If the social dimension of health is lost

by Roberto Polillo and Mara Tognetti

We need a qualitative leap or, to use an obsolete term, a cultural revolution which takes up this noble tradition, made up of culture, participation and social struggles which led to the birth of our National Health Service in 1978 and which over time has been replaced by an exclusively biological vision of health

April 14

Go beyond the biomedical model
We believe it is appropriate, in the context of the debate on the redesign of the NHS, to return and pay particular attention to Community Homes because in our view they are the embodiment, or rather should be, of the One Health approach ( and Hopefully from the welfare perspective One dear to the debate opened by veterinarians).

In addition to being a physical place where various professions are exercised (doctors, nurses, social workers, administrators, psychologists, other professionals, etc.), the Community Houses are a place where the different social components are recomposed and articulated. , health and community. therefore touched and I am attentive to the environment, to the context of life. A place where the different components and their central articulations for individual and collective health come together, combine and unite. In other words, it is a place, perhaps it would be more correct to speak of an occasion, in which it will be possible to regenerate social networks, to build territorial alliances.

The Community Centers are also the first space for interception, for taking charge of the need for health in its various dimensions from that of health, and interface for incoming and outgoing specialized territorial structures. Places where the right to health should be guaranteed to all individuals in a given context.

However, let’s analyze the principle underlying the document proposed by Minister Speranza which outlines how “through the development of local structures, such as community houses, as a point of reference to meet health, social and health needs of health importance for the reference population“.

The limit of an approach still too closely linked to a traditional biomedical model is clearly apparent.

The most critical pointsIn Minister Speranza’s project, little consideration is given to the context and the interactions with the context. The living and working environment, the determinants of health, lifestyles and level of education are relegated to something unsaid which makes them de facto inessential; quite the opposite of what the major epidemiological studies carried out in the cities of Turin and Florence, for example, already highlighted several years ago, demonstrating a clear gradient of health and disease in disadvantaged social and living contexts .

A major health care reform cannot therefore be limited to a simple renaming of health establishments without in-depth rethinking of their real interaction with the context of life by relaunching certain concepts that had been endorsed by the former minister Livia Turco, such as than “winning health” and “health in all policies” and which are, on the contrary, totally absent from the current ministerial draft.

Too little is said about the importance of the involvement and active participation of citizens. Even less is the problem of the tools to be adopted so that participation does not remain just a declaration of intent without any ability to influence.

We have already largely underlined in our previous interventions how the governance of health facilities must be thoroughly reviewed to replace a top-down management model totally centered on the monochromatic and self-referential power of business management by a plural management in which the authority Local and citizen representatives can play an active role in planning services and evaluating results.

Nothing is said about the training of personnel and the role of this culpable general intellect, excluded from any decision-making process and relegated to the status of simple executor of decisions taken elsewhere. Thus, the true dimension of health action is lost; of this type of activity which is only effective if it is saturated with a social and relational dimension in addition to a technical dimension and which is only made possible by active and proactive involvement in the decision-making process. To feel a non-essential part of the whole.

And again in the ministerial project, it is the health dimension that prevails even when it comes to dealing with issues related to the different forms of chronicity; conditions in which the social component plays a fundamental role in overcoming isolation, improving the psycho-physical performance of patients and strengthening the support networks available.

The lack of sociological vision
We recognize the Minister of Health’s clear commitment to lifting health care out of decades of underfunding and brutal cuts. With equal clarity, however, we cannot fail to point out how in this year’s DEF it is stated that the expenditure-to-GDP ratio will fall back from 7% in 2022 to 6.5% in 2025.

The fear is that the honeymoon is coming to an end prematurely and that under the weight of the crisis triggered by the invasion of Ukraine, the old ways of weakening health care will resume.

Beyond that, there is no real epistemic change of pace in the ministry’s project. What is missing is a reading of society and the realization that the only model capable of explaining health and disease, well-being and discomfort is the bio-psycho-social model.

A vision of human health that recognizes in society and in the context of life the ground on which some individuals undertake this painful “career” that will lead them to disease, disability and chronicity, accumulating a series of disadvantages, which we now know begin in the period of management and consolidate in the rest of life.

It is the vision and the approach that are missing in the ministerial proposals; a cultural gap that should instead be quickly filled by taking advantage of what the COVID pandemic has taught us and that has convinced authoritative scholars to use the term syndemic to explain its epidemiological characteristics.

A term that highlights how the effects of the SARS CoV 2 virus are not neutral but show a very clear social gradient exactly superimposable on that of long-term chronic diseases.

The forgotten lesson of Law 833/1978
We therefore need a qualitative leap or, to use an obsolete term, a cultural revolution which takes up this noble tradition, made up of culture, participation and social struggles which led to the birth of our National Health Service in 1978 and which over the time has been replaced by a purely biological view of health.

Roberto Polillo and Mara Tognetti

April 14, 2022
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