BERGAMO, ITALY (NYTIMES) - When Franco Orlandi, a usually hale former truck driver, arrived in mid-February with a cough and fever at an emergency room in the northern Italian province of Bergamo, doctors determined that he had a flu and sent him home. Two days later, an ambulance brought the 83-year-old back. He couldn't breathe.
Italy had not recorded a single domestic coronavirus case, but Mr Orlandi's symptoms puzzled Dr Monica Avogadri, the 55-year-old anaesthesiologist who treated him at Pesenti Fenaroli Hospital. She didn't test him for the virus because Italian protocols, adopted from the World Health Organisation, recommended testing only people with a link to China, where the outbreak had originated.
When she asked whether Mr Orlandi had a connection to China, his wife seemed befuddled. They hardly ever ventured beyond their local cafe, Patty's Bar.
What Dr Avogadri did not know was that Covid-19 had already arrived in her region of Lombardy, a discovery made five days later by another doctor in nearby Lodi who broke the national testing protocol.
By then, Dr Avogadri, hamstrung by those same protocols, had herself fallen ill after days caring for Mr Orlandi and other patients. Her hospital, rather than identifying and treating the disease, was accelerating its spread across Italy's economic heartland.
Bergamo became one of the deadliest killing fields for the virus in the Western world.
Officials confirmed that more than 3,300 people died with the virus in Bergamo, though they said the actual toll was probably double that. Mr Orlandi's town, Nembro, became perhaps Italy's hardest struck, with an 850 per cent increase in deaths in March.
The question of how such a tragedy could unfold in Bergamo - a wealthy, well-educated province of just more than one million people, with top-level hospitals - has remained an uneasy mystery, a bloodstain that the government prefers to avoid as it points with pride to Italy's success in flattening the first wave of infections.
The WHO's guidance on testing engendered a misplaced sense of security and helped blind doctors to the spread of the virus. But missteps and inaction after Covid-19 exploded into view aggravated the situation and cost Bergamo - and Italy - precious time when minutes mattered most.
The director of Pesenti Fenaroli Hospital closed its doors almost as soon as he realised he had an outbreak. But regional officials ordered them opened hours later. Hospital workers, visitors and discharged patients were exposed to the virus and then moved through the province.
For days, there was an expectation that the national government would lock down towns in Bergamo as it had earlier done immediately and decisively in Lodi.
Italy's Prime Minister Giuseppe Conte publicly turned to a committee of scientific advisers, which formally proposed that he follow the example of Lodi and shut down the newly infected towns in Bergamo. Privately, though, national business lobbies urged him not to close the area's factories.
Ultimately, after critical days filled with bureaucratic dithering as well as spats between Rome and regional authorities, the government decided the time to save Bergamo had passed.
With the virus out of control in the province and clusters emerging all around it, the government waited longer but then went bigger. Two weeks after Mr Orlandi tested positive, Italy locked down the whole region. Then the country. But Bergamo was lost.
Throughout flu season, some family doctors in the Lombardy region noticed strange pneumonia cases. The region has business ties to China, and Italian infectious disease doctors had kept an eye on the coronavirus outbreak in the city of Wuhan, China. They also trusted Italy's new and narrower protocols, adopted from the WHO at the end of January, which essentially limited testing to people linked to China.
But hardly any of the pneumonia patients had such a link.
Then, on Feb 20, Dr Annalisa Malara, a doctor in the town of Codogno, in Lodi province, decided to break the protocol and test a 38-year-old man with serious pneumonia who was not responding to standard treatments. The man's test came back positive that same evening, and he became Italy's first known locally transmitted case of Covid-19.
Two days later, on the outskirts of Rome, an emergency meeting was held at Italy's Civil Protection Agency, the national disaster relief body. Mr Conte sat, surrounded by his ministers, as Health Minister Roberto Speranza proposed a dramatic lockdown of towns in the Lodi area.
The ministers unanimously agreed, and the government dispatched Italy's police and army to seal the borders on Feb 23 - a decision that it cites to this day as the metric of its boldness and willingness to put Italy's public health over its economy.
The discovery of the virus in Lodi, just 95km from Bergamo, struck Dr Avogadri, sick in bed at home, with the force of a revelation.
She picked up the phone on Feb 21 and called her colleagues at Pesenti Fenaroli, in the town of Alzano Lombardo in Bergamo's industrial Serio River Valley. She urged them to test her patient, Mr Orlandi.
At first, they ridiculed her, noting that he had never been anywhere near China. But other patients on the same floor were deteriorating, and another man with suspicious symptoms soon arrived in the emergency room. Hospital officials decided to swab test him. By midday on Feb 23, the results were taken to Dr Giuseppe Marzulli, the hospital director. The test was positive.
"It was at that moment I understood we were screwed," Dr Marzulli said. "We had looked for who had been in China, and this was the tragic error."
Given the government's swift action in Lodi, Dr Marzulli began to prepare for a lockdown. He cancelled shift changes so that no new personnel would come in, and he closed the emergency room, mindful that the hospital had only about a dozen swabs to perform coronavirus tests.
Hours later, the region and the Bergamo hospital network overseeing Pesenti Fenaroli decided together to reopen the emergency room, over Dr Marzulli's objections.
On Feb 24, Mr Orlandi's test results came back. He was positive, too.
Days of indecision
On Feb 25, Bergamo province reported just 18 cases compared to 125 in Lodi. Lombardy's top health official expressed concern about contagion at Pesenti Fenaroli Hospital but said, "it's early to say if it's another cluster".
In Rome, Mr Conte discouraged expanding testing, reasoning that health officials had to follow international protocols, "otherwise we would end up dramatising" the emergency.
On Feb 26, with 20 reported cases in Bergamo, Rome's scientific committee said it didn't see any flare-ups that required a lockdown.
But on Feb 28, Bergamo's caseload had jumped to 103, against 182 in Lodi. At a Lombardy regional news conference, leading doctors identified Pesenti Fenaroli Hospital as the outbreak's source.
Confindustria Bergamo, the province's industrial association, responded that same day by posting a video titled, "Bergamo Is Running".
"Current health warnings from Italian government officials are that the risk of infection is low," the narrator stated. The images showed factories humming.
Business leaders and even the Alzano Lombardo mayor resisted a lockdown, telling the local newspaper that it would be a tragedy for the economy and contacting their commercial associations with influence in Rome.
In the capital, Mr Conte stressed that he would be guided by science alone. He declined interview requests for this article but has denied ever receiving requests from Confindustria as his government weighed what to do in Bergamo.
"There was a direct line between Confindustria and the government at that time," said Ms Licia Mattioli, who was then the group's vice-president.
On March 3, the government's scientific committee proposed a red zone around Nembro and Alzano Lombardo. Lombardy authorities considered it a done deal.
But Mr Conte, who needed to approve the decision, has said that he didn't hear of the plan for two more days.
In the meantime, Mr Speranza said, he pressed the scientific committee for a report on their rationale for closing the towns.
The Interior Ministry notified Bergamo's military police to begin preparations for a lockdown, according to Colonel Paolo Storoni, then the head of the Carabinieri in the area. Ms Carmen Arzuffi, the owner of Hotel Continental, said the local police prefect called on March 4 to book 50 rooms for 100 incoming officers.
On March 5, the scientific committee again urged the government to lock down the towns. Mr Speranza said he sent Mr Conte the report that night. A member of Parliament from Bergamo privately pressed Mr Conte's office about what was taking so long, arguing that a human catastrophe was unfolding.
Mr Conte's office replied, according to correspondence seen by the Times, that there would be a ministerial-level meeting on March 7, two days later, and that no decision would come before then.
By March 6, law enforcement had begun setting up at the hotel. As they ran drills, Mr Conte met the scientific committee in Rome yet again. According to Mr Speranza, the committee told Mr Conte that closing Bergamo was no longer the issue. All of Lombardy, including Milan, needed to be locked down.
Two days later, on March 8, Mr Conte did just that.
Later that day, police officers at the Hotel Continental packed up and left.
As the authorities decided what to do, the virus seemed to spread everywhere and touch everyone. Mr Orlandi died the day after his family learnt he had contracted the virus.
No one to blame
All the authorities involved now recognise Bergamo's losses as a tragedy. But invariably they lay blame for it elsewhere.
The WHO said that it limited its case definitions for practical reasons - primarily, not to waste resources at the outset of an uncertain contagion. The rationale, said Dr Margaret Harris, a spokesman for the organisation, was "to limit the testing to a specific population at risk". It is a position that past WHO officials considered reasonable.
But Dr Harris also argued that when the agency updated the guidelines at the end of January, it made clear "that the patient's doctor is the one, ultimately, to decide who to test". Doctors in Bergamo considered that a convenient caveat.
The guidance was "the thing that generated the huge problem of the spread of the pandemic", Dr Avogadri said. "It was a big limitation."
The WHO "made a mistake", said Mr Giuseppe Ruocco, Italy's chief medical officer and a senior official in its Health Ministry, adding that if Italy hadn't automatically followed the organisation's lead, it "could have certainly avoided cases and the infection of medical staff".
Local officials and bereaved families in Nembro and Alzano Lombardo argue that closing the towns in February would have slowed the spread. A local prosecutor is investigating what happened and what didn't happen and why.
But the government would prefer to focus on its closing of Lodi and then the region. And Mr Conte has dismissed questions about the boldness of his decision-making.
"There was no delay," he has insisted.