A-Infos (en) Italy, Umanita Nova #24-25 - The Portrait of Health. For a New Community-Based Medicine (ca, de, it, pt, tr)[machine translation]

THE CRISIS OF GENERAL MEDICINE ---- The crisis of general medicine began 
as early as the 1950s and 1960s, during the era of the "mutue" (mutual 
health funds), and has continued up to the present day, even after the 
creation of the National Health Service in 1978. It is a crisis of the 
role and professionalism of the general practitioner: from the figure of 
the old country doctor -an expert in all branches of medicine and deeply 
familiar with the local area- to the "mutua" doctor, later the family 
doctor, finally the GP, whose competence has been reduced to treating 
the simplest illnesses while his or her bureaucratic burden has grown.

Today the family doctor's office, apart from a few commendable 
exceptions, has become little more than a decentralized administrative 
office of the Local Health Authority (ASL), where bureaucratic tasks are 
carried out and patients are referred to specialists, hospitals, and 
various diagnostic tests. All this has been formalized through the 
assignment of a "budget" -a spending cap covering both prescriptions and 
tests- to each doctor, thus labeling them as a "spending manager." A 
regional, ASL-level, and district-level average is calculated; those who 
exceed the cap by a certain percentage (about 20%) are called to justify 
it and, in some cases, are forced to repay the excess expenditure. This 
applies especially to the prescription of medicines.

Even the state apparatus has noticed this crisis: the Ministry and 
regional governors are pushing -including through financial incentives- 
to decree the end of the single-family doctor and to create district or 
neighborhood polyclinics. These first-diagnosis facilities would be 
staffed by various healthcare professionals (GPs, on-call doctors, 
possibly specialists, nurses, etc.) and equipped with at least basic 
medical instruments (electrocardiogram, ultrasound, etc.). Officially, 
this shift is justified by the need to relieve emergency departments 
from dealing with minor ailments -a clearly felt need.

However, this shift meets with strong resistance: from a medical class 
accustomed to managing the organization (and profits) of its own 
practice and seeing in the new work structure -perhaps not wrongly- a 
prelude to dependency and increased control over their work, moreover 
organized 24/7; but above all because it requires large funds to create 
new facilities, which are evidently not available. The first experiences 
of this kind, launched mainly in Veneto, now face serious difficulties 
because the Region has suspended funding.

Furthermore, many fear this will lead to an even greater 
depersonalization of the medical act: the loss of the direct 
doctor-patient relationship, similar to what already happens in 
hospitals -as many patient experiences can attest.

Yet the crisis of general medicine has a structural foundation: it stems 
from the parcellization and fragmentation of knowledge typical of the 
capitalist division of labor -a process that factory workers have known 
well since Taylorism, if not earlier. In medicine this division favors 
the growth of specialties and ultra-specialties, that is, separate 
knowledge silos that erase the unified (or "holistic") view of the 
person and their body, replacing it with fragmentation. There is the 
heart specialist, the lung specialist, even the brain and psyche 
specialist; and each category naturally seeks to draw "water to its own 
mill" (meaning also flows of money). In this dance, the individual 
patient disappears.

It is the lived experience of both doctors and patients to move from one 
specialist to another without ever finding a unified view of the 
pathological process. In all this, the general practitioner ends up as a 
mere assembler of partial visions created by others -much like the 
assembly line worker, albeit under different class conditions.

THE P.N.R.R.
Regarding the disaster of community-based medicine described earlier, 
the P.N.R.R. (National Recovery and Resilience Plan) offers, at first 
glance, little hope. Public healthcare remains the Cinderella of the 
Plan, which allocates only EUR20.23 billion -a meager 8% of the total 
EUR250 billion package. This is all the more worrying given that the 
2021 Economic and Financial Document (DEF), approved on April 22 by both 
chambers of Parliament, confirms cuts to public healthcare of about EUR7 
billion for 2022-2024 and paves the way for a law implementing 
differentiated regional autonomy.

Consequently, the ratio of health spending to GDP decreases and is 
projected to reach 6.3% by the end of the period, compared to 7.3% in 
2021. Of the EUR20.23 billion planned, the majority -EUR11.23 billion- 
will go to the modernization of hospital technology and digital 
infrastructure: purchasing cutting-edge equipment, digitalizing 
hospitals, replacing all major medical devices older than five years, 
increasing intensive care beds, and modernizing emergency rooms (EUR4.05 
billion). In addition, EUR1.64 billion is earmarked for earthquake-proof 
upgrades of hospitals and EUR1.67 billion for improving data collection, 
processing, and analysis tools -including the electronic health record 
and telemedicine. A smaller portion -EUR3.87 billion- will go to 
research and personnel training.

All this confirms the hospital-centric orientation of healthcare, which 
already caused many problems during the pandemic. Betting on hospital 
centrality serves well to concentrate capitalist profits in the health 
sector. For community-based medicine, a paltry EUR9 billion remains -but 
from this must be subtracted EUR1.5 billion for purchasing vaccines and 
anti-Covid drugs and hiring temporary pandemic-response staff, plus 
another EUR500 million for a vaguely defined "Health, Environment and 
Climate" investment. In the end, only EUR7 billion are left to try to 
rebuild devastated local healthcare.

The Plan divides these EUR7 billion into three parts:

Community Houses. These would be socio-medical hubs serving as 
reference, reception, and orientation points for primary care services. 
Beyond the lofty language, they are essentially the same district or 
neighborhood polyclinics previously discussed, whose record has so far 
been a failure. This new attempt inspires little confidence. To begin 
with, as the National Association of Italian Municipalities (ANCI) 
notes, compared to the old plan the budget for these Houses has been 
halved to EUR2 billion, with the planned number of facilities cut from 
2,500 to 1,288. A bad start.

Home Care. The billions saved on Community Houses are partly redirected 
to nearly double investment in home care (EUR4 billion). It's unclear 
whether this money will actually hire the qualified personnel needed to 
rebuild a strong home-care network for chronic patients, bedridden 
people, or those with viral infections, or whether it will again be 
channeled to private entities and accredited cooperatives that aim to 
profit from illness. Regional telemedicine projects are also mentioned; 
though they have some positive aspects, they risk further 
depersonalizing medical care.

Community Hospitals. The plan foresees creating 381 short-stay health 
facilities serving as an "intermediate" step between home and hospital, 
to relieve hospitals of low-complexity cases (EUR1 billion, to be 
completed by mid-2026). The intention is commendable: small hospitals 
are more connected to their surrounding territory and can engage in 
preventive medicine. The problem is that such facilities already existed 
and most were closed amid local protests. Whether this marks a real 
reversal remains doubtful.

In conclusion, the P.N.R.R. investments in public healthcare do not 
reverse decades of corporatization and privatization; if anything, they 
risk reinforcing those trends.

THE PERSONNEL - THE WORKERS
The Plan envisions each Community House employing 10 general 
practitioners, 8 nurses, and 5 administrative staff. For 1,288 Houses 
this would mean 12,880 doctors, 10,304 nurses, and 6,440 administrative 
employees, with an estimated EUR661.5 million just for hiring nurses and 
administrative staff. These positions would need to be filled once the 
Houses become fully operational in 2027. The issue: the P.N.R.R. 
provides no resources to finance them, as its funding ends in 2026.

The assumption is that the necessary funds will come from "savings" 
generated by healthcare reorganization, but this is highly uncertain. It 
is likely that GPs will be required to work part-time in Community 
Houses or that needed staff will be hired on precarious contracts 
through temp agencies -following the much-criticized "Amazon model." 
Another strong possibility is that management of these publicly funded 
Houses will be handed over to dominant private health groups, in line 
with the infamous "Lombardy Region model."

In any case, the much-praised P.N.R.R. promotes -in healthcare as 
elsewhere- investment in fixed capital (buildings, equipment, data 
digitalization), while for labor (variable capital) it leads to more 
flexibility, precarity, and overexploitation.

THE FLIGHT FROM PUBLIC HEALTHCARE
Doctors and nurses are leaving the National Health Service en masse. In 
Piedmont, for instance, the Medical Association reports: between 2017 
and 2022 about 900 family doctors retired; hospitals have 500 fewer 
physicians than a decade ago, many opting for private practice or 
working abroad. In the latest call for nursing staff only 800 candidates 
applied instead of the expected 1,000.

The shortage is especially dire in emergency departments: in Ciriè 
(Turin) doctors are flown in on call from Rome and paid hourly by 
cooperatives. ER staff are overworked with long shifts and no 
corresponding pay or organizational improvements. Hospitals overall are 
under pressure because of the decades-long dismantling of community 
healthcare. There are serious doubts whether P.N.R.R. funds will 
actually reorganize it.

Meanwhile in Lombardy, much of the effort has amounted to ribbon-cutting 
ceremonies at already existing facilities. Nationally the numbers are 
alarming: between 2010 and 2020, 111 hospitals and 113 emergency rooms 
closed, with a loss of 37,000 beds. Hospitals lack 29,000 staff, 
including 4,311 doctors. At least 1.4 million citizens lack primary 
care. The personnel shortage has produced endless waiting lists and 
difficulty accessing care, which -according to Istat- has slightly 
increased mortality from cancer, diabetes, neurological and circulatory 
diseases. At the same time chronic illnesses are rising, requiring more 
home care.

Faced with this disaster, each region proceeds on its own without a 
national plan for public healthcare -a situation likely to worsen under 
the planned regional autonomy law. Calabria plans to hire 500 Cuban 
doctors; in Mussomeli (Sicily) three of six hospital departments are 
closed and local authorities are recruiting ten doctors from Argentina. 
In Lazio, private accredited providers (AIOP) are demanding higher 
tariffs, citing rising energy costs. This is just one symptom of the 
decades-long wild privatization, accelerated during the Covid-19 
pandemic when public hospitals, overwhelmed by the emergency, closed 
many services and suspended millions of treatments -feeding the private 
market.

The data speak clearly: 1.36 million fewer ordinary hospitalizations, 
1.73 million fewer day-hospital stays; and in 2020, 282.8 million fewer 
services delivered in the community than ten years earlier.

COMMUNITY-BASED MEDICINE
As noted earlier, the authorities have recognized the crisis of general 
medicine but their proposals go no further than a network of polyclinics 
or "Community Houses" which -even if built- could at most ensure earlier 
diagnosis and somewhat quicker treatment. They are not designed to form 
a genuine network for risk-factor detection and prevention across the 
territory.

The social disruptions and upheavals caused by the capitalist 
development model and its crisis have profoundly reshaped the social 
geography. Increased life expectancy has produced a growing number of 
elderly people needing care. Local Health Authorities (ASLs) have 
completely abandoned the home-care sector: lacking suitable staff, they 
simply hand out bonuses or vouchers so families can turn to the market 
of regionally accredited care cooperatives.

These cooperatives -often parceled out according to political power (in 
Lombardy for years dominated by the CL, Compagnia delle Opere)- provide 
home health services while exploiting their workers under the usual 
subcontracting system. Meanwhile, elderly care feeds the booming market 
for live-in caregivers (badanti), mostly non-EU migrants vulnerable to 
multiple forms of coercion, and the lucrative business of 
assisted-living facilities with fees starting at EUR2,500 per month. In 
any case, the care of the elderly has been fully outsourced to families 
or the "social private" sector, further dismantling state welfare.

Chronic illnesses such as hypertension and diabetes are also on the rise 
-mainly due to poor diets, increasingly adulterated food, and pathogenic 
lifestyles linked to work stress, precarious living conditions, economic 
hardship, and new poverty. Every form of social or psychological 
distress is medicalized, fostering the naïve hope that a "magic pill" 
can solve every problem (recalling a popular Renato Carosone song from 
the 1960s). In this chaos, prevention disappears.

Medical discourse says little about environmental and workplace 
pollution, chemical waste, diseases caused by electromagnetic waves 
(mobile phones, antennas, repeaters, power lines, etc.), nuclear 
radiation (after Chernobyl and the war in Yugoslavia, when 
depleted-uranium bombs were dropped in the Adriatic, thyroid diseases 
increased sharply), mental illnesses from work stress, mobbing, and 
increasingly conflict-ridden social relations. The situation has 
worsened with the steady privatization of healthcare facilities. Thus, 
demanding public, free healthcare is still correct: from a worker's 
point of view, it represents an essential part of indirect wages.

A true territorial medicine must be primarily preventive and tackle all 
these issues with an open mind, working with neighborhood collectives, 
ecological associations, and movements promoting natural food and 
healthier lifestyles. This requires a profound transformation of social 
relations and dominant culture -something a structurally crisis-ridden 
capitalism seems incapable of delivering.

It would also be necessary to recover forms of self-managed healthcare 
from the early labor movement, which resurged in the struggles of the 
1970s. Think of the fight against workplace hazards, the creation of 
homogeneous risk groups that valued workers' subjectivity against the 
presumed objectivity of factory doctors and health technicians. Also, 
the feminist collectives that fought for self-managed health centers, 
contraception, and women's freedom to decide about their own bodies and 
health, against medical authority.

We must revive the slogans that fueled recent mobilizations for the 
right to health: "HEALTH IS NOT A COMMODITY - HEALTHCARE IS NOT A 
COMPANY." Only with a truly preventive medicine and a healthcare system 
no longer serving as a source of profit for public or private 
capitalists can we reclaim dignity and collective control over our 
well-being.

Visconte Grisi

https://umanitanova.org/il-ritratto-della-salute-per-una-nuova-medicina-del-territorio/
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