There have been no shortage of voices in recent years that have pointed to the risks of one underfunded public health in the face of growing demand for quantity and quality, and above all the lack of a strategic vision of reviewing welfare structures and promoting health and well-being in the light of the most recent challenges. One of the most authoritative examples is that of Perfect storm, a text published in 2015 by a group of researchers led by Walter Ricciardi, extremely incisive in indicating a series of urgent challenges: ageing, chronicity, disability, scarce resources, inequalities, lack of coordination and national strategic vision, management inefficiency, styles inadequate life.
And it does so by recalling important previous contributions, such as those of Censis, Ceis and Cergas-Bocconi. But we can also mention the work promoted in recent years by the Ministry of Health on inequalities, together with Agenas, Aifa, ISS and Inmp, which has shown with unequivocal data the growth of inequalities in living conditions and access to care in Italy (about 10 years of life expectancy less in the poorest areas of the South compared to the richest areas of the North). And even CREA-Sanità and the Gimbe Foundation have been sending us clear messages every year for some time now on the risks of de-financing the Health Service ($3.391 in public spending per capita annually versus an average of $3.978 in OECD countries).
However, none of these rumors had foreseen an emergency such as that of the Covid-19 virus pandemic, that hits us so hard for two months to this part and which has opened our eyes to the global risks of infectious diseases even in economically and socially advanced countries with a first-level system of health guarantees, such as Italy. Risks that we deluded ourselves had disappeared, or at least relegated to countries with very low levels of hygiene and health care.
The health storm that we did not expect confronts us with the fact that the so-called "double burden of disease" (double burden of desaese), reported by experts as one of the main risks of supply systems for the rapid and critical growth of chronic pathologies alongside acute ones, is no longer sufficient to describe the challenges we face. Is that we need to prepare for a triple or quadruple burden of disease for the resurgence of virus diseases, of which Covid-19 is the living and current example, and for the overlap between infectious diseases, old and new, but above all new, and chronic diseases in terribly fragile individuals.
The pandemic has also led us to reflect in a new way on the organization of health services, on need to prepare in advance compared to similar events, but also and above all on the need to rethink the role of local medicine. A medicine that has been struggling to make considerable efforts, for some years now, to equip itself for the treatment of chronic and degenerative diseases, at home or in an outpatient setting, and which now also has to face the challenge of rapidly spreading possible epidemics on the territory viral, those present and those arriving, to avoid the risks of improper hospitalizations and the collapse of hospital structures.
According to the information available to date, the rapid and dramatic contagion that has occurred in some areas of Lombardy would have also or above all occurred in hospitals. If there had been, therefore, an adequate system of monitoring and social and health assistance in the area, at least it would have been possible contain the impact of hospital contagionwith all its consequences.
Alongside this, the enormous difficulties encountered in the areas of greatest impact of the pandemic regarding care for non-hospitalized patients, with more or less serious symptoms, often left alone, sometimes followed through remote monitoring of weak incisiveness, and often with the only available garrison consisting of distant and overloaded general practitioners, and worried family members and mostly helpless, confirm the need to radically rethink the territorial integration between social and healthcare.
In fact, if the territorial health facilities for prevention and primary care had been more adequately prepared and supplied with good-level personnel and instruments, perhaps even some of the most critical situations could have been avoided, such as those of deaths at home alone and without assistance, and those of the psycho-social difficulties, even before clinical ones, of many citizens and many families.
As the doctors of the Papa Giovanni Hospital in Bergamo wrote on March 21, we have not fully understood yet how important the community dimension is in healthcare, and not only for chronic pathologies and disabilities, as is quite clear to everyone, but also in the face of an infectious pandemic crisis, which is also and above all a humanitarian crisis, which affects the entire population and requires a community approach of population and territory (Nacoti M. et al. [2020], At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation).
To explain this aspect, Pope John's doctors say that the patient-centered health strategy, on the basis of which we have mainly worked up to now, must be accompanied by an equally decisive strategy centered on the community and on the territory. Meaning by community and by territory public health that includes prevention extended also and above all to non-health areas and the close collaboration between the social sector and the health sector. Which also means initiative medicine and comprehensive monitoring of health conditions in the area. Even access to specialized and intensive care in hospitals should find a connection, in this vision, with the control functions and widespread assistance throughout the territory.
The perfect storm that we didn't expect then confronts us with the need to finally become aware of the interrelationships between the health sector and other sectors. As scientists in the biological and evolutionary area have been trying to explain to us for some time, there can be no human health if the rest of the planet and living species are not protected and kept "in good health". And therefore the now frequent, but for now unheard references to the need to take care of the integrity of the physical and animal environment, respect the natural balance, reduce forms of pollution and intensive exploitation of the globe, respond appropriately to climate crisis (under the name of One Health, Cheers), must now be taken seriously.
The circularity of life on the planet in all its forms cannot continue to be considered an elegant model of reflection, but must give rise to strategies and interventions that are truly circular with a view to safeguarding human capital, social capital and the material together, avoiding waste and producing virtuous balances between the factors. The sustainability of health and healthcare will only be given if respect for generational and natural balances is placed first on government agendas.
Is the debate on the so-called Anthropocene, a term little known until recently, although already coined in the last century in the biological and chemical fields, and which today appears to us in all its significance with respect to the attempt to understand how it is possible that in the most developed geographical areas of the globe a viral emergency. According to this approach, in fact, viral emergencies are the result of a dominance of the human species over the rest of the globe.
One of the most recent and clearest contributions, to try to understand the risks for the human species of the hyper-exploitation of the planet and in particular of its natural resources, is the booklet published by Ilaria Capua in 2019, and titled Circular health, which summarizes the history of the relationship between medicine and the environment over the centuries. It is difficult to imagine a more explicit and understandable reasoning on the fact that the environment is not something external to us but "we are actually immersed in it, it is part of us", and that therefore if we treat so badly "our mega sack amniotic”, if we poison, invade and consider the environment as our exclusive property, we should not be surprised if our survival is then put in danger.
But over the course of the history of the last few decades there are many other contributions, developed within different disciplines, which have attempted to make it clear that health is a systemic process that includes the well-being of nature and the animal world. The reference is for example to the sociological studies of Censis in the 80s on health in Italy, in which the concept of "psycho-socio-environmental system" was proposed to define the evolutionary and integrated reality of human health.
And the reference also goes to some environmental and urban ethics experts, such as Corrado Poli (Politics and nature, 2017), who have indicated the environmental problem as a political problem of fundamental bioethical importance. The approach to the question that goes by the name of green washing, ie the introduction in the productive and urban system of some interventions to mitigate pollution and environmental destruction, is not sufficient, according to this line of thought, to promote an effective and global sustainability of human development and its potential.
And even particularly attentive theoretical philosophers and sociologists have repeatedly called attention, at the end of the last century and at the beginning of the current one, to the risks for the human species of the destruction of the physical, natural and animal environment. The same Jean Baudrillard, one of the most important philosopher and sociologist of the last few decades, wrote back in 1992 in his The illusion of the end that "the worst is not that we are overwhelmed by the waste of industrial and urban concentration, but that we ourselves are transformed into residues". It was already clear to Baudrillard then that “the human species, aiming at virtual (technical) immortality (…) is losing its particular immunity”.
As all these authors, and still others, underline, each from their own point of view, the problem is then mainly that of looking to the future with foresight and comparing different disciplines and related studies and results. Returning to the words of Ilaria Capua, we must overcome hyper-specialization and the separation between different fields of study, as happens in the Center that you direct in Florida (One Health Center of Excellence), which aims precisely to study the health of all species and of the natural environment as a whole. And we must make use of the enormous scientific and technical possibilities that the human species has been able to develop for the health of the entire planet. Only in this way can we also promote our health.
Also read: "Public health returns to the hands of the state“, by F. Cavazzuti
