How to Achieve the “Nuova Normalità”?

Interview with Walter Ricciardi, Professor of General and Applied Hygiene at the Catholic University, Advisor to the Italian government for Italy’s relationships with international health organisations.

How was the Italian response to the spread of Covid-19 organised?

Prof. Walter Ricciardi ESMH ScientistWalter Ricciardi: From an institutional point of view, in Italy, there are two entities dealing with public health: the central state and the regions. The Italian National Health service is organised on a regional basis. At the beginning of the emergency, the Italian government entrusted the management role to Protezione Civile (a/n: “Civil Protection” a civil defence organization that is activated in emergency situations). Therefore, the institutional actors are the Central State, operating through the Civil Protection and the Ministries, and the Regions. As the Italian context has been characterised by a marked regionalism, it has been necessary to build a tailored strategy to face the situation.

You were appointed ‘Advisor to the Government’ on February 24th. Could you give an assessment of the Italian response in the period before the beginning of your assignment?

Walter Ricciardi: My first impression was that the emergency management to curb the contagion should be accelerated immediately. When I took office on 24 February, I presented the seriousness of the situation, the need to have a single line of communication and command, and to take extremely drastic measures to contain the spread of the virus. I was and I am still convinced that these were the strategies to be implemented. I believe so because of the information collected during a one-day meeting of the Executive Committee of the WHO, which was held on 3 February in Geneva. On that occasion, it was immediately obvious that the situation was very serious and that every possible effort should have been made to contain the spread of the epidemic. The information we received from Wuhan was also supporting this conclusion.

There is a marked regional decision making in the Italian Health System. Is the Italian public health management system functional so far? How do you evaluate this coordination between the central state and the regions?

Walter Ricciardi: I founded the Italian Observatory for Health in the Italian Regions. I have been following the evolution of the Italian Health System for the last 20 years and I see that there is a great weakness due to a strong disparity between the different Italian regions. Over the years, in the regional health systems of the southern regions – a large part of the country – this disparity from the northern regions has increased. In times of epidemic events, we observe a great gap in the ability to respond. Moreover, the weakness of federal and regional aspects emerges in all its evidences; but not only in Italy, also in Spain and Germany. These are countries where there is not a single line of command. Negotiation and agreement between many decision-makers must always be sought. And this clearly wastes time and therefore benefits the spread of the virus.

Do you expect a European response to take over this multi-layered chain of command?

Walter Ricciardi: At the European level, the same asymmetry is repeated as seen in Italy. The European Commission has no power over the health systems of European countries, except for a few very limited aspects. There is the same asymmetry that occurs within Italy, indeed. Agreements are often based on a sort of European solidarity but not on decision-making mechanisms. For my part, at the Italian level, there is hope that at the European level there will be a single chain of command, because the response to the epidemic is extremely important. This is obviously the case at the moment. My hope is that this will also happen during “normal” times. Because during periods of normalcy, without an ongoing epidemic, in Europe the asymmetries and striking differences are created within the European Union itself.However, this difference in health and in health indicators could only be reduced if Europe plays a strong and not only symbolic role.

What resources could ensure that this non-coordination does not happen anymore but, instead, there will be a prompt response. Is this already being discussed?

Walter Ricciardi: Yes, it is. For a long time. It has been talked about for years but it has never materialised because the member states have a great reluctance to grant prerogatives to the European Union. During “normal” times this can mean that some countries are lagging behind. But in times of epidemic the whole of Europe is involved because viruses have no borders and do not stop at jurisdiction or political sensitivity. So if a country, for example, makes a mistake or lags behind while having the elements to react, then, in the end, the entire European population suffers the consequences.

The idea that we can achieve herd immunity by letting the virus spread continues to be supported by some. How risky is the idea of letting things go without taking action?

Walter Ricciardi: It’s a crazy idea. It’s madness. In fact, it means giving free rein to a virus that, although not one of the deadliest, still has a major lethality. So it means passively accepting the idea that there could be millions of deaths. These millions of deaths are not just among the elderly. It is clear that they are the ones most affected by predisposition, especially according to their physical condition. But when you broaden the range of cases, it’s clear that you have to contemplate that there are also many victims in the younger age groups. This is an unacceptable idea, for any government and any politician.

It is clear that until we find a specific therapy and a vaccine, the evolution will be one that is somehow linked to containment and to avoid contagions, but also to take time. Because herd immunity will, of course, gradually build up. The aim, however, is not to do this by killing people but by trying to slow down the virus and obtain immunity through vaccines.

At the moment, we are living in a constantly evolving context, also from the point of view of communicating with the public. How do you assess today the communication aimed at informing the population about the current pandemic?

Walter Ricciardi: In my opinion, communication during an epidemic is one of the most delicate and professionally sophisticated issues. So there should also be a single chain of communication entrusted to professionals who, of course, take into account the elements given by scientists and crisis managers, but then translate them into the information that people actually need. On communicating data and numbers the way we do today, I have my doubts too.

Is there already, in Italy, a security plan that foresees any problems of public order?

Walter Ricciardi: Some days ago, a plan for psychological support and for the way to relate to the citizens to try to make them more resilient and aware in this extremely difficult moment was launched. So, on the one hand there is a plan that tries to channel this kind of message in the most appropriate way and, on the other, there is also a plan aimed to support the most vulnerable people. I do not think there is this concern about public security, because most of the Italian people seem to me to have acquired a good awareness by now.

It is clear, however, that there is always a few – unfortunately not a marginal one – for which the respect of the rules must be imposed through mandatory enforcement techniques. But I do believe that it is the combination of these methods – the persuasive method and the enforcement method – that guarantees an effective containment. An atmosphere of great collaboration is currently prevailing in Italy. We are aware that in the long run this type of measures will have to be implemented in some way to give results. There could be some défaillance and we are trying to avoid this through a strategy, you know, of psychological support.

What do you mean by défaillance? Groups of people who deliberately choose to break the rules?

Walter Ricciardi: This can only happen on an individual level. There is no organised strategy, in fact. What we have noticed – for example from trade unions, and therefore from large organised groups – is that these associations are calling for more measures to be taken for the safety of workers. We are going in the opposite direction and, at the moment, we don’t see the risk of organised protests.

Much has been said about various national pandemic response strategies that could also be tailored in other countries as well. What strategies have proved most effective in containing the pandemic? What measures, already applied in other countries, do you think will be used in other contexts?

Walter Ricciardi: Let’s consider two containment strategies. The Chinese one, which involves the deployment of security forces, and the South Korean one, which is based on extensive testing of asymptomatic cases and hyper-technological tracking. These are two strategies which, at different times in the pandemic, have worked. The Italian strategy consists in committing to provide all that is needed by the population and in the enforcement of certain rules in the context of a liberal democracy. I believe that in the future there will be the application of what we call the “Chinese model”, a stronger but functional containment in some areas of the country that are experiencing a particularly strong epidemic curve; and the “Korean model”, as regards to the adoption of an approach to testing and hyper-technological tracking that we are already studying.

The “Italian model” is nothing more than the evolution of these models that aim to maximise the positive experiences derived from these two countries. I believe that it will, after all, be a forced choice for the rest of the world as well. A return to a normal life will be possible when there is a specific therapy or vaccine. Meanwhile, we will experience a “new normalcy“, in which there will be a modest return to mobility; controlled, of course. But a partial return to mobility can only occur if the strategies of containment, testing and tracking are pursued. I believe that in the future there will be not as much containment and it will be based less so on large geographical areas, but rather on individual tracking according to the level of risk. If a person is healthy and behaves well, according to the rules, they can also move and go to work. If a person is infected, they must be contained and restricted in their movements until full recovery. It’s an approach that mixes health science and social science. I believe that it will be the only chance we will have to return to a “new normalcy” while waiting for a specific therapy or vaccine.

In the end, who do you think is responsible for their own health?

Walter Ricciardi: In times of epidemic, the freedom of the individual ceases. Because when the individual behaves recklessly, thousands of people get exposed to risk. In times of epidemics there is nothing else to do, especially in times of epidemics with respiratory viruses where simple contact is enough to be infected. There is a need, however, to explain this new social behaviour carefully to the population. Most of the people are aware of this and understand. The few who do not must somehow be contained to meet the needs and priorities of overcoming the epidemic, also through security forces. There is nothing else to be done in this context.

The West, and therefore Europe too, have found themselves completely unprepared for this pandemic, even though we scientists and some entrepreneurs have been saying for some time that it would be possible. This was not an unexpected event, it was just a matter of knowing when it was going to happen. I have to say that, to a large extent, both politicians and the citizens themselves are to blame – recently, not even Western citizens thought that such an evolution of events would be possible. It has happened and it is further proof that there must always be an alliance between science and politics because it is only through this alliance that problems can be solved.

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