What We Can Learn From Italy’s COVID-19 Policy Response
Dr Silvia Camporesi, a reader in bioethics and health humanities at King’s College London, looks at what policymakers can learn from Italy’s pandemic response.
Dr Silvia Camporesi
Italy was the first country after China to face the full ramifications of the COVID-19 outbreak.
On January 31, 2020, Italy declared a state of national emergency, after initial attempts to contain its spread via contact tracing and case isolation were not successful.
For the next three months until May 5, citizens were subject to some of the most stringent restrictions in Europe, with even jogging and cycling prohibited.
On February 3rd, Italy’s government convened a committee of experts called the Technical and Scientific Committee (CTS) to provide policymakers with expert advice for the management of the epidemic.
Policy by experts
The role of the CTS was key in managing the pandemic, especially in the early stage. The minutes of daily meetings were fed directly to government officials, which enabled policies to be produced pertinently and quickly.
This obstacle-free channel connecting expert advice with policymakers was critical at a time when the pandemic threatened to overwhelm the country’s healthcare system, without quick top-down intervention.
For example, soon after the first nationwide lockdown, Italy introduced a data-driven system for organising targeted responses based on infection rates.
Each of the 20 regions were colour-coded and given restrictions based entirely on data.
However, experts were also frustrated by how their evidence was being used as a proxy for policy creation.
Our research demonstrates that politicians were happy to defer to experts for the production of policies. A process that resulted in the wisdom of experts taking on a quasi mythical role in the national consciousness.
The minutes of the CTS meetings came to be regarded as ‘Moses Tablets’ and were used verbatim for the production of decrees and other legislative orders.
The CTS members, however, resisted being portrayed as policymakers by the media, with some stakeholders publicly threatening to resign unless the clear consultative role of the expert committee was maintained.
Why were all the experts men?
The CTS was set up with representation criteria. Members were appointed on the basis that they were representative of the major national authorities and institutions with technical and scientific competences in epidemiology and infectious diseases, and health crisis management.
However, given that Italy is a country where gender equality in the workplace has a long way to go (fewer than half of working-age Italian women are employed), this resulted in no women included as members.
This was corrected in due course after public criticism and the number of members increased from 14 to 20 in April 2020.
However the appointment of women at a second stage was perceived to be ad hoc and those appointed felt they were in less of a position to fully participate in the committee.
This was also because during the peak of the pandemic the caregiving duties fell more heavily on women members.
Where were the socio-economic advisors?
Social-economic advice was not well integrated into the production of policy making. There was a hierarchy of expertise. Decision-making in this field was considered to fall under the role of parliament and was not considered ‘expert’ in the same way as technical and scientific knowledge.
This posed a problem as the CTS had to deal with decisions that included socio-economic trade-offs, such as the opening and closures of schools and gyms. Here there are clear social and economic ramifications, including the impact on mental health and physical wellbeing.
Our analysis shows that implicit value-based judgments entered the discussions and swayed decision making. However because these values were not made explicit, the decisions were presented as neutral evidence-based conclusions.
For example, some members of the CTS assigned implicitly more weight to the value of saving the highest possible number of lives at a given point in time, and argued in favour of closing down gyms and pools. A highly technical public health measure. While, a minority of members assigned a higher weight to the value of liberty and argued that gyms and pools should remain open through the second wave in the fall of 2020, if the necessary precautions were put in place.
This led to one of the first disagreements within the CTS in the autumn of 2020.
For the first time, the oracle of COVID-19 in Italy could not speak with a single voice.
The opposing views were presented as a technical disagreement, but it was actually a clash of values, and demonstrated how, even if not explicitly acknowledged, the values of utility, liberty and equity underpin all public health policy decisions.
What have we learned?
More than two years into the pandemic, I can see three main practical lessons that policymakers could take from the Italian case study.
The first one is that it is a good thing to have an expert committee that is convened expressively for the purposes of pandemic preparedness/emergency planning. This allows for a quick response from a group with vested authority that can efficiently manage the crisis.
However, the terms of reference of this expert committee should include a specific clause on how decisions should be reached, which was not the case for the Italian technical and scientific committee.
Also, gender equality needs to be clearly envisaged and planned for from the get-go. The addition of female members to the CTS ad hoc did not support their full entitlement as members of the committee.
Finally, plans for the end of the emergency should also be included in any plan for the health emergency.
What happens to the expert committees that were set up in response to the health emergency when that is considered over? In Italy, the state of national emergency ended on March 31st, 2022. After this date, the future of the CTS is uncertain. Some have recommended that the expertise the committee has provided for over two years should not be lost, but should be channelled towards the creation of another more permanent committee, or expert body.
The Italy case study also showed a strong tension between the consultative and legislative role of the technical and scientific committee. This needs to be avoided. More distance between expert advice and production of policy making should be built into the decision-making process.
For example, minutes of the meetings should not feed directly into decrees or legislative orders. There needs to be a political filter that does not allow for delegation of political responsibility to experts.
Perhaps the most important lesson from our research is one that can be applied to future infectious disease outbreaks.
By narrowly defining COVID-19 as a health emergency, we shaped the type of knowledge and evidence that could be effectively mobilised in the management of the crisis, to the detriment of the social sciences.
We know now there are many negative outcomes from the outbreak. From economic blows and the spotlight thrown on the unequal division of labour, to the repercussions on mental health and the public’s lack of trust in public health messaging.
In the future, any health emergency should also be framed as a social and economic emergency, and response committees should include socio-economical experts whose advice sits on the same level as the technical and scientific advisors.
To read more about Camporesi’s research, click here.