The body of his son was barely cold when the grieving father was threatened by men from the funeral company. Inside the mortuary of an austere hospital in Lamezia Terme, a city in southern Italy, the dead were not left in peace. Each corpse was now a highly prized commodity, worth thousands of euros to Europe’s most ruthless organised criminals.

The men from the funeral company somehow knew which patients had passed away even before their own families did. Through intimidation they had gained access to the hospital’s central medical records, allowing them to screen for those sickest and most likely to die. If relatives considered picking a different funeral company to take away their loved one, the men would soon ensure they changed their minds. 

“They are almost beating each other up to compete over sick patients,” one terrified medical worker told a colleague in a conversation secretly recorded by Italian anti-Mafia investigators.

Medical staff were powerless to intervene. “They are acting with an unspeakable ­shamelessness,” the employee said. “When the relatives arrived, they found the undertakers were already there.” 

This public hospital in the region of Calabria had been infiltrated by the ’Ndrangheta, a Mafia that remains little-known outside Italy but which has grown into one of the most dangerous, internationally active and financially sophisticated criminal enterprises in the western world.

© Sergiy Maidukov

Over the past two decades, the leading families of the ’Ndrangheta — pronounced “en-dran-ghet-ah” — have expanded operations far outside their small home region. Today they control a large part of cocaine importation into Europe, as well as arms smuggling, extortion and cross-border money laundering. Several hundred autonomous clans have been transformed into one of Italy’s most successful businesses, with some studies estimating their combined annual turnover to be as high as €44bn — believed by law-enforcement agencies to be more than all the Mexican drug ­cartels combined. 

Yet even among such lucrative criminal activities, the riches on offer from plundering Italy’s public health system stood out as a golden opportunity. By corrupting local officials, organised criminals have been able to make vast profits from contracts given to their own front companies, establishing monopolies on services ranging from delivering patients in faulty ambulances to transporting blood to taking away the dead. 

All these services were billed to the Italian taxpayer through the country’s centrally funded yet regionally administered health service, which distributes an annual budget of billions of euros — an unrivalled prize for criminal gangs. So tight was the clans’ grip that doctors in Lamezia Terme reported having to wait outside a hospital ward for men from the ’Ndrangheta to open the locked door with their keys. 

An investigation by the Financial Times has established how the trail of money from these crimes washed into the financial centres of London and Milan. Over the past five years, profits gained from the misery of patients in Calabrian hospitals were packaged up into debt instruments using the kind of financial engineering typically favoured by hedge funds and investment banks. Hundreds of millions of euros of these bonds, many containing dubious invoices signed off by parts of the health system later found to have been infiltrated by organised crime, were sold to international investors ranging from Italian private banks to a pension fund in South Korea. 

The previously unreported use of capital ­markets by Mafia clans profiting from Calabria’s health crisis shows how far a criminal subculture once derided as mountain-dwelling goat farmers has metastasised into a globalised crime syndicate that is as comfortable operating in the world of high finance as it is extorting local businesses. 


How the ’Ndrangheta emerged as one of the world’s most successful criminal enterprises can only be understood by realising how well-suited its agile and entrepreneurial organisational structure, based on blood ties, is to maintaining a stranglehold on Calabrian public life.

Calabria is not only the poorest region in Italy, but one of the most deprived in the EU. With a population of two million, its gross domestic product per head is €17,200, almost half the European average. A US diplomatic cable in 2008 noted: “If it were not part of Italy, Calabria would be a failed state.” The ’Ndrangheta, it said, “controls vast portions of its territory and economy, and accounts for at least three per cent of Italy’s GDP (probably much more) through drug trafficking, extortion and usury”.

A decade — and three Italian recessions — later the local economy has got worse, with the region consistently ranking in last place nationally in almost every category. Unemployment has increased from 12.9 per cent in 2010 to more than 20 per cent today.

€44bn The estimated annual turnover of the ‘Ndrangheta — believed by law-enforcement agencies to be more than all the Mexican drug cartels combined

For decades, almost no one in Italy paid any attention to the ’Ndrangheta, whose name originates from the Greek word for “courage”. By the mid-1990s, however, a huge opportunity opened up before them. The Sicilian Cosa Nostra had been devastated by a sustained anti-Mafia campaign by the Italian state. The Calabrians seized on the chance to take over their relationships with Latin-American drug cartels. 

Unlike the Cosa Nostra, the families that make up the ’Ndrangheta are not organised into a ­centralised, top-down structure, but instead operate their own autonomous units, or ’Ndrine, each rooted in the territory it controls. And, unlike the Sicilian Mafia or the Camorra of Naples, membership of the different ’Ndrine is almost entirely organised around blood relationships or by intermarriage between clans. This has made them more resistant than other organised criminal groups to state penetration of their operations. 

Patriarchs control which clan members are inducted into the organisation’s higher levels, with sons frequently taking over should their fathers be imprisoned or killed. In March this year, Rocco Molè, a 25-year-old scion of one of Calabria’s most established crime families, the Molè ’Ndrina of the port of Gioia Tauro, was arrested and charged with importing a shipment of 500kg of cocaine hidden in plastic containers.

© Sergiy Maidukov

As different ’Ndrine have become hugely wealthy, however, parts of their younger generations have started to look very different from the rural bandits of their grandfathers’ era. With more money and increasingly complex operations, a new class of mobster has emerged that can apply business-school analysis to the challenges of ­running an international criminal conspiracy.

“A number of the younger generation, those who I grew up at the same time as, have degrees from the London School of Economics or even Harvard. Some have MBAs,” says Anna Sergi, a Calabrian-born criminologist at the University of Essex. “They live outside Calabria and appear like respectable businessmen, not directly involved in street-level illegality but there to offer technical expertise when it is needed.”

This increasing financial sophistication is coupled with a brutal approach to internal discipline. Those who are judged to have discredited the name of their family are at risk of being murdered by their own relatives. In 2011, the daughter of one criminal family died in agony after drinking hydrochloric acid. Her father, mother and brother were jailed for abuse after prosecutors failed to prove the more serious charge of forcing her to drink it as punishment for speaking to the police.

While there have been violent conflicts between rival ’Ndrangheta clans, rational co-operation is accepted as good for business. Far less is known about the internal workings of the ’Ndrangheta than other Mafias, but investigators have uncovered evidence of a centralised conflict-­resolution committee made up of the most senior representatives of the largest ’Ndrine

Anti-Mafia investigators say it is common for multiple families to pool their resources into criminal joint ventures, especially those focused on cross-border shipments of cocaine worth hundreds of millions of euros.

It is through ruthless control over the economic activity inside their home territory that these families have created a base from which to rapidly expand their criminal activity abroad, reinvesting profits from extortion into highly lucrative drug trafficking and other criminal ventures. Anyone in their region who openly opposes the clans risks not only their own life, but also being blacklisted publicly. In some cases, the shadow of the ’Ndrangheta stalks them both at home and wherever they go to escape.

Gaetano Saffioti, 59, runs a cement company in the town of Palmi, 100km from Catanzaro, the region’s capital. Eighteen years ago, he became one of a tiny handful of Calabrian businessmen to ­publicly testify against an ’Ndrangheta clan that had extorted money from him. Saffioti lives under police protection to this day.

Eighteen years ago, cement company manager Gaetano Saffioti testified publicly that a ‘Ndrangheta clan had extorted money from him. He remains under police protection
Eighteen years ago, cement company manager Gaetano Saffioti testified publicly that a ‘Ndrangheta clan had extorted money from him. He remains under police protection © Niccolo Caranti

In the years that followed, his business didn’t win a single contract inside Calabria. When he tried in other parts of Italy, his company’s trucks were set on fire. When he won a contract in France, his trucks were torched again. “They demand their part of anything you do — it is a tax that everyone has to pay. You can’t sell an apartment without paying them, you can’t open a business without their permission,” he says, speaking by telephone from his heavily fortified home.

“It crushes the region,” he adds. “We are always getting poorer, but this is what they want. The weaker we are, the less likely we are to resist. The ’Ndrangheta has got inside of us, inside our minds. The majority simply adapt to the system.”


Nicola Gratteri, 61, was born in Calabria and has lived there almost his entire life, but the public prosecutor barely knows what the area around him looks like today. As a consequence of fighting the ’Ndrangheta, Gratteri has been under permanent police protection since 1989 and is unable to leave his office in Catanzaro without a bodyguard. Most days, he eats alone and works late into the evening.

“I don’t know the city where I live. I can’t have normal relationships with people. I can’t go to the cinema. I can’t go for a walk or go to the beach six kilometres from my house. I leave in the morning, I eat in the office in the same room and go home,” he says to the FT by phone.

As a child, Gratteri went to school with a boy whose father was murdered by the ’Ndrangheta. Another girl in his class was the daughter of a famous crime boss. One of his childhood friends later joined a clan. Decades after they played together as youths, Gratteri ended up prosecuting him in court.

Gratteri’s dedication has made him increasingly well known across Italy. Yet he lives out each day in the knowledge that death is stalking him. Police have foiled multiple attempts on his life. In 2005, they discovered a cache of weapons, including Kalashnikovs, rocket launchers and plastic explosives, which they believed were intended to murder him and his bodyguards.

Public prosecutor Nicola Gratteri’s fight against the ’Ndrangheta has led to multiple attempts on his life: he has been under permanent police protection since 1989
Public prosecutor Nicola Gratteri’s fight against the ’Ndrangheta has led to multiple attempts on his life: he has been under permanent police protection since 1989 © Getty Images

As he continues to prosecute cases against Calabria’s leading criminal families, the number of people who want him dead has grown. “They gave me new cars that should withstand explosives, they gave me more security in my house, and on the route I take to the office,” he says. “I’m very careful. I try to avoid dangerous situations, but recently it has become even more difficult.”

There are few areas of Calabrian public life where “the system” Gratteri is fighting against is more evidently at work than the region’s management of public health, where vast budgets create a perfect arena for corrupt local politics, business interests and organised crime to converge.

“In Calabria, the history of healthcare mirrors the failure of the state,” says Sergi. “Every time there has been a new political faction coming in, someone is arrested — and it is always to do with the health system. Healthcare has been a red flag in Calabria for generations.”

As these criminal families’ profits from extortion, drug smuggling and defrauding the state have grown, so has the need to find increasingly complex ways of laundering it. London is one prime destination for ’Ndrangheta cash, according to Claudio Petrozziello, Italy’s financial police representative in the UK, who spends his days investigating how dirty money from organised crime washes up in Europe’s financial capital. 

Petrozziello’s job has become harder as the lines between Mafia thugs and tie-wearing financiers with business degrees have increasingly blurred. “Many people still think of the Mafia as drug dealers and extortionists, but there are many who are involved in moving money out of Calabria who would appear as sophisticated businessmen. They would blend in at an investment bank or a multinational corporation,” he says. 


The story of how money looted from Calabria’s hospitals ended up being routed into the global financial system illustrates the sophisticated ways in which the ’Ndrangheta launders the proceeds of its crimes. Through interviews and the analysis of financial documents and Italian legal filings, the Financial Times has found how the clans made use of a vast financial conveyor belt. The ­proceeds of the horrors of the corrupted hospitals were ­unwittingly bundled up by intermediaries and mixed with other assets into debt products. These then flowed through the City of London, Luxembourg and Milan, eventually ending up in the investment portfolios of the clients of private banks and hedge funds. 

From 2015 to 2018, hundreds of millions of euros of invoices signed off by officials in Calabria’s cash-strapped municipal health authorities were purchased by intermediaries. These middlemen bought the unpaid invoices from suppliers at a steep discount because they were, in effect, guaranteed by the Italian state. They were then sold on to specialist financial companies, who merged them into pools of assets and sold investor bonds backed by the unpaid bills.

While many legitimate companies in Italy have used this process to offload debts owed to them by regional health authorities, the complex chain of intermediaries leaves it vulnerable to exploitation by organised criminals. Indeed, some of these same authorities were subsequently placed under emergency administration by the Italian state for full-scale Mafia infiltration. Several years after the invoices were sold, a number of the companies that had issued them were raided by anti-Mafia investigators for being fronts for ’Ndrangheta clans.

Front companies for organised crime working in the Italian healthcare sector managed to offload invoices owed to them by regional health authorities to unwitting intermediaries, who then sold them on again to legitimate financial companies. They then packaged them into specialised debt products marketed to investors hungry for exotic higher-yielding bonds at a time of record-low interest rates. Other investors in debt instruments connected to the Calabrian health system included hedge funds and ­various family offices, according to people involved in the deals.

None of these bonds was rated or assessed by major credit rating agencies or traded on financial markets. Instead, some were privately placed by boutique investment banks, several of which have offices in Mayfair or the City of London. 

One example of how money tainted by ’Ndrangheta activity ended up in the legitimate international financial sector is a so-called ­special purpose vehicle called Chiron. In May 2017, ­this was one of numerous such entities established by companies specialising in healthcare financing in Italy. 

The Chiron vehicle bought up close to €50m of unpaid healthcare invoices, including bills originating from Calabria and other parts of southern Italy. The ultimate buyer of the resulting bonds was the Luxembourg arm of the private bank of Generali, one of the largest insurance companies in the world, which was seeking to offer its clients higher-interest alternative investment products. The company that constructed the Chiron vehicle was CFE, a boutique investment bank with offices in London, Geneva, Luxembourg and Monaco. The Italian branch of EY, the global professional services firm, acted as a consultant on the deal.

© Sergiy Maidukov

One of the companies that contributed to ­Chiron’s invoices was Croce Rosa Putrino SRL, an ambulance and funeral company servicing the hospital in Lamezia Terme. In late 2018, police arrested 28 people, after an investigation by the public prosecution office of Catanzaro alleged that various front companies for local ’Ndrangheta families, including Croce Rosa Putrino, had seized control of the hospital’s funeral, ambulance and other health services. The case is still being prosecuted.

Banca Generali and CFE told the Financial Times that neither company had ever knowingly purchased any assets linked to the Calabrian healthcare system that had been connected to organised criminal activity. CFE said that it conducted significant due diligence on all the healthcare assets that it handled as a financial intermediary, and that it also relied on the checks of other regulated professionals who handled the invoices after their creation in Calabria. All the assets were deemed to be legal when acquired. CFE said that any invoices connected to organised crime it inadvertently handled made up a tiny amount of its business. Both companies said that any legal issues that emerged after the invoices had been acquired were immediately reported to the Italian authorities. 

How it works

Flow chart on online Mafia

Regular health service companies working for Italian hospitals are owed money by hospitals. Instead of waiting to be paid, they sell on the invoices at a discount. This helps them get cash upfront, but they lose a bit on what they are owed due to the discount.

The buyers of these invoices package them up into a big pool of invoices inside a special purpose vehicle, SPV, and then sell bonds to investors backed by the invoices.

The investors get paid interest on the bonds as the invoices are gradually paid off by the Italian health authorities. Intermediaries work to ensure the bills are paid, and the money flows from the health authority to the investor.

Another privately sold bond analysed by the FT included invoices issued by a Calabrian religious charity caring for African refugees. This was later raided in an anti-Mafia operation for diverting EU funds into the hands of a powerful ’Ndrangheta clan. Gratteri, who led the investigation, described the food being provided to the refugees as “food that is usually given to pigs”. Twenty-two people were convicted.

Last year, Italy’s central government took drastic action. Rome dissolved the regional health authorities of Catanzaro and Reggio Calabria for Mafia infiltration, having discovered widespread fraud and double billing of invoices, as well as officials working inside them who had been banned from public office. They remain under special administration. But about €1bn of these private Italian healthcare bonds had been bought and sold between 2015 and 2019, according to market participants, with significant numbers of invoices originating from the two health authorities under emergency administration. The full scale of how much dirty money entered into the global financial system in this way is impossible to quantify.

Health commissioner Massimo Scura uncovered fraudulent invoicing and double payments when he was sent to Calabria by the Italian government in 2015. He blames ‘a culture of corruption’
Health commissioner Massimo Scura uncovered fraudulent invoicing and double payments when he was sent to Calabria by the Italian government in 2015. He blames ‘a culture of corruption’ © YouTube

“Large banks have stayed away from these sorts of healthcare-related deals in Italy,” says one financial professional who has worked on similar transactions. “It is a difficult sector, and particularly in certain regions there are risks that anyone getting involved is going to have to face.”

Massimo Scura, a Rome-appointed health commissioner for the region between 2015 and 2018, says that during his time there he tried to clamp down on rampant fraud, uncovering multiple cases of fraudulent invoicing and double payments for invoices that were sold on to investors. He is not accused of any wrongdoing. “I pointed out some debts that should not have been claimed, in addition to the payment of some double invoices,” he says.

He blames a culture of corruption for the fraud. “The start of the problem is of an ethical nature in Calabria, it is cultural, because as long as within the companies there are individuals who are clearly conniving, it is extremely hard to ­provide our people with good healthcare.”


The human cost of years of looting Calabria’s health system has been devastating. Italy has one of the highest life expectancies in the world, but the region’s health statistics are among the worst in Europe. The average number of years that Calabrians enjoy good health stands at 52.9, according to Italy’s statistical office, lower than both Romania and Bulgaria. A resident in the wealthy northern Italian region of Bolzano, by comparison, enjoys on ­average 70 years of good health. Calabria also has the highest rate of infant mortality in Italy, while tens of thousands of “health refugees” leave the region each year to get treatment in better hospitals in the north.

Local doctors describe some of Calabria’s ­hospitals, which are suffocating under mountains of debt built up through corruption, mismanagement and embezzlement, as on a par with the developing world.

52.9 The average number of years that Calabrians enjoy good health before they are judged to develop a serious medical condition, compared to 70 years in the affluent Bolzano region

In the corrupt hospital in Lamezia Terme, anti-Mafia investigators found evidence of widespread malpractice. Some employees were recorded joking as they discussed putting a newborn baby into a faulty incubator. “This time prepare ­yourself, in case they arrest us,” one said as he laughed. “That incubator with the melted wires is disgusting. God bless us all tonight. I’ll be at home praying [for the infant] with rosary beads.” His colleague laughs again: “I hope it works.” 

In another recording, an employee tells how a patient in a critical condition was dropped from a stretcher in an ambulance: “Let’s hope he doesn’t die because if he does, there will be trouble.”

The impact of organised crime’s infiltration of the health system has left many of the region’s ­hospitals deeply vulnerable to coronavirus. “Calabria does not have the capacity to deal with [it]. There are not enough intensive care beds to take in patients in a serious condition,” says Scura. (The region’s decision to impose a strict lockdown seems to be working: Calabria has so far suffered fewer than 100 deaths from Covid-19, ­compared with almost 17,000 in Lombardy.)

The vast levels of debt built up by hospitals over the years have left the emergency administrators sent by Rome with few options. Many fear that organised criminal activity in the health service has become an entrenched feature of Calabrian life. “Calabrian healthcare has been in a permanent state of emergency for decades,” says Sergi. “Every two or three years, there are anti-Mafia operations linked to healthcare, and maybe Rome parachutes people in, but soon after another clan comes in and starts it all over again.”


For Gratteri, the public prosecutor, there is no choice but to keep on fighting against this Hydra-like enemy — and there are signs the battle is shifting in his favour. Late last year he struck his biggest blow yet against the clans, after an investigation he led resulted in the arrest of more than 300 people in the largest-ever single case brought against the ’Ndrangheta. 

The Maxi trial against the Sicilian Mafia, which started in 1986 in Palermo. The largest trial in Italy since this begins later this month following a recent Gratteri investigation
The Maxi trial against the Sicilian Mafia, which started in 1986 in Palermo. The largest trial in Italy since this begins later this month following a recent Gratteri investigation © Alamy

The charges include murder, money laundering, extortion and drug trafficking. The trial, due to begin with preliminary hearings later this month, will be the largest in Italy since the ­so-called maxi trial of the Sicilian Mafia in 1986. So many have been charged that the case will be held in the former offices of a call centre outside Catanzaro. “We must go forward, whatever it costs,” Gratteri says. “In recent years, there has been the ­beginning of a new hope for change. We can’t betray the hope of thousands of people for who we are the last resort.”

For others, small, individual acts of resistance are the only way they can try to break the psychological power the clans hold over the region and their lives. Six years ago, the local authorities needed to demolish an illegally built villa that had been seized from a feared crime family. No local company would take on the contract.

Saffioti, whose cement business had been nearly destroyed after he testified against the clans, was the one man who said he would do the job. “When they asked me to help, I said, ‘I will go and do it myself.’ I demolished the house that no one else dared to do. It wasn’t to perform a heroic act, it was to show that a civil society is possible here, that there can be justice,” he says. 

Saffioti remains under police protection but says he feels more free than he ever could by staying silent. “When we die, we want to believe that we did the right things, if we lived as slaves or we lived freely. I picked the second choice. For the good of all of our children, it was the least I could do.”

Miles Johnson is the FT’s Rome correspondent

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