Conversation of Eugenio Santoro with prof Ivan Cavicchi (Editor's note)
I have just finished reading a pamphlet (less than 100 pages) that I liked a lot, a long-time doctor with a long political militancy behind him and that I recommend everyone to read.
The title is "The left and healthcare from Bindi to Speranza with a pandemic in the middle"(Castelvecchi publisher). Its author is Ivan Cavicchi my friend for many years, with whom I have shared many battles in health care, certainly one of the most authoritative public health experts in our country and in any case one who has experienced health policies at least those of the last 40 years directly as a protagonist. For many years we worked together in the hospital, then trade unionist, university professor, essayist, (he wrote a lot of books) but above all as a "reformer", that is, as an independent leftist intellectual who uses criticism as Kant once used it, that is, not only as a reason committed to the interpretation of reality, but as a reason that analyzes the reason that interprets reality in this case health and whose understanding explains the main political choices made in recent years in health care. In fact, his book could easily have another title "critique of the political reasoning of the left in the health field".
I would begin by asking Ivan, just to break the ice, to explain the fundamental thesis of his book
The pandemic actually worked as a stress test, that is, it mercilessly unmasked all the main criticalities of public health, those that have accumulated over 40 years of public health service, consequently unmasking all the main criticalities of that "political reason" that just to be clear has governed health care in recent decades even with questionable choices and some dangerous counter-reformer failure.
Paradoxically, the pandemic becomes an opportunity for health care not so much for an improbable palingenesis but an opportunity to finally set up a new reforming discourse, which in the book I call "the fourth reform". An opportunity made such by the possibility of having a certain financial availability with the recovery fund.
So we need a reforming thought not only with respect to the pandemic but also with regard to the post-pandemic
That's right. The post-pandemic will not be like turning the light back on, that is, like a passing storm, but it will be like a rubber band that will stretch even within a restored normality.
The idea of defining a “fourth reform” for me is the necessary condition for not wasting the opportunity of financing and for making the system more suitable for this complex society and the new epidemic risks that await us.
Without a reform project, that is, if health care, as a system of services, remained invariant, that is, if its historical criticalities were not addressed and resolved starting from the pandemic, it is, on the one hand, simply destined to grow as public expenditure and to enter time in collision with the GDP and the public deficit, on the other hand to clash with a new society in terms of increasingly demanding health.
But today health care is having a lot of money, the era of underfunding seems to be over.
It is true but we cannot heal from anorexia, that is, from the problem of scarcity, with bulimia, that is, with the problem of excess. It was no coincidence that Dante placed the prodigals and the greedy in the same circle, that is, he condemned them as excesses.
The left today all looks like but not Dante. in recent years it has tended to be anorexic in health care so it has been the party of the non-spending of the compatibility of the cuts in the planned definancing, for a while and precisely after it lost lessons in March 2018, it became with Speranza but not only suddenly a party of spending regardless of the incremental nature of healthcare spending, and the problems of sustainability and above all the quality of spending.
Then came the pandemic that put us the load of 12. So money everywhere. But money, alas, not guided by a reforming idea.
But I would admit that after years of underfunding, health care needs to be refinanced.
Health must be refinanced on this, but it is not wise to finance a health system with invariant diseconomies and anti-economies with a health care like the one we have and with an economy that is doing badly. Speranza only cares about enhancing what is there because it is easier, and does not tread on anyone's corns, but in no case does it bother to change what is there to better spend the available resources. This is more difficult and to get someone corns it is inevitable to step on them.
The anorexic and the bulimic are both sick with a common disease that in my book I jokingly call balance-phrenia.
Today, with the money from the recovery fund, it is a question of healing health care from balance sheet problems. After all, in many years I have never seen health expenditure become an independent variable from GDP. It can be independent for a while because there is a pandemic, therefore in very exceptional circumstances, but when fully operational, healthcare spending must also deal with the economy and give it and society some counterparts, particularly if the economy goes bad and society is not happy. This only means one thing: if we put more money on healthcare, what counterparts is healthcare willing to provide both to society and to the economy?
An enhancement of the system up to itself and therefore to invariant criticalities, as Speranza seems to want to do seems to me a short-sighted and breathless policy.
You can give us an example of an expense that qualifies as an investment through change
The pandemic has taught us that we should readjust the number of beds in the hospital system and therefore that we must also radically review the de-hospitalization policy made in recent years. This process of reshedding as I call it cannot take place if at the same time we do not rethink the hospital as an institution, as an organization as a culture. The pandemic found an under-sized hospital but at the same time stopped as an organizational model in the 60s.
In the pandemic we became clear that the dual territory / hospital system that Speranza continues to propose did not work so with a reforming logic we should orient ourselves to rethinking a single and integrated system that works more and costs less. This concerns both the hospital and the territory.
At the same time we understood through the legal disputes that even with the pandemic they did not stop, that the hospital can no longer be the place of estrangement, separation, denial of the sick person reduced to illness but in turn as a public service is called to relate to a society of incompressible and irreducible needs, and therefore to rethink its classic clinical modalities. Therefore the hospital must not only be redefined as an organized service but also culturally rethought as a way of healing. This is part of the "fourth reform".
After the contrast between the hospital territory has failed, Hope continues to think of the territory in an anti-hospital key. A worrying madness. Even today we talk nonsense of hospital-centeredness. I have read that a group of M5S MPs are working on a budget hypothesis for general medicine to combat hospital centricity. Ridiculous. The experiences made in Emilia Romagna of giving financial autonomy to the district have failed miserably. But in the midst of the pandemic, it is still disconcerting to speak of hospital centricity.
The title of the book combines the left as a political subject with healthcare and seems to limit the field of analysis to the last 20 years or so, that is, to that period between Bindi and Speranza, that is, to our days. Can you explain better why?
By left I mean in particular that of government, that is, the one that has governed health care in the various central and non-central institutions.
The left in general, that is a certain paradigm of thought, has two indisputable merits compared to Italian healthcare: it has been its main reforming subject, in the culture of the left the right to health has a privileged place, and the right to health on the left is always it was considered as an instrument of man's emancipation from every disadvantage, from every subjugation, from every form of injustice. At the same time, the government left is the one that more than other political forces has managed health care, and above all administered it at every level.
The obvious thing is that in recent years the left of thought and the left of government have often come into conflict. That is to say in another way, the reasons of those who have administered have often prevailed on the ideals of the left of thought and therefore on political coherence.
All major health policy choices have been made by the governing left or anticipated by the governing left. For example, the reform of title V. the establishment of the company, the unbundling of hospitals from the local health authorities, the territorial unification, the progressive definition of the resources, the criteria for allocating resources to the regions, appropriateness and many other things.
Are you saying that the government left is the one who practically ruled health care?
Yes. Left government and healthcare in Italy are practically the same thing. Through the left we understand health and the opposite. It follows that to understand the problems of health it is necessary to understand the problems of the left and the opposite, that is, to solve the problems of health, one must first solve the problems of the left. That is, the problems of the handle or the reformer.
In the book I explicitly say above all when addressing myself that it makes little sense to propose reforms if there is no reformer. If I don't have wings it is of little use to say that we should fly.
Today we have, since the pandemic, a great need for reform but we have a left without a reformist thought. The emblem of this wingless left is poor Speranza who in this whole affair proposes himself as a scrupulous administrator of the pandemic, a vaccination officer, a color officer of the regions as if the regions were only traffic lights, but not as a politician who follows a reformist design. As a very disappointing left.
And for the couple Bindi / Speranza….
As for the Bindi / Speranza couple, my intention was certainly to limit a historical period but also to understand and study political and ideological continuity. Between Bindi and Speranza, as is well known, there were other ministers (Veronesi, Balduzzi, Lorenzin, Grillo) but all of them, despite their political differences, acted according to an impressive political continuity which, starting from the Bindi reform, extended a vision of health care that not only jumped today with the pandemic but that has shown over time therefore already before the pandemic too many contradictions and too many problems. That is to say, it proved to be a fundamentally wrong political choice today and yesterday.
The case of Grillo, that is of an M5S minister, as a minister is paradoxical. Exactly, like today Speranza and yesterday Lorenzin, Grillo proposed while talking about change at every turn, exactly like the one who limited herself to managing the ordinary. The concept of political management of the ordinary is not mine but Grillo's. Before it was put aside, I wrote an e-book that can be easily downloaded in the daily health newspaper (which is free of charge) with the eloquent title "I'll give you the change". It was June 2019.
So from the Cricket to Hope ...
Mutatis mutandis, the conceptual structure that is Speranza's way of reasoning is completely superimposable to that of Grillo and to that of those who came before and which in turn are completely superimposable to the system of 229, that is to a policy that starting from 'invariance of the system as a whole, it was limited to rationalizing something and opening up to the private sector for reasons of sustainability
Today Speranza is what it is because his party or what has remained is stuck in the politics of the left government of over 20 years ago, as if nothing had happened in recent years, and that it started from a wrong postulate: there is no there is no need to reform the system, what is there is fine (so the company, the new title V, the north / south inequalities, healthcare mobility, the territory, the hospital that exist, etc. are fine) for where an invariant system is simply a matter of managing it better, of rationalizing it more, of making it more appropriate that is with less waste but above all of increasing the spaces for the private sector, that is to admit what Bindi had anticipated with its reform and that after the government Berlusconi (Green Paper Minister Sacconi June 2008) has defined himself as "the multi-pillar system".
Today without Bindi, for example, there would be no corporate welfare, that is, those rules that, within the job act, will pave the way for fiscal welfare, that is, welfare on demand. It is no coincidence that both Lorenzin, Grillo and Speranza have not lifted a finger on this problem in perfect continuity.
In your book the political judgment on the Bindi reform is very severe but perhaps the most interesting thing is the explanation that you give of the political limits of this law with the political limits of the left of the time
The political operation that took place with 229 is twofold and in some ways schizophrenic:
- on the one hand it invests in the public but in particular in the district, on prevention, in an anti-hospital key to satisfy the left in general which has always been unknown why it is anti-hospital.
- on the other hand, it responds to the growing problems of financial sustainability of health care, that is to say to the problems especially of the administrators of the government left with the opening to the private sector.
Since there is no money to finance public health, we invent a supplementary health system paid in part by the citizen and encouraged by the state.
The line that passes with Bindi is that of forced compatibility, i.e. rights must be renegotiated in light of financial limits, therefore it is the right that must be adapted to the limit, not the other way around because it is impossible to do anything else, with the consequence of initiating a change. system. From the universalistic system to the multi-pillar system.
But how did things go in reality?
In reality it happened that:
- Funds, mutuals, corporate welfare for trivial reasons of profit to play only an integrative role earn little for which to really have a market they must necessarily play a substitute role, that is to compete with the State and take away part of the services and performance with systems organized in a parallel way
- The pandemic has reinforced the reasons and the role of the public, making recourse to the private sector much less attractive in the eyes of the people.
Indeed, the pandemic has made it clear that if anything, we need "more public" not less and that it would be better if the money for health care were spent on developing the public service.
So the 229 line has been disproved by the facts.
In your book you define compatibility as an ideology even before a politics, for what reason?
As is known in the Marxian sense, ideology means everything that regulates a society at the service of the economy (cultures, laws, forms of government, the most varied rules, different institutions, health schools, etc.), therefore we mean all the apparatus that justifies starting from an economic structure, a way of being of a society.
All health care until the electoral defeat of the PD in 2018 was governed with the ideology of compatibility and from this ideology companies are born which sanction the end of the right to health understood as an economically incompressible right, which are born the regional reorders to merge companies, which are born the advanced skills to use professional work at a lower price, which is born de-hospitalization and therefore the recent dm 70, which is born the appropriateness an ideology in the ideology that is the principle that what costs less is more appropriate.
So if I understand your speech well, one of the limits of the government left towards health was that of having governed public health by basically reducing everything to compatibility and therefore to administrativism.
You understood well. That's right. Govern something as complex as health, that is the complex relationships between ethics, science and economics, in a society like ours obsessed with compatibility is crazy.
Governing health care is difficult because it is difficult to balance ethics, science and economics.
Being politically subordinate to the administrators only, that is only to their budget problems and deciding everything according to these problems has enabled health care to lag behind first of all on the cultural and social organizational level.
Is this what you mean when you talk about system regressivity in your book?
When I say that health care is regressive I mean a system concerned only with making a living culturally and socially firm that since everything around it changes it is as if, while remaining still, it comes back.
Regression has many particular consequences apart from causing the deterioration of the relationship between services and citizens, thus participating in unfortunate phenomena such as legal disputes, the growth of social distrust and even the violence of citizens against operators, but also causes the petrifaction of practices professional. Today, for example, general practitioners express professional practices similar to those of the time of mutual societies, the same is true for specialists and for hospitals.
If professional practices do not change, it is difficult to affirm any reform, that is, if the work in health care does not change, it is difficult for health to change and it is difficult for citizens to notice any substantial change.
You know well that to this day health workers are still legally defined as any other employee of the public administration, the famous 761. I, on the other hand, am convinced that since medicine is an incomparable science that is not comparable to any other science of nature but wholly specifies whoever practices medicine is a juridically incomparable operator, that is, he needs an ad hoc juridical definition.
But in the field of work we are really very far from any shred of reform and rethinking. We remain prisoners of a largely outdated legal system, with low salary levels, with culturally regressive professional practices.
It makes me wonder but why the left on health has made so many mistakes, is it possible that it is just a question of idiots, or administrators or politicians with limited thinking?
I don't think it's a question of idiots even if the role of individuals and their personal qualities in politics remains important. It is one thing to have a party official as a minister and another to have a politician capable of thinking reform. For example, Bindi, whom I personally respect very much, could have written her reform in many different ways but she wrote it in a certain way that was what the common sense of the left of her time to which she belonged imposed on her.
Common sense works like a fashion and in general imposes conformist choices that are in conformity with the ideas that dominate. The ideas that have dominated health care in recent years have seen Bocconi the maitre a penser who distorted everything by drowning us in a stupid and dangerous economism. While healthcare was drowning, Bocconi on healthcare did its most colossal business.
We have had the fashion of the unbundling of hospitals, of the company, of the appropriateness, of the compatibility, of the sustainability of the guidelines, therefore of the evidence, of reordering, of large areas. In the end, all the regions adopted the same resolutions almost with a stencil.
I think, also thinking about my personal experience, that every period has possibilities and limits and the laws that come out are always a compromise between possibilities and limits.
For example, the health reform of 78 to which I personally attribute enormous political value opens up many possibilities but at the same time has many limits. In recent years we have denied its limits and we have not done anything to overcome them, ending up with the counter-reform attracted by neoliberal thought. This is also why we are at a disadvantage.
Speaking of limits, in your book I found very stimulating the analysis you make on the mistake made on the left about sanity of exchanging contradictions with problems. What do you mean?
If I lose the tap it is a problem whose solution generally does not require the reform of the system, but if I privatize public health to make it financially sustainable then we have a contradiction that cannot be solved like the leaking tap but must be removed by reforming everything creates the contradiction as such. The contradiction concerns the spending system, so it is a question of reforming spending knowing that to reform it we need to reform its main effectors and therefore its main behaviors.
But if I don't do the reform of spending and I just struggle with privatizing a part of the system, it's a big mess. The left in recent years has mostly taken shortcuts, that is, it has reduced contradictions to problems by taking refuge in simplifications.
To the contradictions on expenditure with structurally invariant expenditure it has responded with companies to those on sustainability it has always responded to expenditure which is invariant with funds. Today, with an invariant system with the pandemic, the simplification of Speranza is called territory, house of health, etc.
The logic followed as I said is that of compatibility. That is, for compatibility reasons I reduce the contradiction to a problem. If the left, on the contrary, had decided to remove the contradictions and therefore to reform what we should have reformed, it would have had to change logic by accepting what I call "compossibility" in my little book.
Two different things are compatible with each other if they do not have contradictions. That is, the removal of contradictions is the main way to guarantee compossibility. The right to health is compatible with the economy if there are no contradictions between them. If they exist, it is a question of removing them with reforms.
In the end, I believe, considering everything, that this left has reformed too little in these 40 years while it should have reformed more. But if the left is less and less than the left then how can it reform more?
Yes, we are the dog that bites its tail. But if you are right and if common sense has a great political role then I deduce that the reforming left should to make the "fourth reform" of health that you propose working on a thought of reform without which it is difficult for its ministers to be reformers
For me, a left without a reformist thought stops being left because its general mission is to change the world to make it better more just more comfortable more pleasant and even, if you allow me, healthier.
The crisis of the left that has been talked about for years is the crisis of a world transformation project caused mainly by the difficulty of imagining and devising a better world in this capitalist system. That is, it is the crisis of a thought that fails to reform what it should reform
Having a reformist thought is not easy. We need to study, research, promote culture, invent, discuss, compare, innovate, criticize, invest in research. That is, it is a work on thought that the left should organize almost permanently. In health care, where politics has failed to fatally reform, it has ended up counter-reforming (Title V, mutuals, privatization, advanced skills, etc.
So I deduce that the only way at least in health care not to go back is to go ahead, that is, to continue reforming and then continue to be left-wing. Public health really defends itself by making it more public no less but at the same time guaranteeing counterparts of quality, economy, reliability, humanity, scientificity, worthy of our time.
To make the "fourth reform" even before the ideas that fortunately are not lacking, the reformer is needed, that is, a political will who, analyzing the facts of reality, deduces the need for a change.
With this booklet of mine I wanted to point out the problems of the reformer and therefore of the left. I know firsthand that having ideas without a reformer is vox clamantis in the desert.
Today in healthcare "with a pandemic in the middle" if we do not push forward a reformist thought we risk losing what we have painstakingly achieved in recent years.
If we reform, there is no pandemic that holds, there is no need to privatize public health, the left will no longer exchange problems with contradictions and will no longer have the problem of not being left. The path of reform for the left is not optional but mandatory.