EXPLAINED: Why is Italy’s Covid-19 death toll so high?

All available data shows that Italy is currently suffering a particularly high number of Covid-related deaths. But why? And how accurate are the figures? Here's what the experts say.

EXPLAINED: Why is Italy's Covid-19 death toll so high?
Italy has seen more than 50,000 Covid-19 fatalities since the pandemic began. AFP

After data compiled by Johns Hopkins University appeared to show Italy has the third-highest Covid lethality rate in the world, calculated at 3.8 percent, some Italian media reports have suggested this may mean the virus is somehow “worse”, or more lethal, in Italy than elsewhere.

But some Italian health experts questioned the study’s findings, warning that the apparent lethality rate figure “means nothing” because of the way it is calculated.

While Italy is no doubt recording a high number of Covid-related deaths at the moment, does it really have one of the world's highest lethality rates?

Data expert Matteo Villa, a researcher at the Italian Institute for Political Studies in Milan, slammed suggestions by the Italian press that the virus is more lethal in Italy as “terrible”.

“They are using the apparent mortality rate, which as we know means nothing, to argue that in Italy the virus is worse than elsewhere,” he wrote on Twitter.

So what is the “apparent lethality rate”, and what’s the problem with it?

“The index is calculated on the basis of the ratio between deaths and number of positives, and everyone knows that during the so-called first wave, the number of people traced as positive in Italy, the first Western country hit, was dramatically underestimated,” Alberto Zangrillo, Vice Rector of the San Raffaele University Hospital in Milan, said in an interview with Italian news agency Adnkronos.

Italy’s apparent lethality rate (tasso di letalità apparente) in April was estimated at around 12 percent, a figure which researchers said was “almost impossible”. Limited testing at the time was thought to be skewing the figures.

While patients in a serious condition were being tested, it's thought that milder cases often went undetected until testing was later expanded.

Because this “assumed” lethality rate has been viewed as unreliable from the beginning, it has been little-used by researchers in Italy and is not usually mentioned at the health ministry’s press conferences about the coronavirus situation.

Instead of the assumed lethality rate, Italian researchers often look at the “excess” mortality rate to get an idea of what a more plausible number of Covid deaths is likely to be.

READ ALSO: Italy recorded more than 11,000 'excess deaths' in March

A recent report from the Italian Health Ministry showed the total number of all deaths in the country (not only those from Covid) is far higher than the usual figure recorded at this time of year.

The number of “excess” deaths is derived by comparing the number of deaths in Italy in a recent period to the statistical average for that period over the preceding five years.

At the moment, Italy is recording the highest death toll in Europe.

Last week, when a Covid-19 death was recorded in Europe every 17 seconds according to the World Health Organization, Italy had the highest toll on the continent with 753 victims in one day.

The worst-ever daily toll in Italy was 969 deaths, on March 27th.

On Monday Italy joined the United States, Brazil, India, Mexico and the United Kingdom in passing the symbolic 50,000-death mark.

More than 12.000 of those were within the previous 30 days alone.

Why is Italy seeing so many Covid-related deaths?

Health experts say the country’s aged population is one of the main factors.

“In Italy, the percentage of over-70s is 17%, compared to about 10% in the rest of Europe,” Zangrillo said. “And it is known that Sars-CoV-2 affects especially the elderly population in a lethal way.”

According to the latest data from Italy's Higher Health Institute, the average Covid-19 victim is 80 years old. Nearly all have some kind of preexisting condition, and often more than one. Only 1.1 percent of the dead have been under the age of 50.


Villa explained that, in a way, this does mean that in Italy the virus “is worse than elsewhere”.

“We are second in the world for risk of death, just after Japan and just above Greece, Portugal and Germany.”

“But it is because we are old.”

“Obviously the number of Covid-19 deaths is an interaction between the risk of death and the frequency of contagion of the people most at risk,” he added.

“And it also depends on the saturation of the hospital system.”

Instead of comparing Italy’s data with that from the US, UK, or most other European countries, Villa says we should be comparing Italy with “Japan and Germany; countries with almost identical risks.”

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Key points: What you should know if you need to see a doctor in Italy

Sooner or later, every foreign national in Italy will have to make an appointment to see a doctor. Here are the key things to know.

Key points: What you should know if you need to see a doctor in Italy

Making a doctor’s appointment is usually thought of as a fairly uncomplicated task but doing so in Italy can turn out to be very tricky, especially if you’ve just relocated to the country and are not quite familiar with how the Italian healthcare system (Servizio Sanitario Nazionale, or SSN) works.

On top of that, Italian doctors and other healthcare staff are rarely fluent in English and only very few sections of the SSN’s website provide information in languages other than Italian. 

So, should you ever be faced with the dreaded task, here’s what you need to know about making a doctor’s appointment in Italy.  

Who has access to GPs?

Only people that hold a valid Italian health card (tessera sanitaria) or an equivalent, i.e. a European Health Insurance Card (EHIC) or a UK Global Health Insurance Card (GHIC), can access public GPs’ services.

READ ALSO: Who can register for national healthcare in Italy? 

That said, it’s worth noting that the SSN provides emergency care to anyone in need, regardless of their nationality or immigration status and without asking for upfront payment.

A GP making a prescription

Only people that hold a valid Italian health card or a EU equivalent can access public GP’s services. Photo by Thomas SAMSON / AFP

Those experiencing a medical emergency can call 118 for an ambulance or head to the emergency ward (pronto soccorso) of the nearest public hospital.

How to register with a GP

In order to make an appointment (visita) with a general practitioner (medico di base) within the SSN, you must first be registered with the doctor in question. 

However, registering with an Italian GP isn’t nearly as straightforward as it should be. 

Firstly, patients are expected to view the list of doctors operating within the territory of their local health authority (Azienda Sanitaria Locale, ASL). 

Though in some cases these lists can be found online, in others residents will have to directly ask their ASL to be sent a copy.

Then, taking the location and office hours of the listed professionals into account, patients are asked to pick the doctor that’s best suited to their needs and communicate their choice to the ASL.

While in some areas this can be done online, most ASLs ask that patients turn up in person at their Scelta e Revoca (Choosing and Cancelling) offices and provide operators with an ID card, a valid Italian health card or equivalent (EHIC or GHIC) and a certificate of residence

READ ALSO: Who to call and what to say in an emergency in Italy

Registrations are generally processed immediately and the doctor’s contact info and booking details are emailed to the patient right after.

How to book an appointment

Once you’re registered with a GP, you can go ahead and book your first appointment. 

A booking can generally be made via phone, email or, in some cases, online. However, as previously mentioned, healthcare staff, including booking office staff, are rarely fluent in English, so email or online bookings might be the better options if you’re not really proficient in Italian.

Doctor speaking on the phone

Patients can book an appointment with their GP via phone, email or, in some cases, a designated online booking platform. Photo by Nicolas TUCAT / AFP

It’s also worth noting that, though they provide patients with a set appointment time, Italian GP clinics tend to run a little late, so, depending on the circumstances, you might have to wait up to thirty minutes for your turn.

During the first appointment, patients are usually handed a form to fill out with general information about themselves and their overall health. 

Due to the above formalities, the first appointment might last a little bit more than normal appointments, which are usually around 15 to 20 minutes.

All consultations with an Italian GP, including the first appointment, are free of charge.

Referral to specialists

GPs can refer patients to a specialist doctor (specialista) for further diagnostic exams or medical procedures.

However, unlike in other European countries, people choosing to see a specialist through the SSN cannot select the doctor they will be referred to as they will be given the earliest available appointment within the relevant medical field.

READ ALSO: Five essential facts about Italy’s public healthcare system  

The referral comes in the form of a red prescription (ricetta rossa) with letters P, D, B and U indicating the different levels of urgency associated with the consultation – P marks the lowest priority level, whereas D is for consultations that must take place within 72 hours from the time of prescription.

The ricetta rossa allows patients to book their appointments online, in person or over the phone by calling the relevant Regional Central Booking Office (Centro Unico di Prenotazione Regionale, CUP).

Nurse looking at X rays

Patients choosing to see a specialist through the public healthcare system cannot select the doctor they will be referred to. Photo by Alberto PIZZOLI / AFP

Again, foreign nationals with a poor command of Italian may find that online bookings are the best available option given that most operators are not fluent in English.

Private doctors 

As in other European countries, Italian residents can choose to see private GPs or specialists.

Private healthcare is provided at a fee – typically anything from €40 to €160, depending on the type of service required – and, in most cases, fees must be paid upfront. 

Unlike public health authorities, private providers do not require patients to have a tessera sanitaria or a valid equivalent.  

Aside from the above distinctions however, booking an appointment in the private sector is no different than booking one within the SSN, with patients being allowed to book via phone, email or a designated online platform. 

If you’re looking for an English-speaking doctor, the US Embassy in Rome and the Consulates General in Milan, Florence and Naples provide lists of English-speaking professionals available for private consultation. These can be downloaded here.

The UK government provides a similar list

Essential vocabulary and useful sentences

  • SSN (Servizio Sanitario Nazionale) – National health system
  • ASL (Azienda Sanitaria Locale) – Regional health unit
  • Medico di base – General practitioner 
  • Ricetta – Prescription
  • Visita – Appointment 
  • Specialista – Specialist doctor
  • Farmaco – Medicine
  • When booking by email or phone, a useful phrase is: Vorrei fissare una visita alle ore X di X (I would like to schedule an appointment for [day] at [time]).
  • Should you need to cancel the appointment, you could say: Putroppo, devo cancellare la visita.
  • To ask to reschedule it, you could say: Sarebbe possibile spostare la visita?

To describe your sickness, you can check out our terminology guide for the most common ailments.