Marco Cremaschini
The question to seriously bring to the attention of politicians and programmers is not If territorial medicine held or less, but rather What and how many resources it should have had territorial medicine to be able to cope with the unfortunate wave of the pandemic.
In the narrative of the Sars-Cov2 pandemic, local medicine has been defined by many as the “weak link” of the health systemthe component “that would not have held” in the first pandemic wave and in particular in that terrible March 2020. In the days of the Third National Day in memory of the victims of the pandemic, it is necessary to reflect on this statement which, repeated on various occasions, has transformed in common belief. Without wanting to hide the problems of Primary Care in Italy, this however appears to be a narrative of convenience, useful above all to those responsible for the impoverishment of Primary Care and Public Health, who want to deny the failure, perhaps even inevitable in the face of a pandemic catastrophe, of a system that for decades has focused every health investment almost exclusively on hospital care . A narrative that perhaps is also convenient for those who, if the failure of the General Medicine system were decreed, would be ready to take its place.
With the affirmation that territorial medicine has not held upmore than reflecting on resources (particularly Primary Care), sometimes it is also impliedmore or less covertly, that doctors could have done more, not recognizing them the merit of having spent many, with all possible forces, to do their job as best as possible in a dramatic context in which 9 of them, in our province, lost their lives. For me and for all the colleagues who lived those days in the Primary Care Department of the Bergamo ATS, remembering the pandemic means remembering their faces, the telephone outbursts, the exhaustion and even the tears of many of them who in those days they worked more than 12 hours a day, they sent screenshots of their phones with the number of calls received, they said they hadn’t seen their family members for days due to working hours or self-isolation adopted for fear of infecting them.
I would like to try to tell that March 2020 from another point of view, to open a reflection on this topic, trying to start from the numbers. Because the numbers have been the great absentees of this narrative. Let’s start with the numbers of health workers: how many qualified personnel could you count on to deal with the pandemic in the province of Bergamo in that March 2020?
The army of hospital structures
It is rather difficult to have the exact numbers of health personnel working in the various hospitals in the province. However, we can get an idea from the ISTAT data relating to Lombardy in 2020 (data on a provincial basis are not easily available) which indicate the relationship between GPs and specialist doctors at 1 out of 5 and the relationship between GPs and other specialists at 1 out of 9 health care professions. The calculation brings approximately 3500 medical specialists and 6300 health professions. If we are only interested in the order of magnitude, let’s consider 10,000 health workers, with facilities, spaces, support personnel, advanced diagnostic and therapeutic equipment at their disposal.
The troops of the territory’s medicine
And how many soldiers in General Medicine were there who – in an ancillary vision of Primary Care – should have defended the Emergency Departments from the onslaught of Covid19 patients? In Bergamo in that March 2020 we are talking about 700 general practitioners, with a few dozen part-time study nurses and 150 pediatricians. By adding the Doctors of Continuity of Care and the Doctors of the USCA we do not arrive at 1000 units. About a tenth of the health workers present in hospitals. Among the 700 General Practitioners, the average age was 61, many of them were close to retirement and many were at a high risk of complications or death in the event of Sars-Cov2 infection, due to their age and comorbidity. They did not have diagnostic swabs available (in those months supplied only to hospitals), they did not have specific therapeutic weapons (antivirals at the time were exclusively hospital prescriptions), initially they also lacked adequate PPE, unpurchasable because they practically disappeared from the market: 150 of they fell ill immediately in that month of March.
Cases managed by local doctors
But what did these 700 doctors do in practice (without wanting to forget pediatricians and MCA and USCA) in these conditions? Well, what no one ever tells, they have handled the majority of Covid19 cases of the entire pandemic. That is about 90% of the sick, who remained at home and have never seen the hospital, not even from a distance.
But how many cases are we talking about?
In March 2020, a number of cases in the order of 10,000 were ascertained in Bergamo, all at hospitals, where diagnostic swabs were available, and a number of deaths from Covid19 of around 3500 were recorded (the excess of deaths compared to March of the previous year is closer to 5000). Cases from different sources still do not coincide today, but here, too, we are only interested in the order of magnitude. If the real cases had been only the 10,000 ascertained with swabs, the disease should have had an impossible lethality, greater than 35%. In reality it was already known then that the general lethality of the disease was between 1 and 2%. This means that the real number of cases exceeded by more than 10 times that of those confirmed with a molecular swab (the only ones that appeared in the statistics). In practice, in the month of March 2020 in the province of Bergamo we can estimate a number of cases in the order of 100,000 – 150,000. If we remove the 10,000 hospital patients, this means that in March each of those 700 doctors had about 200 cases of Covid among their patients. About 6 new cases a day, which added up to those of the previous days every day. Considering an average duration of the disease of 8 days, for each doctor there were around 50 Covid19 patients to be followed up at home every day.
Naturally, in the only possible way: anamnesis on the telephone, recording parameters and remote prescriptions, visits only if absolutely essential (sometimes even resorting to USCA). In addition there was close contact tracing to be identified and reported, isolation and quarantine instructions to be given, infectious disease reporting, sickness certificate bureaucracy, medication and oxygen prescriptions…
Among those patients were many who, according to all the guidelines in the world, should have been hospitalized, because they already had severe respiratory failure. But the emergency number 112 didn’t answer, the ambulances didn’t arrive, the Emergency Departments were saturated with long queues of stretchers outside and the beds in the hospital wards were all occupied.
Why yes, it must be admitted, in that unfortunate March 2020 even the hospitals did not hold. Even the emergency-urgency system didn’t hold up. And where did all the patients who needed hospital treatment and who could not find a place in the hospital go? They stayed at home, among those 50 patients that every General Practitioner should have followed up on every day. In that month, each of those doctors was getting 90-100 phone calls a day. We have collected their outbursts and their desperation, because they were exhausted and did not know how long they could continue like this, dealing with terrified patients and relatives. Those doctors who couldn’t say “there’s no more room here” couldn’t refer the case to someone else. After falling ill, many of them continued to work on the telephone as long as their strength allowed. This too deserves to be told.
50 Covid19 patients a day to follow. With these numbers, is anyone really surprised that the doctors’ phones were always busy and it was difficult to contact them? And some are really surprised if some sick doctor (1 out of 4 fell ill in the first 2 months), after useless attempts to find a replacement, stopped answering the phone for a few days, perhaps because he too was in bed with shortness of breath and the fever? Yes, it has also happened that some patients have had to fend for themselves (or even die) on their own. The pandemic was also this, beyond any rhetoric.
An incorrect but necessary comparison
In March 2020, the provincial hospitals as a whole diagnosed and followed up 10,000 cases of Covid. On average 320 new cases per day. They have done a titanic job, in a very short time they have converted entire departments to the management of Covid19 patients. They treated the cases that needed more intensive care and, despite the availability of human resources, they underwent a stress that no operator will ever forget. The comparison is incorrect for many reasons, but if, despite heroic efforts, these healthcare facilities that could count on 10,000 healthcare workers went into crisis with 320 new Covid19 patients a day, how could one think that the Primary Care system, with Could 1,000 operators, with virtually no tools or support staff, handle more than 4,000 new cases per day (some of which required hospital care)?
The question to seriously bring to the attention of politicians and programmers is not If territorial medicine held or less, but rather What and how many resources it should have had territorial medicine to be able to cope with the unfortunate wave of the pandemic. Asking the correct question and responding with consequent investments is the only way to prevent the next pandemic from finding us in the same conditions again.
Marco Cremaschini worked as a Doctor in the Primary Care Department of the Bergamo ATS during the Pandemic. Since June 2022 he has been a general practitioner in the province of Bergamo