It’s Saturday in Geneva, where I’m heading to visit a patient who recently attempted suicide. It almost seems like an ordinary weekend afternoon: people meet friends in the park, though police on rollerblades encourage social distancing. Everything appears under control. Just weeks after the city’s Covid-19 outbreak, there is no lockdown.
Though I have experience as a surgeon, I now practice psychiatry in a Geneva hospital, where physicians have done whatever is necessary during the crisis. On this almost-normal Swiss afternoon, however, I can’t help but think of Northern Italy, my family’s homeland, where I studied medicine.
The streets of Milan, just three hours by car from Geneva, remain empty, the medical facilities still under enormous stress. Before the pandemic, ambulances arrived on site in eight minutes. At the peak of the outbreak, with so many trips to make, it took over an hour. In the region’s hospitals, the typical Covid-19-related death is an 80-year-old with severe preexisting medical conditions, like chronic bronchitis or heart disease; I think of my parents, who, though elderly, don’t have the health issues that would necessarily make a Covid-19 infection life-threatening. Yet, if they had an accident, they’d likely have died waiting for an ambulance to arrive.
The Italian problem was long in the making. Years of cost-cutting have centralized health-care delivery in large, state-run hospitals. Thousands of retired family doctors who treated patients in their own clinics or made home visits haven’t been replaced. As a result, anxious patients with ambiguous symptoms—who were treated near their homes in the past—are overwhelming ambulances and exceeding emergency room capacities. The larger hospitals, charged with treating these patients, must operate under a national bureaucracy that makes it difficult to adapt to a shock like Covid-19.
I speak every day with Italian physicians, including those who somehow continue their family practices, about the crisis. It turns out that only large hospitals have facilities to test patients. Communication between those hospitals and family physicians remains difficult, a trend that preceded the pandemic. The absence of protective materials for local doctors, moreover, risks transmitting infection even further.
Meantime, Switzerland has had a far milder Covid-19 experience, though the virus isn’t intrinsically less deadly or infectious in the country. It’s true that the Swiss system has more money than Italy’s, but most important, it’s better organized to deliver medical care where it’s needed. Switzerland’s health insurance is universal, but it’s still largely private—even large public hospitals receive reimbursement from insurance companies, which operate in a highly regulated market. By contrast, Italian hospitals rely financially on the Health Ministry. Thanks to the country’s efficient system, Swiss hospitals were able to increase their ICU capacity five-fold in just a few days.
This efficiency also applies to family practices, which permit physicians to provide care to patients over the phone or through old-fashioned home visits. Medical specialists assist these family physicians. Otolaryngologists, for example, are now helping general practitioners treat Covid-19 patients. They’re often providing care without admitting patients to the hospital. As a result, patients without serious complications aren’t summoning ambulances unnecessarily.
For now, Northern Italy remains largely paralyzed, in the thrall of panicked public opinion, vague epidemiological models, and virologists offering hope of developing miraculous vaccines and drugs. Now slightly eased, the lockdown may buy time, but without basic changes to how medicine is practiced and delivered, the country will remain vulnerable to renewed waves of contagion or the next pandemic. The traditional Italian “art of waiting” to fix things could be more expensive than ever for lives and livelihoods. Switzerland’s flexible, decentralized system offers an important lesson that my homeland should heed.
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