Covid-19: family doctors are the real defense weapon

Love them ancient, ancient remedies. Sanitary, of course, but also social. And more than apps, it would be necessary to make synapses and neurons work.

Against pandemics the weapons of specialist medicine have sprung up. And, in fact, in the emergency all specialists have returned to being what they are above all: doctors.

Let's not misunderstand: progress is needed, yes. The rapidity, thanks to science and information technology, of mapping the genome of the virus and scanning existing drugs, to find the one that can best slow down the degeneration of the infection and reduce mortality, is very useful.

However, as demonstrated by the cases of Taiwan and, closer to home, Slovakia, the speed of response to the pandemic is the key to success. Together with another ingredient, which the Germans immediately learned from the Lombards (Bratislava also learned from the Italian case): avoid hospitalizing the infected and transforming emergency rooms and sanatoriums into powerful vehicles of contagion.

It would have been also possible in Italy? It will be possible? Why: we must absolutely avoid a new fire by identifying and extinguishing the outbreaks (which will exist) in the bud; this pandemic will not be the last, rather the first in a series.

How to do? Learning from the mistakes and good practices of others and ours. There are many lessons that can be drawn from what has happened and is happening elsewhere. With the same intensive care capacity. For example, that the app doesn't work (Singapore docet): to trace and locate the telephone cells are faster, more precise and timely to process the data.

And yet: the mandatory use of masks, which alone is enough to lower the now famous R0 below 1 and therefore to put out the epidemic. Business for mask manufacturers? Far from it: even homemade ones work well.

Ma back to speed. Everyone knows that prevention is better than cure. And that an early diagnosis can save your life. This also applies to a pandemic in the absence of drugs and vaccines. How can it be done? Again, it is useful to observe and understand what is happening elsewhere: the cases of Taiwan again, which acted even before China closed down Hubei, and Slovakia teach us. Yet, this may not be enough. 

In Italy we have the right weapon: the doctors in the area, the once-conducted doctors. An ancient weapon, in fact, against an ancient evil we are no longer used to, the pandemic, in fact.

In fact, many of the difficulties that modern health systems are exposing depend on having to face this ancient evil: a highly contagious pandemic with high lethality rates. Now, after the disaster has occurred, we often hear it said, rightly, that a pandemic cannot be dealt with in the hospital but it must first be contained in the territory. On this point, almost all western healthcare systems, but not only them, have been put in check, albeit with national and regional differentiations.

If the evil is ancient, the remedies that have worked best are also the ancient ones. Many have gone to meet again the ordinances of the Serenissima Republic of Venice, finding great similarities with the current quarantine and social distancing. Even the Duchy of Milan reacted by isolating itself during the plague of 1300. With forty days one was reasonably sure of covering the entire cycle of the disease, before and after.

Furthermore, the other crucial antidote is to grasp as soon as possible any sign of evil. This appears to have been one of the major shortcomings of modern health and public sanitation systems. Because they are waiting to pick up the signal from the hospital. In this way you are deprived of any outpost. 

Here the doctors come into play, just like sentinels. That is what today are called general practitioners (GPs). It is a known fact that an anomalous onset of persistent pneumonia was already reported in December, but that signal was not taken also because the transmission channel did not exist. Who to send it to? How many dramas, human and economic, we would have avoided if this had happened. Germany immediately alerted doctors in the area and achieved excellent results, also because he observed the Lombard mistakes and did not repeat them.

Why didn't this happen to us? Why the modern healthcare paradigm it is another, a paradigm in which general practitioners appear to be an obsolete element, more useful in stemming the discontent originating from reforms, such as those of Lorenzin (it could have been called in another way: it is the philosophy and the underlying interests that count) , than to stem the Covid-19.

The data processed by REF Ricerche, on the other hand, on the number of patients assisted per doctor, and therefore conversely the availability of GPs in the area, clearly show both the different endowment in the various Italian regions and the dynamics from 1997 to 2017. In the Lombard case, the load per doctor increased by 30%. Or, if you prefer, the availability of GPs has decreased by 30%. 

The impression is that this paradigm continues to guide what is happening today in Phase 1 and will continue in Phase 2. One of the most felt cognitive needs is still now that of knowing how many are really infected, for example, in the tormented Lombardy Region and, therefore, on what level of probable immunity can we hope for (assuming that immunity exists). 

Because no one ever thought of forward a very short questionnaire to GPs on a weekly basis? Just made three trivial questions: 

1. How many of your full-blown Covid patients are there for symptoms? And that they couldn't swab?
2. How many are your paucisymptomatic patients?
3. Are symptoms emerging with anomalous courses? If yes, which ones?

Of course the Lombardy Region preferred an app (and Apple and Google, with a skilful marketing operation, have come together to develop a fantastic one) which has met with very little success, given that only 10% of Lombards have downloaded it and just a third of these have subsequently proceeded to update the information. And how much can it be a significant sample made up only of those who, for demographic and social reasons, have that app?

It is easy to predict what will happen to the national app, born under even less favorable auspices. Concern for privacy will deprive the operation of any effectiveness, as it is not mandatory and no incentive has been introduced to use it.

Leaving aside the dubious value - and also the extreme danger - of one self-assignment of green or red traffic light, having chosen Bluetooth technology, rather than geolocation, prevents one from obtaining one of the most important information and that is where eventually a new outbreak will occur. 

A Korean (South, of course) or Taiwanese system would have immense potential, but this cannot be the case in our case. And this is not so much for a question of privacy or democracy, but for our characteristic distrust of “long” social chains, such as the one that binds us to the central state. The same mathematical calibration models, such as the one developed by Ref Ricerche for Emilia Romagna, register the upward swings of the R0 parameter, but unfortunately with about 10 days of delay.

We must not delude ourselves: with the partial reopening, new outbreaks will rekindle. Unfortunately, the Spanish case already seems to demonstrate this, with new cases on the rise after the restart of many activities on Monday 13 April. Rather we need to be able to spot them immediately. 

This is why it is crucial to bring into play the natural sensor of potential new outbreaks represented by GPs, who could promptly signal them before they lead to a new fire. We don't need an epidemiological detection mechanism based on sample statistics at all, but a capillary detection is needed.

This would also be the first serious intervention in the direction of territorial medicine, which is talked about so much today, with the risk that once the fright is over, very little is done. Until the next epidemic comes.