week who wouldn’t have died of cancer if not for COVID,” Bowers told me in October. “Ten years of austerity has left the system just about coping for much of the year. The pandemic is a real perfect storm in terms of ruthlessly exposing the deficiencies of the system.”
It also exposed how cronyism had trumped considerations of public health. As the government awarded emergency contracts for protective gear, ventilators, and other vital wares, it allowed politically connected businesses to exploit a secret VIP lane12. Among some 1,200 contracts conferred by the central government and eventually made public—deals worth a collective $22 billion—roughly half had been secured by companies that tripped serious questions of propriety. The recipient companies were frequently run by people connected to the governing Conservative Party.
One company headed by an employee of the Board of Trade, a government body, secured a $340 million contract to furnish protective gear for medical staff. It eventually produced 50 million masks at a cost of $200 million. They proved defective and could not be used.
Meanwhile, qualified companies that lacked friends in high places were largely shut out.
As the virus mutated, turning Britain into the epicenter of a rapidly spreading variant in the first months of 2021, the country’s hospital system was again threatened by a crush of cases. Again, elderly patients were shipped off to nursing homes. Again, infection rates soared.
By August 2021, the pandemic was blamed for the deaths of more than 130,000 Britons—one of the worst tolls in Europe.
Even in Sweden, the pandemic revealed the extent to which the degradation of the country’s social safety net had undermined its ability to manage a public health emergency.
Like the rest of Europe, Sweden took note of the disaster in Italy as a portent, while opting for an unorthodox response: The government counseled people to engage in social distancing, but left shops, restaurants, nightclubs, and schools open. Swedes were largely free to carry on with their lives absent rules about wearing face masks.
The government presented its strategy as a more enlightened approach. Forcing people to avoid workplaces and hunker down at home would produce joblessness and despair. The impacts of mental health ailments like depression had to be considered alongside the consequences of the coronavirus.
Around the world, those decrying pandemic restrictions seized on Sweden as an alternative model. “Without locking down13, Sweden—and this is the key—has fared far better than other European countries that did lock down,” declared the Fox News commentator Tucker Carlson.
There was one problem with this assessment: Sweden’s strategy was a disaster.
By the summer of 2020, more than five thousand people were dead in a country of 10 million people, giving Sweden one of the worst per capita death rates on earth, and exponentially higher than in neighboring countries—twelve times worse than Norway, seven times worse than Finland, and six times the level in Denmark.
In exchange for this wave of death, Sweden had gained essentially nothing14 in the way of economic benefits. It was ensnared in a recession no more or less bleak than in neighboring countries, where lockdowns had been imposed.
Proponents of the government’s strategy insisted that it could be fairly assessed only over the long term. But by the middle of November, a brutal second wave was again sending Swedes to hospitals15 at one of the fastest rates in Europe.
Nearly half of those killed by COVID-19 had been residents of nursing homes. Champions of the official strategy were implicitly dismissing their deaths as collateral damage—a stance that provoked uncomfortable memories of Sweden’s experiments with extreme social engineering. As late as the 1970s, the government had imposed forced sterilizations on women deemed not socially acceptable, such as orphans and teenagers who had gotten into trouble.
Sweden’s state epidemiologist, Anders Tegnell, the architect of the national strategy, was privately expressing interest in pursuing so-called herd immunity16, exposing enough people to the virus to yield antibodies that would prevent further spread.
As criticism about Sweden’s strategy intensified, officials began excising the elderly from the conversation. Yes, there had been a problem in the nursing homes, but otherwise Sweden was doing great. If you looked past the places where lots of people had died, not that many people had died.
