The state of the National Health System is one of the main concerns of Italians. Yet not even the significant resources of the National Recovery and Resilience Plan (NRRP) seem to have set it on a path to make it capable of facing the challenges ahead, leveraging the lessons of the pandemic. This contributes to increasing inequalities between generations and between people of the same age.
When talking about inequality, the reference is almost always to income gaps. However, differences in people’s health conditions are often much more pronounced than differences in income levels. Gabon has an average income, in purchasing power parity terms, of more than a third of the average income in the United States; but in Gabon five out of every hundred live births die in the first year of life, compared to five out of every thousand children in the United States. There are also profound differences in life expectancy within the United States: those born and raised in rural areas, a significant base for Donald Trump, live on average up to 30 years less than those living in large cities. Gender differences are also becoming increasingly apparent: women live longer than men but are more likely to suffer from diseases that cause pain and disability.
Unequal ageing and youth ill-being
Over the past 70 years we have gained about two years of life per decade thanks to extraordinary medical advancements. But the increase in longevity is not equal for everyone, and the likelihood of ageing in good health is even less equal. The presence and intensity of cognitive decline and diseases such as Alzheimer’s allow for very different lifestyles among people of the same generation.
Neurological diseases and depression create profound differences not only among seniors of the same generation, but also between different generations. Until 15 years ago happiness, the wellbeing declared by individuals, had a U-shaped curve, with the peak of depression coinciding with the so-called “mid-life crisis”. People used to struggle the most in their 50s. However, depression is higher today among young people than in any other age group. It is mostly girls under 25 who are distressed, scared and depressed, while things gradually improve with age. The issue of children’s mental health and youth depression is a true social emergency forgotten in countries where voters and elected officials are getting older and older (as documented in the previous issue of eco).
Coverage and quality of health care play an important role in generating growing divergences in life expectancy and quality of life. But simply introducing universal free healthcare programmes is not enough to break down differences in health status and longevity. Despite the UK’s universal access to health care since the immediate post-war period, free health care for all has gone hand in hand with increasing health disparities among British families over the following 40 years. Even in Italy, a country with a healthcare system that offers, at least in principle, universal coverage, there are significant differences in life expectancy, especially healthy life expectancy. As documented below, those who live in Naples live on average four years less than those who live in Trento and, more importantly, this gap seems destined to widen because the increase in life expectancy is higher in the regions where people were already living longer to begin with. At the same time, differences in health status based on income level are increasing. The gap in life expectancy between the richest 20% and the poorest 20% in wage distribution is wider among the generations of the 1950s than among those born in the 1930s and 1940s.
The emergency within the emergency
To ensure that everyone has access to adequate health care, it is important to match the supply and demand for health services. The congestion of emergency rooms in various parts of Italy is a main indicator that this match is currently lacking. Many people turn to emergency medicine because otherwise they would face long wait times for diagnostic tests and treatments. Furthermore, there is a shortage of general practitioners capable of better guiding the demand for health services. At the same time, emergency rooms struggle to recruit staff even to handle actual emergencies, resorting to temporary personnel (gettonisti), often recent graduates with no specialisation. In fact, the shortage of general practitioners is compounded by shortages of specialists in emergency medicine and nurses, leading, on the one hand, to increased patient inflows to emergency rooms and, on the other, to reduced outflows to hospital wards. As a result, many people are kept in the emergency room, often on stretchers, for days on end. This is a full-blown emergency within the health emergency.
However, the congested nature of our emergency rooms is only one aspect, although perhaps the most visible, of the failure to match supply and demand for health services. It is then legitimate to ask: why, faced with a growing demand for doctors in key roles, is the supply not increasing? In Italy, medical training is heavily subsidised. Studying medicine costs much less than in other countries, which should lead to an increase in the number of people choosing to study medicine. However, the average income of doctors is also significantly lower than elsewhere. When deciding on their field of study, people consider not only the immediate costs they will face – in our case, among other things, tuition fees, possible relocation, loss of earnings because they are not working while studying – but also the return that this initial investment will produce in terms of career opportunities and future income. And doctors in Italy are paid much less than in other countries. Moreover, for a long time, the number of grants for specialisations has been completely anachronistic given the demand for health services and the number of graduates, with the result of pushing many future doctors, on whose education our educational system had already invested heavily, to emigrate.
Artificial intelligence to “read” health data
Beyond differential access (or lack thereof) to health care, cultural, environmental, social and work-related factors profoundly affect living conditions, diet, and disease prevention. The most effective treatments for some conditions are often too expensive even for the most generous of national health systems. In fact, longer life expectancy has coincided with many diseases that were previously terminal becoming chronic, and chronic disease treatments are very expensive. The economic sustainability of medical advancements, given an aging population more exposed to the risk of developing these diseases sooner or later, requires much more accurate and targeted preventive diagnostics. This applies especially to people with clinical profiles that increase the risk of the diseases occurring. To do this, it is necessary to allow health professionals and those with the skills to read and interpret health data to access this information. Artificial intelligence can be a very powerful tool in expanding prevention because it can read clinical tests in a way that complements what the doctor’s eye can do. It is very concerning that in Italy there is a negative culture towards data access. It is also concerning that there is still a strong degree of vaccine hesitation, which entails high costs for the health system in treatments that could be avoided and puts everyone’s health at risk when there is hesitation regarding vaccinating against contagious diseases, as we learnt very well during the pandemic years.
Working conditions – the place where we spend a substantial portion, in some cases the majority, of our time (around 1,500 hours per year for Italian employees) – significantly affect our health. It is no coincidence that security personnel at age 50 have a life expectancy on average five years shorter than those working in a ministry. The incidence of work-related deaths, non-fatal injuries and occupational diseases is concentrated in a small number of activities: construction, transport and agriculture. Immigrants, who often do the jobs that Italians no longer want to do (leather tanning, fruit and vegetable picking, machine sewing, caregiving, maritime work) are particularly exposed to these injuries, especially when they are undocumented and have temporary jobs. Regularisation and naturalisation of immigrants can play an important role in reducing this aspect of inequality by improving, as we document, the quality of work especially for those who start at a greater disadvantage.
Health expenditure will inevitably increase in the coming years due to the rise in the share of the population requiring more frequent medical care. Italians, unsurprisingly, indicate in opinion polls that healthcare investment should be a government priority, and yet we are at a standstill. This is even more surprising because with the NRRP we received 69 billion euros in grants from Europe and 123 billion euros in low-interest loans, plus 30 billion euros allocated from the Complementary Fund. Since these resources were granted in the aftermath of the pandemic, it was reasonable to expect that we would use these significant resources towards a definitive solution to the country’s number one problem, starting by building a true territorial healthcare system. It is indeed paradoxical that, after receiving these enormous sums the EU, we find ourselves discussing the health crisis as if almost nothing had happened. And instead of getting closer, the solution is moving further away, because in the meantime, with the NRRP and the home renovation bonuses, we have taken on almost 20 % of national income in additional debt. The decree approved by the government on the eve of the European elections is an acknowledgement that there are no additional funds for healthcare.
In short, health, especially the health of children, is an emergency for our country, and in recent years our health system does not seem to have reduced in any way its vulnerability to events such as a new pandemic. There is ample room for improvement if we make the best use of the data already collected by our health system and learn from the positive lessons as well as the mistakes of other countries.
Our commitment, little as it may be, to our readers is to continue focusing on health issues and how to make health spending sustainable and more equitable. It will, from now on, be a regular feature in our magazine.
direttore@rivistaeco.com
