It is a day in mid-August in Phnom Penh, in Cambodia. A mother is giving birth to a child in a hospital and she doesn’t have the money for the necessary Caesarean. She dies. There is no sanitary system protecting her. Across the globe, part of the world dreams of vaccinations in order to be free from the nightmare of terrible diseases. These would be harmless like measles if there was vaccination, Part of Italy and of California believes the fairy tales of the “no vax” movement and another part resists the reintroduction of compulsory vaccinations. Part of the world without access to universal vaccination looks at these Europeans and Americans who are doubtful about the necessity of universal vaccination for some diseases - which need to be eradicated - and thinks that we are crazy. The wealthy can lose the understanding of the true proportions of problems.
We need Peace. There is no greater waste of resources, of humanity, than war, even if some make a profit out of it. European and Western democracies are weakened and struggle to give proper answers to growing inequalities. These inequalities and the absence of growth favoured the rise of populist movements that intimidate democratic ruling classes. Inequality is the great challenge for all democracies in this time of globalization and social media. Health is a huge, fertile terrain of planet-sized inequality which is present within every country and can be tackled now.
Health is measured by the capability of producing life. For this, the new human right of the XXI century is called health. It coincides with life. But how is it achieved? I speak on behalf of a country that has the highest life expectancy at birth in Europe for women, the third highest for men, placing itself second in the world, together with Japan. Italy has a national health service that, compared to similar countries like Germany, France and the United Kingdom, has lower total costs. 147 billion for 60 million of citizens, 113 of which are public and 34 private, ranging from out of pocket expenditure in the form of citizens’ contributions to insurances. Public sanitary expenditures for each Italian citizen average at 1.838 Euros. Naturally this depends on the region, with peaks ranging from 2.300 to 1.750 Euros.
To this day, the yearly sanitary expenditure per capita for a US citizen, is the highest in the world, averaging at 9.237 $, a little less than 8.000 Euros. For a Somali citizen, however, it only amounts to 27 Euros, 33 dollars. This figure is enough to understand the huge differences existing in the world in terms of sanitary expenses, which in turn result in dramatic variability in terms of health and access to healthcare. The global average in the world is around 1.279 $, just over 1.000 Euros. But, obviously, funds are not enough, as the US takes a very poor place regarding life expectancy at birth. It is ranked 50th for the likelihood that a 15-year-old boy will reach the age of 60, and 63rd for the risk of maternal death. According to the Centres for Disease control and prevention, half of maternal deaths in the US are avoidable. The key point is not only the existence of services, but its accessibility and distribution.
The saying: politics is too serious to leave it to politicians alone. But health is also too important to leave it to physicians alone. Because it depends on the nature of the whole society.
Equality in health is a an uphill journey, but it is not impossible. It depends on access to healthcare, quality of supply, distribution, but also on everything that revolves around it. This would demand pre-school education, infrastructural improvements in neighbourhoods, overcoming the tendency towards what J.K. Galbraith 60 years ago described as “private opulence and public squalor”, which is indeed a visible trend, from Johannesburg to Rome.
A child born in the poorest area of Washington DC, Houston or Manchester has a far greater chance of living 20 years less than one born in the richest area of the same city. And the same applies to Europe, if one is born in the poorest part of Kaunas, or Tallinn or Budapest, instead of in the richest part. For girls the situation is less dramatic, as the difference in life expectancy can be five or six years, or two years if one is born in Italy. But if one looks at London, Inner London and Outer London, life expectancy at birth among males in the five year period between 2006 and 2010 varied from a minimum of 73.5 years to a maximum of 84.6 years, which is a span of 11 years. If one looks at infant mortality, it is possible to see how the European Union is a great mitigating factor of inequalities and that inequalities in life expectancy at birth have diminished by 10% among males and by 3% among females.
There are differences regarding infant mortality within Europe. Thanks to the EU the gap has diminished. Between 2002 and 2004 16 more children died in the five poorest European countries than in the five richest. Now this gap has gone down to ten children more compared to 2010.
At first glance there are unexpected inequalities even among highly developed countries. The UNICEF Innocenti Report compares levels of childhood wellbeing in the European and American continents’ highest income countries and the changing occurred during the 2000-2010 decade. It sees Sweden dropping from the first to the fourth position, Norway rising from the fifth to the second, Holland from the second to the first, Germany ascending from the 7th to the 5th, Spain falling from the 13th to the 20th, Italy stable like Canada at the 14th position. But the US remain ranked 20th both at the beginning and the end of the decade. Last position shared, in 2000, with the United Kingdom, which rose to the 16th position in 2010. It is the synthesis between material wellbeing, education, behaviours and risks.
Thousands of surveys on important diseases and social disadvantages, such as obesity, smoking habits, diabetes have focused on different social and genetic groups. Invariably, even in the case of strong genetic factors, like obesity in twins, it is possible to come to another variable, which is the social gradient and, finally, the degree of education. Marmot reports a famous coloured map of the US, covering the period spanning from 1985 to 2010, where the intensity of green represents obesity and white represents its absence. It starts with an almost completely white map of the United States with light green in the east and California, arriving - in the new millennium - to an “all green of medium intensity”. This represents the 10% and the 19% of the population with obesity, up until our decade that sees an all emerald green occasionally blending to a deep night green, with minimums of 20% obesity and beyond 30% in Texas and other States. Genetics do not matter that much and what Marmot calls “the life-line”, that being the “waistline”, the abdominal circumference of the planet branches out, but it is not healthy. In Egypt and Mexico 70% of women is overweight, due to what is defined as Coca-colonization. In low-income nations, getting fat can be a public signal of victory over poverty. But when the development rate grows, behaviour patterns in a country get closer to those of richer countries: the higher the education level, the lower the obesity rate.
We have already seen that in Europe we are not all the same: not only at 25 years of age the average life expectancy goes from 46 more years or a bit more in Estonia, Hungary and Romania for men aged 54-55, 8 or 9 years more in Norway, Sweden and Italy. But if one relates this figure to the level of education, it is possible to see that men with a higher education level in Estonia get closer to the Italian or Swedish average, with a yearly 53, while those with a low education level fall even to 37 or 39 in Hungary. In the Czech Republic this variation goes, for the low education level, down to 40 years and exceeds the average of the countries with an higher life expectancy with 56, 57 years for the most educated part. (Eurostat)
A good health, as we know, is not only a matter of medicine. Medical science everywhere knows how to make giving birth totally safe both for mother and child. In Italy, a world leader in this field, there is one maternal death on every 17 thousand women throughout the whole of fertile age. But in the US, as noted by Michael Marmot - to whom we should all be grateful for his studies on “unequal health” - we count only one maternal death on every 1800 girls of 15 years in fertile age.
Also in Japan, the country with the strongest life expectancy at birth, there are inequalities.
It also applies to Japan
In The Lancet Shuhei Nomura and colleagues use trend data for burden of disease between 1990 and 2015 to document comprehensive health measures on mortality, morbidity, and injuries and variations across prefectures in Japan. Between 1990 and 2015, average life expectancy has increased by 4•2 years. Although similar rises have occurred between men and women, the gap between the lowest and highest prefectures widened from 2•5 years in 1990 to 3•1 years in 2015. The average health-adjusted life expectancy (HALE) overall increased by 3•5 years over this period, but the disparity between HALEs in the highest and lowest performing prefectures has slightly widened across the period, from 2•3 years in 1990 to 2•7 years in 2015.
This study also shows prefecture variations in burden of diseases; for example, Shiga prefecture located in the western region of Honshu island has the highest number of diseases with mortality rates that are significantly lower than the national mean, hence Shiga has the highest life expectancy at birth in 2015. By contrast, Aomori prefecture in the most northern part of Honshu island has the highest number of diseases with mortality rates that are significantly higher than the national mean. For example, in Shiga the age-standardised mortality rate in 2015 for ischaemic heart disease was 39•8 deaths per 100 000 individuals, whereas in Aomori the mortality rate was 50•1 deaths per 100 000 individuals; the national average was 44•7 deaths per 100 000 individuals. Such large variations in age-standardised mortality rates across prefectures should prompt further investigation of the causes and policy interventions to minimise the prefecture gaps.
Within Italy there is huge inequality as well. These inequalities have to be held accountable for much of the sanitary mobility. From Cagliari to Milan, on Monday morning, aircrafts are stocked with families going to Lombardy in order to grant their dear ones proper healthcare. In 15 years the LEA (Italian acronym for Essential Levels of Assistance) have been integrally implemented in merely 8 out of 21regional entities and territories, between 2002 and 2016. The main reason of this is a regional autonomy in the sanitary sector that is used in a non-appropriate way. The constitutional referendum, rejected by the people, reintroduced a principle of equality and a key role for the State in order to achieve major equilibration. It is necessary to work towards equality in other ways now.
There are 21 sanitary services in Italy, one National Health Service that with fewer beds per person and with less per capita spending than other European countries - and an overall low budget - remains an example of General National Health Service. It is affected by inner instabilities and enormous inequalities. There are 45 caesarean sections in Campania and 14 in Trentino; hospitalizations for acute diseases amount to 2,2% in Campania and twice as much in the bordering region of Puglia; sanitary expenditure per capita of 1724 Euros in Calabria and 2160 in Val d’Aosta. But there are even more differences within social expenditure: 77 Euro per person in Sicily, 277 in Val d’Aosta, 167 in Emilia Romagna, 122 in Lombardy. 46 in Campania e 27 in Calabria. Life-saving medicines are free of charge in one region while they are not available in another region. The average social cost per person on the city’s budget equals 117,3 Euros. If one looks at disability related expenses, besides a national fund for non-self-sufficiency, an important effort is made. There are differences that are hard to justify and explain fully: disability related social expense per capita rank first in the autonomous province of Bolzan with 21.268 Euros per person affected by disability. This expenditure is almost double the expense in the bordering autonomous province of Trento (12.417 Euros), that immediately follows her in the ranking. Far higher expenditure than the national average (2.990 Euros) are found also in Sardinia (8.517 Euros) and Friuli Venezia Giulia (7.604 Euros). On the contrary, the lowest expense per person affected by disability is registered in Val d’Aosta (307 Euros) and immediately before Calabria (469 Euros).
Nurseries and kindergartens. According to ISTAT data, in the academic year 2013/2014, 13,459 units of social-educational services for early childhood were surveyed in the national territory, of which 35% were public and 65% were private. For children under three residing in Italy 360.314 places are available, covering 22.4%.
For social-educational services aimed at early childhood, City Councils have spent around 1 billion 559 million Euro in 2013: 3% less compared to the previous year.
In 2012 and 2013 households contributed around 310 million Euro to the City Councils funds. Within the 2003-2013 decade, the share of household contributions has increased from 17.5% to 20% of the total Municipal expenditure for kindergartens.
Territorial differences in the amount of children benefitting from public services or services funded by the public sector are still strong. In northern Italy, public and private facilities cover 28.2% of the children under the age of 3, while in the South there are 11,5 places for every 100 under age residents. Over 17% of children living in the North are accepted in Municipal Services or services funded by Municipalities. In the South it is less than 5%.
What should be done in order to reduce mortality and improve health?
Weird as it may sound, we need to invest in education. The WHO (World Health Organization) Commission on Social Determinants of Health shows that in all countries with a high infant mortality rate, it is doubled or tripled when a mother is totally uneducated, compared to children with mothers educated in the same country. In the spectacular case of Mozambique - so dear to the community of Sant’Egidio - depending on the degree of education, for every 1000 children born alive, 60 to 140 die with an average of 120.
Inequalities become even tougher when we move from numbers to living things, like life expectancy free of disability for elderly over 75. In Trento, Bolzano, just like in Lombardy and Emilia Romagna, the elderly can count on 9 more years to live happily autonomously, while in Sicily and Campania it does not exceed 6.2 and 7.4 years respectively.
Even the proportion of people refusing to be cured because of extreme costs or waiting lists varies dramatically from one area of our country to the other, with the South usually lagging behind. 15.3% in Campania, 13.9% in Apulia and 11.6% in Calabria just can’t afford the expenses, while in Trento less than 1% of the citizens renounces healthcare and in Piedmont, Friuli and Basilicata (a happy exception in the South) the percentage is still around 3%.
Chronic diseases and aging of the population are inevitably intertwined. For the first time in the last few decades, there has been a decline in the population in Italy, largely due to the negative death / birth ratio.
Today immigrants and refugees, who may well be part of the solution in the rebalancing of the pyramid - nowadays upside down - of ages, retirement accounts, population rejuvenation, and competitiveness per capita of the employees, are perceived - in an irresponsible way - merely as a problem. And keeping them in the limbo of a temporary status for too long causes the loss of great opportunities for development and increases anomy, fragility and insecurity. 65 million forced refugees in the world and less than 4 million in Europe, 180 thousand a year in Italy - who are less than the 250 thousand that would be needed at least for work reasons, contributory rebalancing and population renewal - cannot be considered an emergency. And there are strong movements that demand to exclude them from any sanitary protection. The highest percentage of abortions and violence on women regards immigrant women.
Even among the Italians, the differences remain enormous. Meanwhile the necessity to learn how to live with chronic diseases is turning into a key health issue. The answer lies in reducing a hospital-centred healthcare model, bringing the majority of non-emergency and non-acute care to local services even in cases of oncologic patients. Another part of the answer is unblocking resources which are nowadays absorbed by the hospital system, reducing the fatigue of living to access health services, as well as times and travel related stress, enhancing local services, homes, family and social networks, reconfiguring the capillary networks of pharmacies and services as local services, and delivering specialized home assistance, re-energizing social solidarity.
North vs South
Chronic illnesses also reflect the social disparities affecting the country: an emblematic example is the prevalence of chronic diseases that goes up to 4% in the age group 25-44. Among graduates it falls down to 3.4%, while in the population with the lowest level of education it rises up to 5.7%. This is just one example in a wide range of disparities. In terms of health conditions, territorial inequalities are evident. Let’s try to simplify the matter: in 2015, a citizen of Trento could hope to live on average 83.5 years, while a Campania resident had a life expectancy of only 80.5 years. And the South is still lagging behind concerning the reduction of mortality. Over the past 15 years, mortality has declined throughout the whole country, but such reduction, especially for men, did not affect all of the regions: it decreased by 27% in the North, 22% in the Centre and 20% in the South.
In conclusion. Health is the essential right of the 21st century, like the right to peace. It is a part of it. Investing in health, including education, is the key to reduce social conflicts and inequalities, including that inequality which is the mother of all inequalities: fewer years of life to be lived. For the Roma people (Gipsy), for the outcasts, for the many Souths of the world and of our own home.