Voices from the ward: To test or not to test

Part of a larger independent investigation into Italy’s pandemic response, this piece draws out key insights from interviews with healthcare workers. It reports on workers’ experiences on the front lines of the emergency, emphasizing the themes persistent across testimonies, but which are little reflected in official narratives on the pandemic. We learn answers to the question of swabs, to which the medical and healthcare staff are subjected (or not!).

The topic is highly debated at the political level in Italy and in the world: for example, the rankings of the more or less virtuous countries are drawn up through the number of tests. However, this also declined starting from the workers‘ experiences and the consequent implications from a health and psychological point of view. The interviewed staff agree that access to testing would make it possible to live the family context and daily life inside and outside the hospital with less anxiety.

At the same time, testimonies reveal different management practices from one hospital to another. This confirms a lack of precise guidelines in the emergency and, often, leading to decisions that put workers‘ health at great risk to ensure the functioning of hospitals. These interviews were made between late March and early April and were collected in the North-West of Italy, in the provinces of Genoa and Turin. Most of these cover public hospital staff and, in particular, nurses.

S., a nurse in the infectious diseases department in Genoa, and A., a socio-health operator in the Covid department in Turin, clearly summarize the main limits of corona tests: inadequate timing, fear of being contagious while waiting for the result, and the fact that they are not universally available.

“I made the swab on March 12 and I was informed of the result on the 31st, almost twenty days later. The problem is that during these days I didn’t know if I was positive or negative or asymptomatic and in any case I had to go to work which brought me in contact with other people. The swab issue was handled a little badly. Even wrong reports have arrived here informing people they would be positive but then later they turned out to be negative. Waiting times are very long and in any case today if you are not symptomatic you are not given a test. This is absurd for me, especially with regards to healthcare professionals. I know not everyone can be tested – that I know would be illusory, since resources are limited – but I think that at least the health personnel must be guaranteed access to it and a result in a short time. They should not wait 20 days like me, in which I could have infected all my family members including my father who until recently had to continue going to work doing a job defined as essential “.

“In the hospitals, Alberto Cirio (the president of the Piedmont Region – in the North-West of Italy) wanted to do a one-time test, which was a joke, because for example you make a test now and I’m negative, but who tells me that the next day I don’t come to contact and become positive? Or do it one every 10 days or 15 days, otherwise if you do one if I am exposed 24 hours for 60 days in a row, it does not make any sense to do it to people who are always at risk of contagion… in short, testing once is an absolutely useless thing. You should make a swab every 10 days otherwise make one just to show that you do it, well today I am negative but tomorrow I can be positive and maybe asymptomatic and infect everyone.”

The demand is very simple: swabs to all health professionals! However, the reality seems to be very different. The tests which at least in some hospitals were initially guaranteed, are now not conducted except for those who show obvious symptoms. The interviewees seem to suggest that hospitals, not being able to afford losing staff members, prefer to avoid finding out who is truly positive so that not too many shifts become uncovered, thus risking undermining the operation of the structure itself.

 «I think that [the tests] should have been done immediately to all the health workers at least because this was how you isolate people who might be contagious, but unfortunately this was not the reality. […] The issue of swabs was a question handled incorrectly and opaquely. The doubt I have is that they cannot do it until we are symptomatic because otherwise they would have to send home half a hospital and they cannot afford it. This is just my impression, I am not saying that it is certainly like that. But it is absurd that if I worked in a closed department for Covid you don’t test me until I have a fever and a cough “says S.

A. also explains the underlying reason as follows: “I am one of those operators who have not been tested because I work for a private clinic that depends on winning contracts… Why hasn’t it been done? It’s simple: We know, even though haven’t told us explicitly is that if you are asymptomatic and you can go to work it is better that you don’t undergo testing … because if you do it and then you are positive you have to stay 15 days at home and you are not part of the workforce anymore. In fact, there have been cases where colleagues have tested positive but were asymptomatic and have been at home – rightly so – so we did our shifts and those of others. So the reasoning that followed was that if you have symptoms we do it if you are asymptomatic instead we don’t do it. “

Furthermore N., a nurse in the emergency room in Genoa, adds: «I am a person who tries not to be pessimistic even if there is a difficult situation. The issue was handled in two ways: initially those who were symptomatic or otherwise had been in contact with Covid patients without adequate protection had been swabbed, but we talk about a month ago and we talk about huge number of people. All those swabs were negative or “never arrived”: they were lost, there were too many to analyze … so initially nobody tested positive. Now they are doing blood tests instead – This is conducted as part of experimental study designed to protect us. In these tests, some of my colleagues tested positive. There are two criteria that have to be met in order to get tested: either you have been in contact with the virus and you already had it and now you are fine, or the fact that you have it now. These people have been swabbed to see whether the disease was really over. I have always used protections and fortunately I have never had symptoms … the swab was never done to me, here! […] I also agree that they should have swabbed everyone, but I am also convinced that they could not do it because there would be too many positive cases. From the hospital management’s perspective, this would be an impossible situation. And they made a choice of convenience »

The hypothesis is disturbing, but it does not seem unfounded to us; in particular, if we add to these testimonies those of nurses in old age homes/retirement homes for the elderly where, as the data on mortality are demonstrating and as N. claims, highlighting the relationships between the management of these institutions and public health, «they made a slaughter , a proper slaughter. Now most of the people who arrive [to the hospital], most of them, are old people from retirement homes where the virus simply spread from one resident to the next. “

The example of the community of Brandizzo, in the province of Turin, is important: only after pressure from the mayor by the citizens did the swabs arrive in the RSA (Health Care Residences- they are non-hospital structures, but with a health care profile and with both public and private management). A. community educator tells the following story “There is no connection between the reports out there and what is happening in the hospitals. The real numbers are much higher than the numbers told. This in my opinion gives us an idea of ​​a healthcare system that –  whether intentionally or not, but it certainly has responsibilities – hushes up and leaves out many cases. If they are not part of the numbers, do you remember those people of those forgotten cases? Let’s talk about the left out, those are the ones who are angry, they are the ones who protest against an unfair system that does not treat everyone the same. “

As these interviews with doctors and healthcare staff shows, the question of whether or not to test, both for health personnel and for the whole population, implies uncertainty and little reliability compared to the official data concerning the mortality and contagion rate thus compromising the assessments themselves on the progress of the virus and on the perception of improvement in terms of healing.

“It is unknown whether there is actually a decrease in Corona cases due to the fact that a lot of data is distorted by the fact that fewer swabs are conducted than before. If you run fewer swabs, you get a lower number. But since there is no parameter at European or world level for the execution of tests, it changes from region to region, there is no uniform protocol, and then there are cases of falsifying data almost everywhere. Let’s say that in China the mortality rate is “a number total percent”, for example, while in Italy the average mortality is 6% and in Lombardy 10%. These are not comparable because Lombardy is the region in which the largest number of tests are performed. In China they tested a lot, in China they were also performed on asymptomatic people, in Italy they are mostly performed on symptomatic patients. If you make tests available only to symptomatic people, it is normal that the mortality is higher, because you are doing an analysis on samples of the infected population that is already very bad, not on the asymptomatic. A lot of people may have contracted the virus, recovered at home, never had a test and recovered. In Germany there may be other distortions which makes the mortality rate appear lower on paper, but not because the virus is less lethal there. The more tests you do, the more the mortality rate seems to be reduced. Because data collection varies so drastically between each region, it is difficult to compare or even make predictions. “

The situation of uncertainty has heightened the concern for loved ones and the anxiety of being a possible vector of infection not only in the workplace, but also at home within families, a fear shared by all the interviewees. « That is the thought that accompanies us all and will accompany us until the end of this pandemic. […] It creates a lot of anxiety ». (N., nurse in first aid department). Most institutions where interviews were conducted did not propose solutions that could address the concerns of operators and medical workers. In very few facilities, for example, there is a free psychological support service for employees. Furthermore, there are almost no proposals to provide alternative housing for those members of the intensive care unit who fear to infect their family: «I repeat, it is a stressful situation. I already feel it with my parents, but I imagine all those colleagues who maybe have small children, grandparents at home … […] For this reason I say that 100 euros are fine (a government proposal is to increase the salary of health workers by 100 euros during the pandemic period. The average salary of a public health nurse in Italy is € 1,450), but there would be better ways how to address the issue. Surely, money will undoubtedly be useful for many people, but in my opinion more psychological support would also not be bad “(S., nurse in the virology department).
This appears to put the burden of responsibility to fight the virus on the shoulders of individuals rather than providing institutional support.

“Of course there are some common sense practices that one can follow as individual. I don’t leave the house, I don’t go shopping or if I go I put on a mask, but I or all those who have not been tested, certainly we are a time bomb! So we avoid meeting people, even among colleagues we talk with a distance of one meter – these are measures that a health worker can follow. But imagine those who live with elderly people, colleagues who live with parents, people at risk, potential subjects. “

It is fundamental, therefore, to emphasize the hazardous conditions in these workplaces, urging that swabs should be made available to all health personnel and that the results should be provided in a short time and communicated in a transparent way, keeping in mind the burden of the job and people’s legitimate daily worries. To conclude with the words of P., a medical radiology technician:

«As far as the definition of” heroes “is concerned, I don’t have much to say. I don’t agree, we only do our duty and we always have. In the hospital we do not only have Covid-19 patients, we also have HIV patients, syphilis patients, TB patients and so on … This emergency has put the spotlight on many problems in public health, especially how much money should be invested in public facilities, rather than in private. Due to the lack of funds and the cuts made over the years, we find departments with staff already halved normally. Now, the staff who did not get sick find themselves working in conditions of extreme stress, with a workload two, three times higher, due to the lack of the already few colleagues, who remained at home in quarantine. In many hospitals, like ours, they have found a solution which is not doing the swab, but only the blood tests. Depending on the outcome, a swab is made, but, if the employee is asymptomatic, he must continue to work, knowing that he is positive with the corona-virus. This is because the staff is missing and this lack has been known for years. We may have been wrong not to actively protest, but in this situation there is a chance. We only ask, for one thing – not to forget this emergency very soon. We are not heroes, we are citizens, like everyone else”.

These interviews have been conducted and commented on for the pandemic academic by the infoaut collective. The Italian version can be found here.

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