The story from Italy: COVID-19 and inequity

Italy was the first European country to be hit by the COVID-19 pandemic. While the rest of the world watched, staff at the Italian National Institute of Health were under pressure to understand the spread of the disease, the impacts on health and inequalities, and the connections to social and economic factors. Here they share some of their experiences and actions.

Written by Anna Maria Giammarioli, Rita Maria Ferrelli, Loredana Falzano, Paola De Castro, Aldina Venerosi, Emanuela Medda, Benedetta Mattioli and Raffaella Bucciardini, in collaboration with their colleagues. The authors are researchers at the Italian National Institute of Health and members of its Health Equity Unit .


The SARS-CoV-2 outbreak did not affect everyone equally. Currently, epidemiological data on the relationship between the number of SARS-CoV-2 infected Italian people and their socio-economic position are not yet available. However, it is possible to speculate on two main aspects: 1) the most socially and economically disadvantaged people might have been more exposed to infection and 2) they will suffer greater socio-economic repercussions at the end of outbreak.

The spread of the outbreak

Italy was the first country in Europe to be hit by the COVID-19 outbreak and it was caught off guard. At start of coronavirus outbreak, no European Union (EU) country responded to Italy’s call for aid and in addition, both France and Germany imposed export bans on vital medical equipment. Only in recent times the EU has offered “a heartfelt apology” to Italy and has tried to give a unified and coordinated response to the pandemic. Meanwhile our Northern regions, where most economic activities are located, were the worst affected. The Italian government made significant efforts to contain virus spread by means of first local and then countrywide restrictions; social distancing and lockdown measures were introduced, while resources and attention were focused on services and public health needs. However, remote work was not applicable for those working in essential services (healthcare, food sales), further exposing themselves to the infection. Although in Italy the health care system provides free of charge universal coverage, there was still speculation that the most socially and economically disadvantaged people might have been more exposed or more susceptible to the coronavirus.

Unequal exposure to the virus

We identified four factors which may contribute to increase exposure and heavier impacts of the virus.

Firstly, the ability to understand how to take precautionary measures. Lower health literacy may produce limited awareness of information on precautionary measures. We were also concerned about the impact on migrants living in Italy who do not speak Italian well, and might lack information in their language on how to defend themselves against the transmission of the virus.

Secondly, working conditions. A lower social position is generally associated with poorer working conditions. We noted that for some people it can be difficult to balance good health and work. For instance, it might be difficult to maintain physical distance at the workplace, but staying at home means being in danger of not being paid or even losing your job. Remembering the effect of financial crisis of 2008, the Italian government specifically designed some measures to sustain the labor market in favor of both employers and employees. Among these, dismissal procedures (both individual and collective) were banned for 60 days if started after the start of the pandemic (February 23, 2020) and have been recently extended for another 60 days. To avoid dismissal and to face temporary business contractions, companies were able to activate lay-off support, financed with public capital1,2 .

Next, pre-existing conditions. Clinical evidence suggests that most fatalities induced by COVID-19 will be among those with previous chronic illness such as high blood pressure, diabetes and heart or respiratory disease especially among the elderly population. In 2019, approximately 23% of the Italian population was aged 65 years or older. This may partially explain why the impact of COVID-19 has been substantially more severe in Italy than other European countries 3 . Cultural factors may also have played a role, as in Italy different generations tend to spend more time together, often under the same roof. These habits may have facilitated contagion in the elderly.
Over the last decades, epidemiological studies have shown that in Italy as well as in other countries the most socially and economically disadvantaged are more likely to suffer from chronic diseases 4,5,6 .

Last but not least, socially excluded groups, including prisoners, the homeless, and migrants, might require tailored responses. In Italy, due to overcrowded jails, prisoners and prison guards might find difficulties to be adequately isolated from the other members of the community.

Unequal socio-economic repercussions

Currently, epidemiological data on the relationship between SARS-CoV-2 infected people and their socio-economic position is not yet available. It will be necessary to wait for the end of the acute phase of the pandemic to assess the distribution of the infection with respect to the socio-economic gradient existing in Italy before the pandemic.

The old and the young, and the effects on mental health.

Some concerns arise from the choices made in the education sectors. Although they appear necessary to deal with the health emergency, the closure of schools due to the pandemic has highlighted some important gaps and weaknesses of the education system. It is particularly important to note that some families may be lacking the technology for virtual education, in particular a computer and an internet connection. This should be ensured for all students 7 . It is also important to mention that minors with learning difficulties and neurodevelopmental disorders might be affected by changes and disruption to support routines 8 and the educational setting must implement timely protocols to answer to their special needs 9 .

Elderly people, already heavily affected by COVID-19, have seen their family support and networks interrupted by social distancing measures. Particularly those with multi-morbidities might be more affected by isolation, loneliness, and sadness, which can be exacerbated by the digital divide.

Similarly, people with existing disability and mental health issues, including those with severe mental illnesses, might be affected by a possible exacerbation of symptoms in response to pandemic-related information and behaviors, and suffer from the interruption of community interventions 9 .

Finally, it is predictable that the most affected will be the most economically fragile people: caregivers, housekeepers, precarious workers and all those who do not have adequate socio-economic protection and who are not working because of the restriction policies for containment of the pandemic 10:11. Next to these, small business owners, who have closed their businesses since the outbreak of COVID-19, are at risk of reduced income or poverty. In the agricultural sector, many of seasonal workers are migrants who work illegally for long hours and are underpaid by criminal organizations. Under the COVID-19 crisis, authorities are concerned that these criminal organizations may exploit the situation more than ever. People unable to bear the basic needs of their families could follow a greater use of legal and illegal forms of indebtedness and underworld organizations could gain economic and social power.

To cope with the consequences of the lockdown, the Italian Government has come up with a comprehensive recovery plan and unprecedented investment. The Law Decree No. 18/2020 (also named the “Cura Italia” Decree) established the first and most relevant provisions taken to strengthen the National Health Service, facilitated economic support for families, enacted new rules and protections for seasonal workers, and planned immediate aid for workers and Small and Medium-sized Enterprises (SMEs) through extension and deployment of existing instruments and complementing measures. Further actions have been approved in Law Decree 34/2020, informally named “Relaunch Decree”, because it provides for further measures focused to promote a re-launch of the Italian economy 1,2 ).

The role of Italian National Institute of Health

Since the start of the coronavirus pandemic, the Italian National Institute of Health (ISS) has cooperated with the Government as a member of the National Scientific and Technical Committee. In particular, ISS has coordinated the surveillance system integrating the epidemiological data provided by all Regions and Autonomous Provinces and the containment measures were developed on these data.

Online training courses for health operators were immediately organised with large participation from all Italian Regions, as well as virtual workshops and teleconferences with the Italian Regional authorities and meetings on specific topics, such as guidance for prevention and control of SARS-CoV-2 infection in long term care facilities. A series of technical reports were also published 12  to support health operators to manage the different aspects of the pandemic. Some reports were also translated into English following the requests received from different countries outside Italy 13.

ISS has also created a web space dedicated to the new coronavirus, in which the main topics on COVID-19 have been translated into easy and accessible language for citizens. The site has also managed fake news, FAQs, brochures, videos and some infographics easy to be understood. Some documents are also translated into English and other languages, such as “Coronavirus: A practical guide for caregivers of elderly people” which was translated into 8 languages 14 .

ISS has also developed research reference documents in different fields of study to facilitate: i) the collection and analysis of data disaggregated by sex in COVID-19 patients, ii) the analysis of groups of pathologies with specific needs, iii) risk analysis and guidelines for the interrelationships between SARS-COV-2 and the environment for the safety of air, water and soil, iv) analysis of the implications of the COVID-19 epidemic in veterinary public health and food safety and hygiene v) indications for the correct use of telemedicine and digital health systems. A selection of some publications produced by our researchers in the scientific literature are also reported 3,15,16,17,18 .

Now in Italy, the spread of the outbreak is significantly decreasing but it is evident that societies will have to live with the virus until a vaccine or treatment is found. Thus, this will require constant and detailed monitoring to reintroduce new measures if needed. The ISS will be called upon to strengthen the health surveillance systems, which are already in place. In addition, new epidemiological studies should be planned to monitor how the secondary effects of COVID-19 have affected human and social systems and their environments and how government interventions can impact these.

Looking to the future

The COVID-19 pandemic has highlighted some mechanisms that could underpin health disparities. A comprehensive recovery plan and unprecedented investment have been initiated by the Italian Government to counterbalance the socio-economic impact. But in ways we have never seen before, the pandemic has called into question the principles of globalisation on which the global economy and relations between states are based on. ISS and other national and international multidimensional institutions should be in charge of providing accurate and evidence-based scientific information that could make it easier for economists and politicians to rethink the economic model with an eye on equity.

References

  1. Law Decree No. 18/2020. Available here .
  2. Law Decree 34/2020. Available here .
  3. Onder G, Rezza G, S Brusaferro . Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA
  4. Global Report for Research on Infectious Diseases of Poverty. WHO; 2012. Available here .
  5. Quinn SC, Kumar S. Health inequalities and infectious disease epidemics: a challenge for global health security. Biosecur Bioterror. 2014 Sep-Oct; 12 (5): 263-73. doi: 10.1089 / bsp.2014.0032 . PubMed PMID: 25254915; PubMed Central PMCID: PMC4170985.
  6. Blumenshine P, Reingold A, Egerter S, Mockenhaupt R, Braveman P, Marks J Pandemic influenza planning in the United States from a health disparities perspective. Emerg Infect Dis. 2008 May; 14 (5): 709-15.)
  7. Key Messages and Actions for COVID-19 Prevention and Control in School. 2020. Available here .
  8. Holmes EA et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. 2020 Lancet S2215-0366 (20) 30168-1
  9. Lee J Mental health effects of school closures during COVID-19. thelancet.com/child-adolescent Published online April 14, 2020   https://doi.org/10.1016/S2352-4642(20)30109-7
  10. COVID-19 – A social emergency for millions of precarious workers in Europe by: European Federation of Food Agriculture and Tourism Trade Unions. March 19, 2020 Available here .
  11. Adams-Prassl, T. Boneva, M. Golin, C. Rauh The large and unequal impact of COVID-19 on workers. April 8, 2020. Available here .
  12. ISS COVID-19 reports. Available here .
  13. https://www.iss.it/rapporti-iss-covid-19-in-english
  14. https://www.iss.it/covid-19-opuscoli
  15. Riccardo F, Ajelli M, Andrianou X, Bella A, Del Manso M, Fabiani M, Bellino S, Boros S, Urdiales AM, Marziano V, Rota MC, Filia A, D’Ancona FP, Siddu A, Punzo O, Trentini F, Guzzetta G, Poletti P, Stefanelli P, Castrucci, MR, Ciervo A, Di Benedetto C, Tallon M, Piccioli A, Brusaferro S, Rezza G, Merler S, Pezzotti P. COVID-19 working group. Epidemiological characteristics of COVID-19 cases in Italy and estimates of the reproductive numbers one month into the epidemic. medRxiv  2020.04.08.20056861; https://doi.org/10.1101/2020.04.08.20056861.
  16. Matricardi PM, Dal Negro RW, Nisini R. The first, holistic immunological model of COVID-19: implications for prevention, diagnosis, and public health measures. Pediatr Allergy Immunol 2020; Epub 2020 May 2; https://doi.org/10.1111/pai.13271.
  17. Gagliardi MC, Ortona E, Ruggieri A. ACE2 expression and sex disparity in COVID19. Cell Death Discov. 2020; (in press).
  18. Giorgi Rossi P, Ferroni E, Spila Alegiani S, Leoni O, Pitter G, Cereda D, Marino M, Pellizzari M, Sultana J, Trifirò G, Massari M, ITACOVID19 working group. Survival of hospitalized COVID-19 patientis in Northern Italy: a population-based cohort study by the ITA-COVID19 Network. medRxiv 2020; https://medrxiv.org/cgi/content/short/2020.05.15.20103119v1.
Anna Maria Giammarioli

Researcher at the National Institute of Health in Italy, carried out studies on innovative therapeutic approaches aimed at controlling and modulating processes of relevance in human pathology with particular reference to gender differences. She is currently involved in studies on the social and biological factors that would concern the generation of health inequalities.

Rita Maria Ferrelli

M.D., specialist in public health, has been working in Primary Health Care and Health Equity projects in South America since 1988 and in health cooperation projects at the National Institute of Health of Italy since 1997. Her interest focuses on reducing health inequalities.

Loredana Falzano

Loredana Falzano is a researcher at the Istituto Superiore di Sanità, the National Institute of Health in Italy. Since 2008 she has been working in Italian and European health projects on public health. She is currently involved in studies focused on reducing health inequalities. She is also member of the Operational Unit  “Health Equity in ISS “.

Paola De Castro

Director of Scientific Communications at the National Institute of Health in Italy. She develops communication strategies addressed to different stakeholders and carries on multidisciplinary research and training for public health, mainly focused on science communication and scientific writing, health equity and health literacy, with research partnerships in Europe, Latin America, and Africa.

Aldina Venerosi

Aldina Venerosi is researcher at the Italian National Institute of Health since 2002 . She carried out studies of applied psychobiology in neurotoxicology to highlight and study risk factors for the development of neurodevelopmental disorders and for neurodegenerative diseases. Since 2010 she has been starting research on epidemiological and service for Autism Spectrum Disorders and more generally mental disability.

 

Emanuela Medda

Emanuela Medda is senior researcher at the Italian National Institute of Health. She has a long-standing experience in epidemiological studies and she is currently involved in studies on psychological well-being and mental health. Recently, she has also focused attention on health equity.

Benedetta Mattioli, PhD
Italian National Institute of Health

Benedetta has worked at the Italian National Institute of Health (ISS) since 2000 - first in the Department of Therapeutic Research and Medicines Evaluation, where she was involved in different projects in the field of immunology, NCDs and HIV. Since 2017, she works at the Centre for Global Health at ISS. Here she is involved in the scientific management of different national and international projects in the field of public health.

Raffaella Bucciardini

She has been working as researcher at the Istituto Superiore di Sanità, the National Institute of Health in Italy since 1992.  She has been working as scientific coordinator from 2000, highly specialized in operational research in the public health field. Since 2019 she is director of the Operational Unit “Health Equity ISS”.

Health Equity ISS (HEISS)

Health Equity ISS (HEISS) is a cross disciplinary Unit at National Institute of Health involving about 60 researchers from different backgrounds.  The members of HEISS represent all technical-scientific operational area of the Istituto Superiore di Sanità (ISS): 6 Departments, 14 National Centers, 2 Reference Centers and 5 Technical-Scientific Services.  The general objective of HEISS is to orient research towards closing knowledge gaps on health inequalities. It also aims to strengthen awareness on health equity and finally promote effective actions to drive policies to health inequalities reduction.

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