Paolo Barcello: Interview with Francesca Nava. The Pandemic System (Il sistema della pandemia), first publicated in Italian in: Erbacce. Forme di vita resistenti ai diserbanti (November 7, 2020), online in: https://www.erbacce.org/il-sistema-della-pandemia/
As a freelance journalist and documentary filmmaker for Rai 3 Presadiretta, TPI and other newspapers, Francesca Nava closely followed the spread of the pandemic in her native Bergamo. She has drawn from it various studies and a book, “Il Focolaio. From Bergamo to National Infection” (Laterza publishing house), which now seems all the more important in view of a new increase in cases, hospitals under pressure, new containment measures. With care and intelligence, Nava focuses on the essential issues to fight an epidemic that could have devastating consequences because of the way it cuts through the structural limits of our system of production and consumption and our conception of health and public health. As she tells us in this interview, the challenges of the pandemic go far beyond the discovery of a vaccine.
Lombardy is seen as the advanced part of Italy, its productive heart with a state-of-the-art healthcare system. Certainly, healthcare is available in the region and people are being treated, but Covid-19 has uncovered contradictions and short-circuits in this system. In your opinion, what was the main cause of the slump in the spring?
The quality of health care in Lombardy is there, it is hospital excellence. When a person needs a particularly innovative cancer treatment or high-tech operations, they come to Lombardy. However, this hospital-centered model, which was strongly influenced by a private logic of high technological specialization and purely curative medicine, showed all its limitations during the pandemic. Our region has a mixed health care system in which the private partner’s facilities receive about 40% of current health care expenditure. But private health care is not at all interested in less profitable sectors, with a modest profit margin compared to huge investments in equipment and operators, such as prevention, emergency and first aid departments.
The private sector earns according to the number of sick people and the nature of the diseases, and when prevention takes away sick people and diseases, profits fall. Healing counts much more than prevention. This even applies to examinations: Private institutions choose to accredit themselves for some examinations and not for others, which are more expensive.
The Region of Lombardy has applied the logic of the private sector to the public structure as well, reducing all territorial medical services to a minimum. For this reason the alarm system did not work. First aid and hospitals in Lombardy have become the first and last trenches of citizens without answers and reference points. The abandonment of basic medicine, the weakening of prevention, the lack of investment in home care and the lack of coordination between the hospital and the territory have contributed to the catastrophe that we experienced in the first wave of the pandemic and that is now happening again. In Lombardy we had a mortality rate in intensive care of 55%, compared to a national average of 25% to 40%, because a great number of patients were hospitalized at the end of their life. If the goal is the excellence of the hospital, it is obvious that the area is exhausted and no longer serves as a filter. Many insiders have been saying for a long time that it is necessary to change the philosophy behind this health model, starting from the needs of the community and not just the individual. We must work to ensure that patients do not arrive at intensive care units and receive care earlier, outside the hospitals. Those who study epidemics know that they are combated with careful planning and, above all, with preventive services. But prevention – we know this – does not create consensus, it does not bring votes.
Given the work you have done for the book and your recent surveys, what do you think is the scope for reform of the Lombardy health system?
The health model in Lombardy revolves around an experimental law of 2015, the so-called Maroni Reform, which expires at the end of the year. A reform that has fragmented the health system, halved prevention and weakened local medicine, creating a mixed public-private system that is often unbalanced in favor of the latter. The majority that governs the Region of Lombardy has stated that it intends to revise this law, but many politicians and health professionals believe that it should be radically changed or, better still, replaced.
In March, some doctors at the “Pope John XXIII” hospital in Bergmao – in view of the health collapse of the first wave – highlighted some critical points in a letter published in the scientific magazine New England Journal of Medicine (NEJM) and proposed amendments, saying that “this epidemic is not a phenomenon that affects only intensive care, but is also a humanitarian and public health crisis”.
In particular, the letter stressed that “Western health care systems have been built around the concept of patient-centered care (an approach in which clinical decisions are guided by the needs, preferences and values of the patient). But an epidemic requires a shift in perspective towards a community-centered approach to care”.
In conclusion, the doctors of Bergamo wrote: “This catastrophe could only be avoided by a massive deployment of community services on the territory. To cope with the pandemic, solutions are needed for the entire population, not just for the hospitals”. And they continued with a list of measures to be taken immediately. To date, nothing has been done. The same group of doctors – strongly criticized by the health administration of the hospital to which they belonged – recently promoted another open letter to the institutions with detailed proposals for the reform of the health system in Lombardy, with special attention to the territory and primary care. In practice, we are faced with the task of implementing structural interventions, especially outside the hospital. An emblematic signal that goes beyond the pandemic emergency. Almost 800 health care workers in Lombardy have signed this document: Doctors in hospital and primary care, nurses, pediatricians of free choice, who have already made initial contacts in the region and at the Health Commission in Rome.
The need to reform healthcare systems based on primary care and integrated social and health services is also the proposal of the “2018 Primary Health Care: Now or Never” campaign, which will present the “Towards the Blue Book. An open manifesto for the reform of primary care in Italy” (“Verso il libro azzurro. Un manifesto aperto per la riforma delle Cure Primarie in Italia”) project in the coming days. The aim is to trigger a collective and participatory process that will lead to a radical change in territorial health care: It’s now or never! A real call to all professional and non-professional associations, stakeholders and people who want to participate in the collective elaboration of a proposal for the reform of primary care in Italy. The project was born to be shared with others, and initiates a process of lifelong education that lays the foundations for the creation of a common vocabulary. In short, something is moving.
In your book, you have made many reflections on the responsibilities of regional and national institutions in the Lombardy disaster, when, for fear of an economic catastrophe, they did not want to stop productive activities, or only partially. In recent weeks, the climate has become violent again and economic tensions over health are increasing. How will the institutions act and to what extent will they be able to take on important tasks? And above all, who will be able to do so?
I believe that the challenge facing governments around the world, namely to find a balance between health and the economy, is a challenge of epochal proportions. It is clear to everyone that no country is currently able to do this. The leitmotif, repeated in chorus by those who govern and escape unpopular measures such as lockdown, is: “We must learn to live with this virus”. Unfortunately, however, people forget that in order to live with a new and highly contagious virus, you have to be prepared in time. Failure to contain small outbreaks, to create special structures, to isolate infected people, to plan the needs of health workers and, above all, to take preventive measures, will always catapult us into necessary, more or less extensive closures. In this context, the economist Mariana Mazzucato, in an essay just published for Laterza with the emblematic title “Let’s not waste this crisis”, offers us some interesting ideas that go beyond the purely health-related aspects.
“Everywhere, states are using economic stimuli while desperately trying to slow down the spread of the disease in order to save lives and prevent economic collapse. And yet there is a problem, Mazzucato emphasizes: intervention would require a very different structure than the one chosen by governments. Since the 1980s, governments have been called upon to take a step back by letting companies take the lead and create wealth, and to intervene only when problems arise in order to solve them. As a result, governments have not always been sufficiently prepared for crises like Covid-19. In addition, there is a lack of a safety net for people working in societies characterized by growing inequalities, especially those who work unprotected in the gig economy and the informal sector.
Today we have the opportunity to use this crisis to understand how we can make capitalism different. We need to rethink the role of the state: instead of simply correcting market failures, governments should take an active role by designing and creating markets that deliver sustainable and inclusive growth and ensure that partnerships with companies that receive public money are driven by the public interest, not profit.
Unfortunately, however, not even the little we could do has been done, and now, to chase the consensus, we are chasing the virus and taking half-hearted and belated containment measures that are often ineffective or even counterproductive.
Perhaps the right key to our approach to Covid-19 comes from the editor of the scientific journal The Lancet, Richard Horton, who, in an editorial at the end of September, defines Covid not as a pandemic but as a syndemic, with the words synergy, epidemic, pandemic, endemic. His approach explores the synergistic interaction between two or more diseases and the social situations in which pathological states occur, taking into account not only the classical biomedical definition of comorbidity states, but also the interaction between genetic, environmental and lifestyle factors.
The main consequence of classifying Covid as a syndemic is to emphasize its social origins. The vulnerability of the most vulnerable people, such as the elderly and the necessary labor force, who are generally poorly paid and have less social protection, highlights a truth that must be taken into account: no matter how effective a treatment or vaccine is, the search for a purely biomedical solution for Covid-19 will not be successful. If governments do not establish policies and programs to eliminate the deep social inequalities that exist today, our societies will never be truly safe.
Covid is established and thriving not only for health reasons, but because it finds conditions that have their origins in the inequalities of the political, economic and social systems.
If we do not address the systemic causes, which include education, employment, housing, nutrition and the environment, we will never really defeat the pandemic.