On 7 March, Luca Franzese, an actor in the internationally acclaimed TV series Gomorrah, released a brutal video of his sister’s dead body online. Teresa Franzese died in Naples days after being infected by Covid-19 at the age of 47. The video shook many and made them realise that the invisible disease was no longer a remote possibility.

Naples’ bars were still packed the weekend before she died, despite national guidelines on social distancing. The state ended their defiant party when it implemented a nationwide ban on gatherings and travel, put a 6pm curfew in place, and closed most non-essential business as of 10 March. The restrictions were initially drafted for the northern regions where death and contagion have been highest. They were subsequently extended to the rest of the country after tens of thousands of people tried to flee the lockdown by boarding buses and trains to the south.

Fighting an epidemic with limited resources

Italy’s situation is dramatic: on 18 March deaths surpassed those witnessed in China and cases continue to rise. While media attention has mostly focused on the crisis in the north of Italy so far, it is clear that the outbreak has rapidly spread across the country. We have spoken to healthcare workers who are concerned that lower numbers in the south merely reflect lower capacity to test and diagnose. They fear it will be a matter of days before evidence of widespread, on-going contagion in the south emerges. In Naples, for example, a family doctor confirmed that many of the latest cases recorded in his region are people who escaped from the north’s lockdown.

The spread of cases to southern regions is particularly concerning. Southern regions, with few exceptions, have under-resourced health services that will struggle to cope with the epidemic. Doctors in these regions are particularly worried about the heavy burden of concomitant diseases, especially among the elderly population, at a time when many ordinary medical services are being suspended to free up resources. Although intensive care units are being expanded, capacity in the south is still inadequate. As Covid-19 cases accumulate doctors will have to make difficult choices and triage patients based on age and likelihood of recovery.

Lack of equipment is another serious concern. At a time when the World Health Organisation is emphasising the importance of testing to expose symptom-free cases, healthcare staff in the south have told us they are often working without face masks even in the emergency units. Staff who appear healthy are required by law to keep working even after they come into contact with Covid-19 cases, increasing the risk of hospitals becoming hotspots. While a number of countries are stepping up financial efforts to increase testing capacity, Italy’s southern regions will struggle to respond to the crisis in similar ways.

A social disease

Previous epidemics show us that we ignore social factors determining the spread of disease at our peril. As the disease moves around the country we need to understand how it will put different groups of people at risk. We are already seeing how coronavirus exacerbates existing problems in Italy’s social and economic structures.

Teresa Franzese reportedly caught the disease from a neighbour whose family members were infected. Eight members of Luca and Teresa’s family were waiting in the house when a specialised team arrived to collect the body. The whole area is host to mostly low-income households and has very high population density levels. The poorest basement and ground-floor dwellings, known as bassi, can have up to eight people co-habiting in a single room. In such spaces self-isolation is impossible. Overcrowded migrant centres are concentrated in many of these same areas. The people living there face similarly challenging conditions and lack access to even basic healthcare. A case in one of these centres in Milan confirmed health workers’ fear that contagion was already underway in those kinds of spaces.

Coronavirus poses a particular threat to the elderly. In Italy, because care for the elderly is overwhelmingly a family affair, it is difficult to isolate them and keep them safe. The government passed extraordinary economic measures in an effort to contain the economic effects of the crisis, including cash transfers to freelancers, mortgage and utility bill freezes, and sick leave for those in quarantine. But for those employed informally, like many migrant workers, or frontline factory workers, the risks remain high.

Trust, trust, trust

Our work during the 2014-16 Ebola outbreak in Sierra Leone taught us that trust is key to ensuring collective support for stringent emergency measures. This is especially important as the emergency deepens and spreads to the south, given the economic and social realities in those regions.

Italians have historically low trust in institutions, and this is particularly marked in some areas of the south. For example, in neighbourhoods like Luca and Teresa’s, poverty, a lack of opportunities, and the presence of organised crime have long strained inhabitants’ relationship with the authorities. Many did not initially buy into the government’s alarm over a new epidemic originating in China and affecting the rich northern regions, and were reluctant to follow new regulations.

In the first week of the lockdown the government managed the Herculean task of building a sense of shared responsibility and commitment in the face of mistrust. Mass media campaigns and institutional messaging around national unity were accompanied by citizen-led mobilisation, like the musical flash-mobs on balconies that are all over social media. However, as the lockdown is extended indefinitely and rising numbers of violations are recorded (40,000 were filed on 18 March alone), the challenge of maintaining national solidarity will grow.

Is a Hubei-style, prolonged strict enforcement strategy feasible in Europe? Some concerned citizens, especially amongst the wealthier classes, are already calling for the military to enforce the lockdown. This could easily backfire. In an already strained social context, the militarisation of the response could damage social cohesion and lead to escalations of violence.

What makes a response effective?

To maintain trust in a time of crisis, an effective response should have multiple components. First, it must have community engagement strategies that directly target the social and economic issues we have described. These should include a broad understanding of who is vulnerable and who will find self-isolation most challenging. Targeted messaging that takes into consideration regional differences is key to this.

At the same time, we need to step up testing efforts, support health-care workers’ mental health, provide them with critical equipment, and increase their numbers. In order to address the diversity of social costs and ensure effectiveness, regional emergency task forces must include not only political representatives but also medical professionals, local community stakeholders, social scientists and experts in communicating scientific knowledge and risk.

Finally, other epidemics across the world have taught us that international solidarity is key. Italy’s response has been strong and citizens are making daily sacrifices. However, as the disease spreads, especially to southern regions that are ill equipped to face a health crisis of such proportions, it is time to step up international support of equipment and expertise to avert a humanitarian crisis.