In Calabria, the Locri hospital often sends patients elsewhere for a lack of doctors and equipment.
Its lifts are endlessly in disrepair, and the CT scan works one day, but not the next.
Infiltration by the mafia, severe doctor shortages, and a regional health agency hundreds of millions of euros in debt are just a few of the challenges the hospital confronted in 2019 alone.
And that was before the coronavirus outbreak.
Now, as coronavirus deaths rise in the region, residents of Locri are bracing for what they fear could be an inexorable march south of the Covid-19 disease that has killed over 17,000 people in the country.
The exterior of Locri hospital.
To date, Italy's devastating coronavirus crisis has been centred in its prosperous, industrial north.
In regions such as Lombardy and Piedmont, some hospitals are among the best in Europe, and yet unrelenting waves of patients have brought them to breaking point.
Residents fear that an outbreak in Calabria would mean an unmitiated disaster.
“It's adding a crisis on top of a crisis,” Locri's mayor Giovanni Calabrese told AFP.
The fact that Locri has so far been spared any deaths, he said, was “the only good news we've got”.
Health authorities have warned for weeks that if a similar surge in cases erupts in the south, the consequences could be even more devastating.
“If all these patients start coming in, like what's going on in Lombardy, how would we do it?” asked Emanuela Barbuto, regional leader of the Fsi-Usae union which represents public health workers, among others.
She said residents felt “abandoned”.
“The system can't hold up.”
For now, only eight people have been infected with coronavirus in the vicinity of Locri, a beachfront town whose hospital serves an area of 150,000 inhabitants.
A view of the seaside town of Locri from the hospital car park.
But a recent sharp rise in infections elsewhere in Calabria, the mountainous toe of Italy's boot, has caused authorities to bar access to 14 towns deemed “red zones”.
Calabria's death toll has risen to 60 since the first fatality reported on March 14, with an average of four new deaths each day over the past week.
Three days before the first Calabrian died, the region's president, Jole Santelli, activated an emergency plan calling on provincial authorities to decide which hospitals would be designated “Covid-19” centres.
One choice was Locri.
A subsequent announcement by the provincial health authority that manages Locri's hospital specifying that the facility would dedicate 37 beds to coronavirus patients caused disbelief, and panic.
“There aren't conditions to guarantee even minimum standards,” said Barbuto. “How do we handle this if we don't even have the basic things?”
The problems at Locri's hospital date back years and are well documented. Nevertheless, locals say promised changes never arrive.
Even before the coronavirus crisis gripped Italy, Locri residents in February formed a citizens' group to save their local hospital.
Built in the 1970s, its concrete edifice is crumbling in places, exposing rusting steel bars. Tall weeds line the driveway.
Inside, things aren't any better, with those who spoke to AFP describing a litany of problems.
An MRI scanner bought three years ago has yet to arrive. Radiology is closed nights and weekends. The lifts, fixed for now, have broken down repeatedly in the past – any that still worked had to transport patients, medical supplies, food, and corpses.
Last year, when all five lifts were out, staff were forced to carry patients to cardiology on the fifth floor.
The Provincial Health Agency of Reggio Calabria (ASP), which oversees the hospital, has been run since March 2019 by a special commission after being dissolved for the second time in a decade due to infiltration by the 'Ndrangheta, Italy's most powerful organised crime syndicate based in Calabria.
An investigation by prosecutors found a series of anomalies, including invoices paid twice, some in the millions of euros, contracts given without public tenders, and salaries paid to officials banned from public office.
From 2013 until 2018, the ASP operated without a budget.
The agency had a cumulative debt of over 420 million euros ($455 million) by the end of 2017, credit rating agency CRIF Ratings wrote in report last year.
“Normally in an administration that doesn't have a budget, they shut it down or they arrest someone,” said Bruna Filippone, a Locri resident who started the Defend the Hospital group.
A decade ago, a parliamentary investigation into healthcare in Calabria uncovered a host of problems at Locri.
Investigators cited purchasing conducted “in systematic violation of the anti-mafia regulations,” injunctions related to accrued debt arriving “daily,” unreliable data and weak auditing controls, according to the 2011 report, which urged “radical change”.
The ASP did not respond to repeated requests for an interview.
In November 2018, just four months before the special commission took the reins of the agency, Prime Minister Giuseppe Conte paid a visit to the Locri hospital, vowing swift action to fix its problems and promising to return.
So far, he has not.
A doctor at the hospital, who requested anonymity, told AFP that the regional health agency was “the most crippled agency in Italy”.
Locri's hospital, he said, offers “third-world health care”.
Losses, corruption… and ants.
Italy guarantees free universal health care for its citizens, but where you live often determines the service you'll receive.
While many areas are able to offer a high standard of care, some regional varations are extreme.
Calabria, like its neighbour Campania and other southern regions, falls short.
“In Italy, in our constitution, we have the right to health care,” said mayor Calabrese. “This right has never been respected in Locri.”
Because corporate and income tax contribute to each region's health budget, struggling regions like Calabria, with fewer thriving businesses and more low income and unemployed citizens, have less funding.
Bruna Filippone, a Locri resident who in February started citizen's group 'Defend the Hospital'.
But that alone does not explain the problems with healthcare in the south, experts say, who also blame corruption and organised crime, severe shortages of doctors, nurses and equipment, and weak, if not incompetent, management, with many hospital administrators nominated to their temporary posts by politicians.
Failings occasionally are exposed and investigated, provoking uproar.
Local and national media revealed cases of hundreds of ants crawling over a woman and her breathing tube in a Naples hospital bed, bacteria causing Legionnaire's disease found in another Naples hospital's boilers after a water maintenance contract expired, and a Calabrian doctor filmed cleaning cuttlefish in a hospital sink for his dinner.
But systemic issues have not been fixed.
A 2019 European Commission study found those living in southern Italy had an “almost doubled probability” of a health care need going unmet versus the north, with even higher waiting times and distances travelled to receive care.
Seven regions' health systems, including Calabria's – all in the south or centre-south – are under financial recovery plans.
Since last year, Calabria's has been managed by external administrators.
In an October 2019 review of Calabria's system, Italy's Audit Court wrote that “services offered continue to remain at inadequate levels”.
The system had a deficit of 213 million euros at the end of 2018. Some 23 million euros alone was spent that year on interest and legal fees related to healthcare debt, the court said.
Over 75 percent of the region's total budget is spent on health, but hiring of doctors has been curtailed under the external administrators.
Calabria places last in Italy according to the so-called “LEA grid,” a government study using various indicators to measure regional disparities in healthcare.
'Those who can, go north for treatment'
Inequalities take various forms.
Calabria has the fewest hospital beds per 1000 inhabitants, at 81. That compares to 138 in Emilia Romagna in Italy's north, the highest, according to 2017 data from national statistics agency Istat.
Delays in service are common.
In Calabria only about 35 percent of patients receive surgery within two days for a hip fracture, against nearly 80 percent in Tuscany and the national average of 60 percent, a 2018 joint audit by the national health service and agency for regional health services found.
Hundreds of thousands of Calabrians travel north for healthcare needs each year.
The Locri doctor told AFP the hospital primarily cared for terminal cancer cases, heart attacks, and chronic conditions of the oldest patients who can no longer travel.
“Everything else, from age zero to 60 years old, you don't come to Locri, you take a plane and you go to Milan,” he said.
Locri may be one of the most visible examples of failing health care in Calabria, but it is not alone.
A 40-minute drive away is the grim-looking hospital in Polistena, also in short supply of radiologists, anaesthesiologists, pediatricians, intensive care physicians and key equipment, its mayor has said.
Last week, the special commissioner appointed by Santelli to manage Calabria's coronavirus crisis, including medical equipment purchasing, resigned after saying in a televised interview that medical supplies didn't interest him and he didn't know what a ventilator did.
'We'd all be dead'
Back in Locri, a blue tent with two beds assembled in a rush nearly a month ago sits in the car park outside the emergency room for testing those with coronavirus symptoms.
With luck, it may be the closest Locri's hospital gets to the COVID-19 emergency, after an about-face decision by the region late last month to use the larger metropolitan hospital in nearby Reggio Calabria for all coronavirus cases in the province.
It's just as well, as a new batch of testing kits only arrived this week the mayor said, and questions still remain on how to safely test, and isolate, any potentially infected arrivals.
After raising nearly 20,000 euros in private funds, Defend the Hospital has begun to issue masks, visors, gloves and even bronchoscopes to doctors and nurses at the hospital.
“It's been us – citizens – bringing the hospital disinfecting gel,” said Filippone. “They didn't have anything.”
Those who spoke to AFP said initial hopes that coronavirus solidarity could jolt the hospital towards longterm improvement were dashed after the chaos, lack of preparation and missing leadership in recent weeks.
“I regret to say it,” said the doctor. “It's yet another defeat.”
Many in Locri praise efforts over the years by doctors and other staff to care for patients despite sustained problems.
But coronavirus would be one challenge too many for this beleaguered hospital, said the union leader Barbuto.
“If it happened here we'd all be dead. We all know it.”