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Covid-19's first wave largely missed southern Italy. The second wave is hitting it hard.

A patient gets his respiration rate checked in Bergamon, Italy. Among the first 750 patients screened, about 30% exhibited breathing trouble and permanent lung scarring.

ALBERTO BERNASCONI FOR THE WASHINGTON POST

By CHICO HARLAN | The Washington Post | Published: October 17, 2020

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ROME - Italy is about to test the value of "flattening the curve."

When northern Italy became the epicenter of the pandemic in the spring, one urgent concern was that the country's coronavirus outbreak would quickly spread to the less-prosperous south and overwhelm under-resourced regional health systems.

That fear wasn't realized. A strict nationwide lockdown largely contained the virus in the north and brought the outbreak under control.

But now the virus is raging again, through Europe and through Italy, with a spike that is again hitting the north but this time also the south. In Campania, which includes Naples, the daily number of detected new cases is five times larger than March's peak.

So the question becomes whether Italy bought itself enough time.

Compared with six months ago, there is more space to accommodate critical patients in southern Italy. There are more ventilators. Still, many hospitals in the south remain understaffed, and have fewer beds per capita than those in the north. They could reach a breaking point if the number of critical patients soars.

The regional governor of Campania has ordered a school closure through the end of October and threatened a lockdown if the numbers continue to rise.

"Are we dramatizing it?" the governor, Vincenzo De Luca, wrote on his official Facebook page. "No, simply doing a calculation that will prevent us from a crushing situation in our hospitals."

During the first wave, Lombardy - the northern region that includes Milan - accounted for about one-third of all infections. Now, it accounts for one-sixth, even though it has seen cases rebound sharply as well. Lazio, the area around Rome, has the highest number of people hospitalized with covid-19, the disease caused by the coronavirus; Lombardy and Campania are next behind.

Perhaps the most startling aspect is how quickly the virus has surged in the south. Some regions went for days over the summer without detecting a single case. In mid-June, Campania had 125 people known to be infected with the virus. Now, it has more than 13,000.

Over the past six months, southern Italy has tried to prepare for the virus - and make up for years of hospital mismanagement and financial cuts.

In Puglia, the large region that is the heel of Italy's boot, the government has dedicated specific hospitals and buildings to handle incoming coronavirus patients - a means to reduce the risk of contamination. Puglia has three times the number of ventilators that it did in the spring, said Pier Luigi Lopalco, an epidemiologist who has consulted with the region on its response.

But, Lopalco said, even though Puglia has the lab capacity to process 15,000 coronavirus tests a day, it has only enough health workers to administer 5,000 or so daily tests. The region has struggled to recruit doctors and nurses. It recently tried to hire 30 nurses and could find only six.

"So many of these young nurses are now working in those [northern] regions, with a very good contract," said Lopalco, who will soon become Puglian government's health chief. "It is not that simple to convince these people to come back home."

Campania has made its own preparations, including the opening of residence units for people who are discharged from the hospital but are still positive for the virus. Such facilities give the region a better chance at keeping hospital beds open for the most critical patients.

But Giuseppe Galano, the head of a regional anesthesiologists association, noted that Campania's health system had dealt for years with mismanagement and runaway spending - only to then be placed under external administration that froze hiring.

"Campania is still lacking at least 200 to 300 anesthesiologists," a job required for intubations, Galano said. "This is a big handicap."

Walter Ricciardi, a World Health Organization adviser to Italy's health ministry, said the south is "definitely not ready" for an explosion of coronavirus cases.

"They had to invest money in improving staff, systems, and in some cases they didn't do enough," said Ricciardi, who argued that officials in some regions were complacent and underestimated the risk of the virus's resurgence.

"This is very sad," he said. "For some southern regions, if there is a similar epidemic wave, the consequences will be more severe."

For now, hospitals have not yet reached a critical point. The number of patients in intensive care nationwide is one-seventh the total from the peak in March. But Italy's national health institute has warned that about half of Italy's regions - both in the north and south - could see at least 30 percent of their ICU beds occupied by covid-19 patients within the next month.

"I think we will have more and more [hospitalized] cases," said Lopalco, who said it was still possible that restrictions might slow the contagion and keep the situation from spiraling. "The risk we are running is that we will have to close the normal hospital activity. That is the risk we are trying to avoid."

Italy last week mandated mask-wearing even outdoors, and this week curbed the hours on bars and restaurants. Officials say the aim is to avert the need for a second, inevitably bruising, national lockdown. But they say localized or even regional lockdowns may be necessary.

A few small towns, after seeing cases skyrocket, are already sealed off. One, Galati Mamertino, a town in Sicily, had registered zero coronavirus through the first six months of the pandemic.

Then, the first person fell ill and tested positive, said Antonino Baglio, the mayor. The town carried out more swabs and soon realized 122 people - among 2,600 in total - were carrying the virus. The vast majority were asymptomatic, but several nights ago, a 50-year-old who had seemed in good health was rushed to the hospital with trouble breathing. The man's father was hospitalized, as well.

Police and army are now positioned at roads into the town, controlling access. Some 600 people are in isolation after being in contact with known people known to be positive.

"We thought we were free," Baglio said. "Then, all of a sudden, you're thrown into the thick of it and realize the tragedy and its size. You reconsider everything. You realize that it's very important to have a vision, and not to think that we're immune. That what you see on TV is absolutely real. And very, very much a burden."