In the past, politics tried to seduce Professor Silvio Garattini, an internationally renowned pharmacologist and founder and president of the glorious Mario Negri Institute, offering him the seat of Minister of Health but – the scientist from Bergamo says today with a smile – “it is better not to be done nothing, because I believe that if I had tried to implement the ideas I have about the Italian health system, they would have kicked me out after 15 days". What his revolutionary ideas on healthcare were and what they still are today Garattini explains it extensively in this interview with FIRSTonline and his more than reasonable answers make it clear immediately how much his innovative and profoundly democratic vision has the scent of heresy . Some examples: doctors and nurses? We need to hire many more and pay them better. Waiting lists? "A scandal unworthy of a civilized country". The intramoenia? “This is not healthcare but healthcare classism”. But here are all of his thoughts on the present and future of Italian healthcare.
Professor Garattini, after being inundated with information on Covid in the most dramatic months of the pandemic, today we no longer know much about how the virus is doing in our country: what is the real situation?
«Fortunately, the news is good: today in Italy there is a significant decrease in the circulation of the virus thanks to the massive vaccinations that have been carried out so far and mortality from Covid almost exclusively affects the unvaccinated. But no one can predict the future until we vaccinate the whole world and the danger of new variants that escape the already available vaccines is always lurking. The virus circulating in China, which was and is the continental area most at risk, is no different from the one that has circulated and is circulating in the West and which vaccines allow us to deal with successfully. However, vaccines age and the discovery of new variants is always possible: for this reason the recommendation is always to get vaccinated as soon as possible, if you have not yet done so or have done so in a partial way, especially for fragile subjects ».
Don't you think that, also due to a different approach by the new government, there is a risk of letting our guard down?
«We must always be on the alert because we do not know what will happen in the near future and how the virus will evolve. We need a real national anti-virus plan, not just anti-Covid. As in the defense sector, we must equip ourselves to also defend the health of Italians and not oppose the defense of the economy to the defense of health, because if there is no health, there is no economy that holds".
You often hear in the newspapers about new variants arriving and you yourself have warned that this is an ever-present danger, but are the vaccines we have so far able to deal with the situation or not?
«The new bivalent vaccine is adequately able to deal with the Omicron variants but obviously the game is not resolved once and for all since the Kranken variant circulating in the United States is very contagious even if it is very limited in Italy, at least until today ».
Professor, have you got an idea about the true origins of Covid?
"It has been impossible up to now and I think it will be the same in the future because China is a dictatorship and we cannot trust the data it disseminates."
It is the general impression that the Italian health system - apart from some sensational cases such as in Nembro and Alzano inexplicably not immediately declared a red zone - has withstood the pandemic emergency discreetly, but Covid has also highlighted all the chronic weaknesses of our system healthcare: from the flight of young people's vocations and the exhausting shifts of trainees and new doctors to the continuous emergency of the emergency room and the inhumane waiting lists of many hospitals, not to mention the low percentage of health expenditure on GDP. If you were the Minister of Health, what would you do as a priority to improve Italian healthcare?
«Faced with the pandemic, the Italian health system has held up but has revealed its structural weaknesses and its unbearable classism whereby, contrary to the provisions of the Constitution, only those with their own money are guaranteed to be able to take care of themselves while the less well-off can wait even months and years before a hospital visit. The waiting lists, which last an indefinite but usually not short time, are a scandal unworthy of a civilized country".
So fighting the unsustainable length of waiting lists would be your priority?
«The reduction or exhaustion of waiting lists is certainly very important and the virtuous example of Portugal, where hospitals are put in competition with each other to grab public incentives aimed precisely at seeing and treating patients as soon as possible, tells us that eliminating this scandalous situation is possible. But I would take a step back and first of all I would focus on prevention. It would take a real cultural revolution based on prevention that starts from kindergartens and schools and reaches all health structures, from territorial ones to hospitals, to involve all Italians and give them a culture of prevention that does not yet exist And. I'll give you two examples to highlight the urgency and importance of prevention".
Prego
“Let's limit ourselves to smoking and alcohol. The most up-to-date surveys show that only 25% of smokers have received a recommendation from general practitioners to change their lifestyle and stop smoking or at least reduce smoking. Does that seem enough to you? But so far things have gone even worse in the fight against excessive alcohol use: here only 6% of alcoholics have stopped on the basis of a prior recommendation from doctors. Too little. But after a cultural revolution in the name of prevention it is necessary to attack all the weaknesses of public health, from the increase in health expenditure to the simplification and bureaucratization of procedures, from the shortage of medical and paramedical personnel to the improvement of their salaries, from territorial medicine to the reorganization of hospital network and equitable access to healthcare».
“Vaste programme” General De Gaulle would have said. Let's go into the details.
«The numbers speak volumes about the insufficiency of current health expenditure: Italy spends 7% of its GDP on health care, against over 8% in the major European countries. It is therefore not surprising that 30 doctors and even 80 nurses are lacking in Italy and these basic data already give an idea of the structural deficit of Italian healthcare. Then, of course, there is a question of quality and reorganization of the entire healthcare system. But to do so, the National Health Service must be freed from the rules of public administration and public employment: it is inconceivable that to obtain a new medical device in an ASL or in a hospital it is necessary to wait two years or even more. This is why de-bureaucratizing, simplifying and speeding up interventions in the health system becomes essential".
Then there is the emergency of doctors and nurses, who are too few and earn little.
"Exactly. We are at the point, as the newspapers have written, that the Calabria Region has imported Cuban doctors. There is an increasing number of cooperatives offering healthcare establishments doctors per night or by the hour which cost much more than doctors who belong to the National Health Service earn and among other things these are doctors who often do not have the necessary qualifications for first aid and for certain specialist interventions. It is also very important to abolish the intramoenia service, i.e. the free profession exercised by doctors in hospitals. It is unacceptable that, in order to earn more, doctors in hospitals or health centers work for themselves for a fee rather than for the public structure and that only those with the most money can bypass the long waiting lines and seek immediate treatment. This is not health care but health classism ».
But doesn't abolishing the intramoenia risk turning into a boomerang? I understand the sacrosanct principle of equal right to health regardless of wealth but abolishing the intramoenia without reorganizing the entire health facility does not run the risk of increasing rather than reducing the waiting lists which, in addition to less well-off citizens, would end up increasing incorporating those who can no longer resort to intramoenia?
«In the meantime, the equal accessibility of all citizens to the National Health Service is a right enshrined in the Constitution and in Law 833. And therefore we have to abolish a factor which is against equity. Then I have already said that it is necessary to increase the salaries of doctors and health care workers who are lower than the European average at purchasing power parity. Finally, if incentives are given to regions that reduce waiting lists, it will be possible to differentiate who can wait, compared to those who have more urgent needs".
Don't you think that the abolition of intramoenia, while just in itself, would end up - if detached from a general policy of reduction of social inequalities - by fueling the recourse of the wealthiest to hospitals and private laboratories, thus becoming a shortcut that does not reach the objective of guaranteeing real equal rights for all users of public health?
"Those who have economic resources can still use hospitals and private laboratories today."
These speeches raise another crucial one: can the public and private sectors coexist in healthcare or are they destined to wage war on each other? Are there examples of virtuous collaboration? You yourself are the President and founder of a worthy private pharmacological research institute such as the Mario Negri of Milan and Bergamo.
“The National Health Service is by definition public. The private sector should be integrative when the public service fails to complete its tasks. Among private organizations it is necessary to distinguish foundations such as Mario Negri which are non-profit from private hospitals which instead have profit purposes».
Professor, you also mentioned earlier the need to reorganize the hospital network and local medicine: in what sense?
“I think the current proliferation of small hospitals, which often have low physician productivity because there are too few patients, should be avoided. And I think instead that the health activities and more complex medical skills should be concentrated in a few large hospitals".
In addition to the need to reorganize the hospital network, the pandemic has also highlighted the need to strengthen and redesign local medicine: what do you think should be done?
«We should increase the number of doctors which today is too low and which becomes the primary cause of the clogging of the emergency rooms. Community health houses should be established, which have already been the result of experimentation. It is a question of bringing together more doctors for a given geographical area by hiring the current family doctors on a permanent basis so that they keep the clinics open 7 days a week and 8 hours a day. Doctors must be integrated with nurses, family paediatricians, psychotherapists, having at their disposal an office with a good computer system. In health homes, routine analyzes can be performed using automatic equipment and telemedicine must be available to communicate with patients and hospital specialists. It must be integrated with social services in order to take care of the needs of the sick or the elderly at home. Volunteering from the third sector should be gathered around the Health Homes in order to create a structure that is truly at the service of citizens. As he sees, if the will is there, there is no shortage of ideas for reorganizing and strengthening local medicine ».
Let's go back to the Mario Negri institute: what is it like today, what kind of activity does it carry out, how is it financed, how many people work there?
«The Mario Negri essentially carries out three activities: research with particular reference to the mechanism of action, efficacy and toxicity of drugs; the training of researchers through research doctorates and PhDs; information aimed at citizens, doctors and health authorities. It is located in Milan and Bergamo. 700 people work there. It is financed through public funds by being a Scientific Hospitalization and Care Institute (IRCCS), by participating in national and international calls for tenders, by receiving bequests and donations and by collaborating with industries on the basis of well-defined rules. The total budget is around 32 million euros per year. The Institute is independent from politics, finance and industry and does not patent but publishes the results obtained».
How has the pandemic changed your research programmes?
«At the headquarters of the Mario Negri Institute in Bergamo, for example, we have launched a large study on the genetic influence of Covid: the results will arrive in years but it is a work of great interest. In the Milan office, on the other hand, we have begun to study the consequences of Covid on people's mental health with a research involving 45 subjects. In collaboration with other institutions, we are studying anti-Covid drugs".
One last question about the disease of the century, about cancer. You were also President of the European Research Organization on the Treatment of Cancer (EORTC) which remains the great bogeyman even in our times despite the progress made by medicine: realistically, what hope do we have today of definitively winning the fight against cancer and in what times?
«Yes, cancer can be eradicated but only if we change our mentality and lifestyle and above all by relying, as I have already said, on prevention. Suffice it to say that 70% of cancers are preventable, but in Italy as many as 180 people die of cancer every year. What does it mean to do anti-cancer prevention? It means intervening on pollution, smoking, obesity, nutrition, alcohol and making systematic use of screening. In other words: it will be possible to defeat cancer but it will also depend on us ».
