What experts? Whose advice? The “Delphi oracle” and “Moses tablets” in the management of the covid-19 health emergency in Italy.

The lockdown measures in Italy in 2020 were the strictest in Europe: benches were cordoned off, walking and jogging were prohibited, parks were patrolled by drones. People could go out, one at a time, only to go grocery shopping. As an academic, I could not help reflecting on the ethics of it all.

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Italy declared the national state of emergency due to the covid outbreak on January 31st, 2020, the first country after China facing the SARS-cov-2 pandemic, before the WHO declared it a pandemic on March 11th, 2020, and even before the new coronavirus was given its name by the The International Committee on Taxonomy of Viruses (ICTV) on February 11th, 2020.

After a first attempted phase of contact tracing which involved the army and tried to cordon off the towns most affected of Codogno in Lombardy (North-West Italy) and Po Euganeo in Veneto (North-East Italy) a national lockdown was declared on March 8th, 2020. This was to last until early May and be one of the strictest lockdown in Europe.

The lockdown measures in those ten weeks in the spring of 2020 were surreal for those of us who lived through them: outdoor benches were cordoned off to prevent people from sitting on them, parks and playgrounds were closed to entry and patrolled by drones, police patrolled the streets to enforce the measures. People could leave their households only to go grocery shopping. Walking and jogging were prohibited.

As a professional ethicist, I could not help reflecting on the ethics of it all: the criteria for prioritizing access (triage), the justifications of the public health measures in place, the extent to which it was reasonable and proportionate to limit basic individual freedoms. I recorded all of this here (https://aeon.co/essays/a-bioethicist-on-the-hidden-costs-of-lockdown-in-italy ). Because I am an academic and do research across Italy and the UK, it was inevitable that I became interested in comparing the public health measures in the two countries I know best. Although the politicians in both countries kept saying they were following the advice of the scientific experts, the public health measures in place were different.

 It is in this context that I was very happy to accept the invitation by Roger J. Pielke, EScAPE (Evaluation of Science Advice in a Pandemic Emergency, https://escapecovid19.org/ ) project leader, to lead the Italy case study and investigate what type of expert advice had been mobilised in year 1 of the pandemic in Italy, and how the expert advice fed into policy making. We put together a small team: two Italian academics working in the UK (myself and Professor Federica Angeli, chair of management at the University of York), and an excellent research assistant, Giorgia Dal Fabbro, trained in international law working at the University of Trento in Italy.

After securing ethical approval from King’s College London for the interviews, between September and December 2020 we recruited nine experts who had played a key role in advising the government in the early and most tragic phases of the pandemic in 2020. These were members of the Technical and Scientific Committee (CTS), which had been set up following the declaration of the state of emergency, members of the socio-economic committee (CES), and members of the national bioethics council (CNB).

Our definition of expert was the following: the expert that belongs to an expert committee. Our choice depended on the fact that in Italy, there was a clear top-down approach to the production of expert advice. Clearly the CTS was the committee among the three above mentioned whose advice fed most directly into the government’s policy making at that time. Our findings were striking in this regard. In the first phase of the SARS-cov2 outbreak in the spring of 2020, the government requested the CTS to provide the minutes in word format, and the following day (or later the same day), decrees were issued which contained the same words, with a clear "copy and paste" feature. A decree in Italian law is an official order that has the force of law that can be passed by ministers in case of crisis or an emergency. There were more than 200 the number decrees produced in Italy in 2020. (https://www.openpolis.it/coronavirus-lelenco-completo-degli-atti/ )

Our analysis also fed on the secondary analysis of decrees and documents, which were for the most part analysed by our research assistant GDF. For the interviews, a combination of two out of three researchers was always present (all interviews were conducted via zoom), and the transcripts were manually annotated by the team. The CTS in those early phases of the pandemic was referred to as ‘Delphi oracle’, and the minutes as ‘Moses’ tablets’.  The minutes of the CTS were not initially made public, however their non-disclosure led to a heated debate in the Parliament. A compromise was finally reached as follows: minutes of the CTS meetings were released in the public domain, however only after 40 days. This compromise aimed to quench the public debate. As one of our stakeholders put it: “Democracy and management of the epidemic do not always go easily hand in hand”.

Italy adopted a cautious approach to the management of the coronavirus outbreak. In our comparative Italy/UK analysis (https://www.nature.com/articles/s41599-021-00839-1 ), we identified three main values which underlined the measures in place: liberty, utility, and equality. These values   were not made explicit in the expert discussions, but implicitly dictated the public health policies which were implemented.

For instance, in Italy in the first wave of the outbreak in 2020, jogging was prohibited, while in the UK it was not allowed (even encouraged, as one might recall) although limited to once a day, either alone or with members of the same household. Always in Italy, face coverings were mandatory at all times both indoor and outdoor in the first wave of the outbreak (and this is is still the case at the time of writing, March 28th, 2022), while in the UK they were coverings mandatory only indoor  in the first phase of the outbreak in 2020.

What underpinned the different decisions?  The graph (https://www.nature.com/articles/s41599-021-00839-1/tables/1 ) highlights how values are differentially embedded into containment policies trough context- and time-specific trade-offs. The figure highlights how two countries started from very different positions, with measures in Italy in the first wave almost entirely guided by utility (public health) considerations, with strong restrictions of individual freedoms and little appreciation of differences in vulnerability levels across populations and regions. The United Kingdom started from a much more libertarian stance. In the second phase of the covid-19 outbreak in 2020, the policies in both countries showed an evolution towards liberty and equity considerations against a slight reduction of utility-focused measures.

This was because in the first phase of the outbreak in the spring of 2020, the only value in place in Italy was utility: saving the highest possible number of lives. Only later in the fall of 2020, other values entered the discussion, there was for the first time talk of “trade-offs”, as it became necessary to take into account the consequences of lockdown on economy, mental health, and other social parameters. In the first phase of the outbreak, the CTS was able to always reach consensus, i.e. decisions were always reached unanimously, and the minutes were signed unanimously as well . Although the terms of reference of the committee did not include a specific clause regarding how decisions were to be reached, the CTS was always able to achieve consensus. This played in favour of the perception of the committee by the public opinion as the “Delphi oracle”. Although the members of the CTS tried to resist the portrayal by the media as such, it was difficult to avoid it, as the minutes fed directly into the decrees.

The tension between the consultative role with which the CTS committee was set up, and the political role it came to play, was evident in the words of our stakeholders:

We have become legislators. The problem is we don’t want to be legislators, we only want to be a consultative tool. We are trying hard to keep our function of consultative group however it’s not our own strength but others’ weaknesses which transforms us into something else.

Only in the second phase of the covid outbreak in 2020 disagreements started to emerge. These were due to a number of factors: the perception that trade offs were necessary, the value laden-ness of the decision at play (e.g. schools opening/closure, pools opening/closure), and also the fact that new “players” (new stakeholders) started populating the Italian scene. The Control room is a consultative body of the Italian government, which was set up with decree on April 30th, 2020 with the mandate to provide a weekly updated classification of the level of risk of uncontrolled and unmanageable transmission of SARS-CoV-2 in the Regions/autonomous provinces. Although was it was introduced in late Spring of 2020, the Control room started playing a significant role in November of 2020, at the same time when the governors of the twenty regions of Italy also started playing a more prominent role in the management of the health emergency. After the first nation-wide lockdown, Italy introduced a data driven, region-based system according to which each one of the twenty regions would have colour-coded (white, yellow, orange and red) restrictions in place based on the data produced by the region about the spread of the virus. (https://www.nature.com/articles/s41599-022-01042-6/figures/4 ).

Perhaps one the most interesting findings from our research was the following: politicians in Italy were very happy to resort to expert (scientific) based evidence in the first phase of the outbreak in the spring of 2020, when the level of uncertainty was highest and there were no trade offs to consider. In that first phase, it was lockdown for everybody. The epidemiological considerations and evaluations made by the CTS were regarded as ‘expert knowledge’ in a way that the socio-economical evaluations made by the socio-economic committee and the ethical considerations of the bioethics national committee were not. Many of the members of the CTS did not even know that other committees existed, and were producing expert advice. Socio-economical considerations were considered the “realm” of the parliament. In the words of one of our stakeholders,

 While analysis of the epidemiological progression of the virus relies on specific competencies, analysis of business and socio-cultural recovery involves the entire parliament.

 The gendered dimensions of the committees, whose members worked pro bono, did not escape our analysis. When the CTS was first set up, there were no women in the committee. This was not a “deliberate” choice, according to the members of the committee, but a "natural consequence" of the fact that Italy privileged a top-down approach: the experts that were called to be part of the committee were not called directly for their proven expertise in a particular field, but they were nominated on the basis of representation criteria, i.e., as representatives of the major national authorities and institutions with technical competencies in the management of infectious disease outbreaks (link to Ordinance n. 630, Department of Civil Protection, 2020).   As the composition of the CTS reflected the top management of the main national authorities for health and emergency management in Italy, women were not present in the initial composition of the CTS, as much as they were excluded from any of the senior roles represented in the committee. This was later changed to introduce women in the composition of the CTS; whose nomination was however perceived to be ‘ad hoc’ by the rest of the members. The perceived responsibility of the CTS diminished considerably in the fall/winter of 2020, for the reasons outlined above (new players, trade offs, disagreements). In January 2021, Italy was the first country (and to date, still the only one) going through a political crisis: Prime Minister Giuseppe Conte was forced to resign on January 26th, 2021 after the split in the majority over the recovery package post-covid. A new technocrat was called to step in as Prime Minister: Mario Draghi, former governor of the EU Central Bank.  

Italy has a long history of technocratic governments, starting in 1993 with Carlo Azeglio Ciampi, a former Bank of Italy governor, who was nominated by the at that time President of the Republic Luigi Scalfaro with the task create a government of “social cohesion” and above political parties. In the last 30 years several technocratic governments have been formed to manage the EU Crisis (Mario Monti, 2011), the populist crisis (2018, Mario Monti) and in 2021, the covid-19 crisis (Mario Draghi).

The CTS was set up only in response to the emergency declared on January 31st, 2020. Previously, there had been no scientific and technical committee in place in Italy. As the state of national emergency in Italy is due to come to a close on March 31st, 2022, the future of the CTS is uncertain. According to its terms of reference, the Committee mandate is also coming to an end, as it was set up to remain in place only for the duration of the emergency. However, the utility of the committee to provide expert scientific and technical advice to the government is potentially something that could be channelled towards the creation of another more permanent committee, and some think it would be a good idea not to lose this type of expertise. For now, there are only speculations and it is not clear what will happen to the CTS in just a few days, after it has provided scientific and technical advice to the Italian government for more than two years. This is an open-ended question which we plan to explore in another paper. 

In the meantime, the full paper documenting the mobilization of expert knowledge and advice for the management of the Covid-19 emergency in Italy in 2020 can be accessed open-access here: 

https://www.nature.com/articles/s41599-022-01042-6

 

Dr Silvia Camporesi

Reader in Bioethics & Health Humanities, King's College London

Bioethicist with interdisciplinary training in biotechnology, philosophy of medicine and social sciences. Based in the Department of Global Health & Social Medicine at King's College London, in the United Kingdom.