ROME—The coffins are lined up in rows inside the church of San Giuseppe in the northern Italian city of Bergamo. There are 80 in all, many made hastily of rough pine that will never be varnished. Signs with handwritten numbers taped to the floor identify who is in what box, like some sort of grim lottery.
Funerals have been prohibited all across Italy since March 10, so the most the dead will get is a sprinkling of holy water and a group prayer before being sent to the crematorium. Many of the victims had underlying health conditions that gave COVID-19 a lethal edge, but they all share a striking similarity: They all died in isolation and their final farewell will be silent.
Father Mario Carminati, who leads the local parish in the one of the hardest-hit areas of Italy’s corner of the COVID-19 pandemic, greets each coffin as it is wheeled into the church from a funeral parlor, a hospital morgue, or a private home. A ban on public gatherings means there are no family members to mourn. No tears are shed publicly.
Carminati told a local television station that his basilica is now a cemetery. There are more coffins in the store room and adjacent school gym, idle now that schools are closed. They will all be cremated because the local cemeteries are closed for burial and, anyway, there are just too many bodies and not enough burial space for them all.
More than 12,400 people have died with the coronavirus since the pandemic started gutting this country last month, making Italy’s mortality rate around 10.2 percent in comparison with 4.2 percent or less elsewhere, based on World Health Organization figures.
People have tried to justify the deaths by pointing to Italy’s large elderly population; 23 percent of people are 65 or older. The median age of death in the Italian cluster of the pandemic so far is 78, and more than three-quarters of those who have perished had one or more underlying pathologies, from cancer to diabetes to heart problems.
But the real explanation for Italy’s staggering mortality rate is more complicated than that. Massimo Galli, who heads the infectious disease unit at Sacco Hospital in Milan, says it is because Italy’s more than 105,000 cases of coronavirus infection merely scratch the surface. The real figure, he says, is “much, much more,” and if the true number of infections were known the percentage death rate would be more in line with other countries.
Italy’s Civil Protection Department agrees and says the total number of cases is likely 600,000 or more.
In the beginning, long before the novel coronavirus spread across Europe and through the United States, almost anyone in Italy with a COVID-like symptom or who had been north of Florence got a test. That quickly changed as the number of serious cases multiplied in the wealthy northern provinces, putting pressure on the health care systems there and making it dangerous for symptomatic people to go to emergency rooms.
The fear was that if tests were too easy to get, everyone would rush to their doctors for them, potentially infecting scores along the way. Now, anyone with a fever or other symptoms is just told to stay home and quarantine for 14 days, even if they have come in contact with a COVID-positive person. Only if they need hospitalization will they be tested by technicians who make house calls in full hazmat gear.
Another reason Italy’s mortality rate seems so high could come down to how Italians count their dead. The scientific adviser to Italy’s health minister said last week that Italy counts anyone who died with the coronavirus as a COVID-19 death. “Only 12 percent of death certificates have shown a direct causality from coronavirus,” he said, meaning their true cause of death was a result of their underlying condition and pneumonia caused by the virus simply sent them over the edge.
Spain, which has the second highest mortality rate in the pandemic so far, also counts anyone with the virus at the time of death as a COVID-19 fatality. Many other countries with relatively low mortality rates, like Germany and France, have not made public just how they count their far fewer dead.
But experts also warn that the death count, like the number of total infections, could actually be much higher than what is being reported since many people who die at home or in nursing care facilities are not tested if they were asymptomatic.
“It is plausible that deaths are underestimated,” Silvio Brusaferro, head of Italy’s National Health Institute, said Tuesday at the daily civil protection press conference. “We report deaths that are signaled with a positive swab. Many other deaths are not tested with a swab.”
Several authorities in Italy have pointed to a surge in mysterious pneumonia cases that swept northern Italy in December and early January before testing for COVID-19 was underway. Italy’s Ministry of Health points to a lighter-than-normal flu season that spared so many elderly people who might normally have died, instead leaving them vulnerable to the ravages of the coronavirus.
Perhaps the most disturbing reason for the soaring death toll is that doctors in the most affected areas have had to make life or death choices when it comes to resources. Using triage techniques referred to as “disaster medicine,” they have been forced in some cases to dole out intensive care unit beds and respirators based on life expectancy.
Italy has averaged more than 800 new deaths a day over the last five days, but looking at the fine print, it is easy to see that the number of people in ICU wards has gone down as well, implying that those who just died have freed up beds for many who might live.
Italy’s Society of Anesthesiology and Intensive Care sent out 15 ethical recommendations for how to prioritize resources in war zone-like conditions, which the pandemic has created in much of northern Italy. One recommendation was tragically explicit. When dealing with severe shortages of health resources, it said, doctors should “aim to ensure intensive treatments for patients with greater chances of therapeutic success: it is therefore a matter of prioritizing the ‘greatest life expectancy.’”
Thousands of grandparents and family elders are now simply gone without a trace. The urns will be all that is waiting to be picked up when the nightmare is over. Italian cases are starting to stabilize, which authorities hope precedes a fall in the infection curve and an eventual return to whatever the new post-pandemic normal turns out to be. But the number of dead in Italy will be the most lasting scar when this horrid plague eventually is over, and undoubtedly the hardest from which to recover.