For health I see it hard

by Ivan Cavicchi

The dramatic issue for me remains entirely political: after the pandemic, we would need cultural changes, profound rethinking, reforms, a new vision of health but, in the submarine we are in, (recovery plan), with a captain therefore a government left that opposes health care reform because it does not know how to reform it, that is, that it shoots and fires missiles at us, not only for prevention, but for all health care, I see it really hard

07 JUNEPremise
I would like to publicly appreciate the contribution that Filippo Palumbo, regarding the recovery plan and therefore of PNRR, is assuring us all, with his punctual and competent analyzes.

I, too, like him, believe that the PNRR should be an opportunity not to be missed and, like him, I am worried because if I consider everything, starting from the inconsistent political and cultural depth of those who manage the hut, how we are proceeding, and the lack of level of technical and cultural quality of the texts developed, without forgetting the pressure of private interests in the field, I feel like crying.

When I think of the recovery plan on health, I don’t know why a war film comes to mind in which an inexperienced captain of a submarine fires a missile at the enemy that comes back at him, blowing up his entire crew. At the moment of impact I remember the informal sentence of his second: “you screwed us all, asshole”.

The three critical points of Palumbo
In his latest article Palumbo (QS 4 June 2021) on PNRR addresses three critical issues: prevention, territorial assistance, and finally the public-private relationship. I agree with all his concerns even if on the question of the public-private relationship, I do not believe that the basic problem is, as he says, accreditation, that is, it is “technical” but first of all “political”. Of course, if we privatize parts of the public health system then, to avoid laissez faire, we will need to credit, but the question is why privatize, especially after a pandemic, things that should be public for so many reasons?

Evidently Speranza does not believe, like me, that after the pandemic:
– health should be more public and not less,
– the first subjects that the State should take care of, should be precisely the fragile subjects
– health should reform to be more public
– if health care becomes less public after a pandemic then it means that it has been counter-reformed

The question of prevention

On several occasions, precisely in this newspaper, I too, like Palumbo, have pointed out that in the recovery plan, the issue of prevention is treated neither more nor less as a petition of principle. That is, as a fallacy because its strategic value is only supposed theoretically but not funded at all and least of all elaborated and organized. That is “crap”. Just like community houses.

I confess that I had not reflected on the risk, highlighted by Palumbo, who, in this regard, mentions Forastiere, Saracci and Vineis, which is run as a country, when, precisely on prevention, after a pandemic, Europe is offered “crap” in place of a serious proposal. Also because it should not be forgotten that our legislation and our services on prevention have always been ahead of everyone since the reform of 78. With the recovery plan we have been given the opportunity to become cultural leaders on this matter but with the shit you do not become a damn thing.

Unlike Palumbo, however, I believe that, before “rearranging” the prevention sector, before “strengthening” it structurally, before talking about the “institutional and organizational structure”, it is necessary to clarify culturally and politically what we are talking about. That is to define the strategy.
Even for prevention, referring to the rules that exist in my opinion is not enough. It takes reforming thinking. I find the distinction that Palumbo introduces between “reform” and “regulation” to be correct, fearing a sort of DM 70 for prevention, but I fear that those who wrote mission 6 are unfortunately not even able to grasp this important difference.

I, who academically deal with epistemology and logic in medicine and health, therefore with science and methodology, organization and practice, assure you that the conceptual apparatus, with which, up to now, we have defined prevention and from which the services we have derive, compared to the complexity imposed by the pandemic, the most epistemically outdated that one can think of.
Our glorious prevention really deals with complexity, the real one, since it was organized into services before (78) and departments after (99), never did.

From an epistemic point of view, it is a purely casualistic linear reasoning that without a determinism, assumed a priori, in the face of complexity goes into crisis, that is, it remains largely powerless. The pandemic has actually imposed complexity as the big game to play.

I must tell you that I was forced to learn the lesson of complexity, several years ago, when the CGIL, in which I was the national head of health (therefore including prevention) decided to organize the “environment and health department” of which I was entrusted with the responsibility. For me it was a fundamental experience and that today, precisely with the pandemic, it is good again (The new forecast, technology environment health 1990 Editori Riuniti).
At that time, that is, about thirty years ago, the contradiction between health and environment was to guarantee health in the factory and allow the factory to damage the health of citizens, today the pandemic presents the same contradiction (economy, environment, health) even if it is dramatically amplified. Today, in fact, even in view of future epidemics, the treatment of the pandemic is far less strategic than any prevention strategy.

We therefore have a nice saying One-Health, the latest slogan that everyone cites to look cool, a variant of that other “Health in All Policy” launched by the European Union in 2006 but remained only a slogan. Unfortunately, especially for those who make it as simple as the recovery plan, but not only, the epistemic and organizational translation of these slogans implies:
– a cultural and scientific redefinition in the name of the complexity of the relationship between environment, economy and health
– a rethinking of operational models, approaches and methods of intervention, tools but above all the necessary professionalism, therefore the various scientific knowledge required
– a rethinking of strategies

I would like to remind you that in 99, with the ter reform, an attempt was made in the name of coordination to overcome the dichotomy between environment and health, calling the prevention services “departments”, that is, doing the same nominalist operation that is done today for health houses . Unfortunately, these dichotomies cannot be overcome without first undertaking real cultural, epistemic, institutional, methodological and professional reforms. And in fact things have not changed.

Today I wonder if it makes sense, after a pandemic, to say one health and to have three distinct ministries, economy, environment and health? Or keep the economy separate from health? Or talk about the ministry of health when in reality, as the pandemic has shown, ours is a ministry of health tourt court.

In this newspaper last year, in making a list of the things that in my opinion we should have reformed after the pandemic (QS 17 September 2020) in the first place I put:
– the redefinition of the idea of ​​”protection”, that is the idea of ​​defense and protection, as a premise for redefining the old concept of prevention and therefore its institutional and organizational cultural declinations,
– the introduction of the “duty of health” alongside the right to health to say that in the pandemic complexity without an active role of the community it is useless to talk about prevention and one health. Duty to health in the Kantian sense therefore as a moral obligation, that is to say as an obligation of the State to educate consciences about health, not a legal obligation.

The dramatic issue for me remains entirely political: after the pandemic, we would need cultural changes, profound rethinking, reforms, a new vision of health but, in the submarine we are in, (recovery plan), with a captain therefore a government left that opposes health care reform because it does not know how to reform it, that is, that it shoots and fires missiles at us, not only for prevention, but for all health care, I see it really hard.

Ivan Cavicchi

07 June 2021
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