Questo documento ha una versione in italiano: Storie dell'assistenza sanitaria pubblica

Dieses Dokument gibt es auch in einer deutschen Version: Geschichte(n) des öffentlichen Gesundheitswesens

Histories of public healthcare

Around the world, the Covid-19 pandemic is forcing governments to face the question of healthcare as a universal right that should be publicly funded through general taxation and feely available to all.

On March 17th, 2020, The Spanish Ministry of Health has announced that the government is putting all private hospitals in the country under state control indefinitely, to combat the spread of COVID-19 infections. “For the duration of this crisis the State will take control of all private hospital facilities and manage all of the resources for the common benefit of all of our people,” Ireland’s Health Minister Simon Harris declared on 24th March. In the UK instead, the NHS will need to ‘to rent 8,000 private hospital beds for £2,400,000 per day’. South Africa Department of Health spokesperson Popo Maja said in an interview with Business Report that the government was not looking to nationalise private hospitals because of the epidemic.

In this context, this session puts together some stories of how the national health services came into existence in various countries and thanks to important social struggles. What becomes apparent again and again is the link between pirate care practices, social struggles and the creation of publicly-funded welfare provisions.

(If you wish to contribute to cover other countries/region, please get in touch - contacts in the intro page).

Italy: Servizio Sanitario Nazionale (SSN)

Italy is a major case of policy success in health. According to the 2017 OECD data, life expectancy at birth in Italy is 83.1 years, compared to the 80.9 years of the European Union average: but the total health expenditure per inhabitant is 2,483 euros, against 2,884 of the average EU (a 15% gap). It is a paradox worth probing that the European country with the longest life expectancy has achieved this result with reduced spending. ).

The pressure for creating a public health care system in 1978 was born from an unprecedented alliance between left political forces, advanced experiences renewing medical practice, radical health activism, struggles by trade unions, workers’ groups, student and feminist movements.

The outcome – the 1978 reform – was a universal, public, free health service, offering a wide range of provision outside the market, largely modelled on the British NHS and reflecting the definition of health spelt out by the WHO in 1946.

Abandoning the tradition of a corporatist health system with its limited coverage of separate professional groups, Italy’s reform introduced a public and universal health service, financed through general taxation, freely available to all – not just to Italian citizens, but to all those living in the country.

In several areas – mental health, occupational health, women’s health, drug treatments - new knowledge on illness prevention, new practices of service delivery and innovative institutional arrangements emerged, with a strong emphasis on territorial services addressing together health and social needs.

Image from: L’Ambiente di Lavoro, by Ivar Oddone et al.

The intellectual guidance for Italy’s health reform came from personalities that combined strong competence and political commitment. Besides Franco Basaglia and his work on radical psychiatry, Giulio Maccacaro was the founder of ‘Medicina Democratica’, a radical health movement; Giovanni Berlinguer was a scientist and member of parliament for the Communist Party; Alessandro Seppilli was a public health specialist and Socialist mayor of the city of Perugia; Laura Conti was a key figure of the Socialist Party and pioneered the Italian environmental movement; Ivar Oddone was an occupational physician and a former partisan – he inspired a character in Italo Calvino’s first book.

Out of their work, an integrated vision of health – physical and psychic, individual and collective, linked to the community and the territory – emerged. A new, less hierarchical type of doctor-patient relationship was proposed; the model of a decentralized health organization was introduced, with elements of participation; the centrality of preventive medicine over cure was emphasised. As Giulio Maccacaro had argued in 1976, the strategy was a bottom-up “politicization of medicine”, challenging the way industrial capitalism was exploiting workers and undermining health and social conditions in the country.

This political strategy viewed health as combining a collective dimension and an individual condition; collective struggles were therefore needed to address the economic and social roots of disease and public health problems. This approach was paralleled by the feminist movement in addressing women’s health issues, including the important experiments in self-organized health clinics.

Decades of ‘managerial reforms’, cutbacks of funds and privatisation efforts have indeed lowered the standards of service, introduced ‘tickets’ paid for by patients, and led to a highly uneven capacity of services across Italy’s regions today.

One of the first actions by the Italian government on March 17, 2020, when the pandemic broke out, was to increase funds for the health emergency by 3 billion euros and to hire 20,000 doctors, nurses and supporting staff. This was a recognition of past policy mistakes – cutbacks, privatisation and commodification – and of the need to fully recognise the role of universal public health as an alternative to market provision.

The birth of Britain’s National Health Service (NHS)

Serving over one and a half million patients and their families every day, the NHS (National Health Service) is the biggest service of its kind in the world. It is universally regarded as a national treasure - the most remarkable achievement of post war Britain.

Yet the National Health Service very nearly did not happen at all. In the months leading to its launch it was bitterly opposed - by the Tory Party and the national press. But its most vicious and vocal opponents were the very people its existence depended on - surgeons, nurses, dentists and Britain’s 20,000 doctors. To get the NHS at all required the persistence and determination of one man - Nye Bevan, Labour’s minister of health.

Before July 1948, Britain’s 2,700 hospitals were run by charities or councils. The only people entitled to free treatment were those with jobs.

In 1945, the new Labour government came in on a manifesto that promised a revolution in health care. Health minister Nye (Aneurin) Bevan, wanted to build a health service based on four principles: it was to be free at the point of use, available to everyone who needed it, paid for out of general taxation, and used responsibly.

Bevan, who came from a miners’ family, was inspired by the Tredegar Workers Medical Aid Society in South Wales, a pioneering mutual aid scheme which provided medical benefits, dental care and funeral expenses to its members for just pennies a week.

Public health in the USA

SOURCE: (AUDIO) (EN) How the Bad Blood Started, episode 4, 1619, New York Times podcast. Hosted by Nikole Hannah-Jones. September 13th, 2019.

We begin this story in the fall of 1866, with a woman named Rebecca Lee Crumpler. Rebecca Lee Crumpler is a young black woman who was born free and raised in Pennsylvania by her aunt. Her aunt was a medicine woman. She used to go from home to home tending to the sick, and Rebecca liked to tag along and to help her. She liked it so much that she went on to become a nurse, and she was so good at being a nurse that she makes the really unusual decision to go on and become a doctor. So she eventually goes to the New England Female Medical College, which is a college that was specifically built to train women in medicine, and that’s really extraordinary. Because around the time she graduates, there’s about 54,000 doctors in the country, and only 300 of them are women, and only one of those women is black. And that woman is Rebecca Lee Crumpler. And so about a year after she finishes medical school, the Civil War comes to an end, and she makes another unusual decision, which is to completely uproot her life and to head down to the South because four million people have just been released from slavery into freedom. And Crumpler knows that it’s going to be a huge challenge to help these people assimilate into society and to address their many basic needs, including health care.

These were people who just literally were told, you’re free to go, but given no resources to go with. So they were forced to take up residence in abandoned prisons, former military barracks, empty churches, refugee camps. They’re crammed together in very close living quarters. They don’t have the tools necessary to maintain good hygiene. And as a result of all of this, they’re getting sick. But they can’t tap into any health care system, because at that time, there really isn’t any organized health care system to speak of. Most medical care is provided at home by family members, or by doctors who would actually visit the house. And the only hospitals that exist are much more like institutions for the very poor or for people who get sick and don’t have any family members to take care of them. And those facilities were private, and they were run by charitable groups. And when the newly emancipated turned to those facilities for help, they were turned away. They were told no. And they start dying in really high numbers, so much so that in some towns and cities, their bodies are littering the streets.

This is a massive public health crisis. And so to deal with this crisis, the federal government creates what ends up being the nation’s first federal health care program. It’s called the Freedmen’s Bureau Medical Division. And this is what Rebecca Crumpler is heading south to do.

One of the crazy things about the Freedmen’s Bureau Medical Division, which is, it was founded in utter ambivalence. Officials wanted their communities clean enough to prevent diseases that might eventually spread into white communities, but they don’t want to provide any free assistance, because they’re worried that it’s going to create dependency among the black American community. And so what they do is they open these hospitals, and they staff them with a few doctors. But then they close them down at the first sign of progress, and they refuse to send resources that their own doctors, including Crumpler, are requesting.

As you have all of these people dying from preventable things, a theory emerges.

And the theory goes that this high death rate is actually just nature taking its course. So black people aren’t dying for want of basic necessities, they’re actually dying because they’re biologically inferior to whites and ill-suited for freedom. The argument became that African-Americans specifically were literally going extinct, and that to provide any type of funding or resources to fight that would be wasteful and foolish, because you’re just trying to prevent the inevitable.

So this is the first example of government-funded health care, and it is an example of something that was set up to fail.

And Rebecca Lee Crumpler understands this, and she decides to write a book. It’s called the “Book of Medical Discourses in Two Parts.” And it’s not addressed to her colleagues in the white medical community or to segregationists in Congress. It’s addressed to the black community, specifically to black mothers and black nurses. And what she tells them in this book is how to take care of themselves, how to prevent diseases like cholera, how to treat basic ailments like hemorrhoids and bronchitis. And what’s so profound about this book is that she’s telling black Americans, you’re not inferior. You’re not going extinct. You can take care of yourself.

Fast forward to January of 1947. President Truman wants a government-run health insurance program that everybody pays into ahead of time and that people can draw from when they need it.

By the time Truman’s giving this address, the nation’s health care system has grown up a bit from the days right after the Civil War, but not by much. All of the hospitals that were created through the Freedmen’s Bureau have been closed down except for one that’s in Washington D.C. And other hospitals have been built, but there’s not nearly enough of them, especially in the South. And to make matters worse, the hospitals that do exist are all segregated. In fact, a “separate but equal” clause had actually been written into the law. And what that meant was black patients had to either go to their own black facilities, which were few and far between in a lot of places, or they were relegated to the basement wards of white hospitals, and those wards were small, and they did not provide as good care as you got in the white facilities.

But it’s not just black Americans who are not getting enough care. It’s many poor white Americans as well. So at that time, most Americans were not insured. And the insurance that did exist was employer-based, which means you had to get a certain type of job where the employer actually offered this benefit, and then you could have it. Basically, the whole system is not working, and Truman sees this as one of the most pressing problems the country is facing. And so he decides that national health insurance is the fix.

But then, days after Truman wins the election, the American Medical Association, which is the largest and arguably the most powerful professional organization for doctors in the country, launches this massive campaign to take it down. What the A.M.A. understands is that a national health insurance program is probably going to hurt their profits.

The A.M.A. hired a P.R. firm. It’s actually the first political consulting firm in the country. And together, they devised this plan to completely torpedo universal health care. What it looks like is all-out war. It’s radio ads. It’s newspaper ads. It’s magazine ads. They’re delivering pamphlets and mailers to people’s homes. In the end, they send some 100 million pieces of literature all across the country. And what’s on that literature and what’s in those ads is a campaign slogan. It says, “Keep politics out of medicine.”

And that campaign works. Popular support for the bill suddenly plummets. It fails to get through Congress, and the health care system the nation is left with at the end of this fight is still too expensive for most Americans to afford and as segregated as it has ever been.

Medicare is actually born from the ashes of Truman’s failed national health insurance program. Beginning under President Kennedy and continuing under President Johnson, under Montague Cobb’s leadership, the nation’s black doctors (who had formed the National Medical Association, or the N.M.A., because they were excluded from the A.M.A.) come out in full force to support Medicare. They lead protests, they lobby Congress, and they launch their own public relations campaign explaining to the nation that, in fact, this won’t destroy medicine. This will make medicine more equitable. And their message is what it’s been for a long time: Health care is a human right, and that any program that expands access to health care is the duty of a free and democratic society. Meanwhile, the fight for civil rights is escalating all across the country outside of the medical world.

Of course, that effort culminates in the Civil Rights Act of 1964, which says that discriminating on the basis of race is unconstitutional. And more specifically, it says that the government can pull federal dollars from any facility or entity that does not comply with the law, and that includes hospitals.

And so Medicare passes in 1966, and what happens is within four months of implementation, nearly 3,000 hospitals desegregate. But of course, the health disparities between black Americans and white Americans persist to this day.

Further Resources

COVID Ready Communication Playbook for Medical and Front Line workers A crowdsourced playbook put together by VitalTalk (a start-up based in Seattle) to provide some practical advice on how to talk about some difficult topics related to COVID-19 Available from their site for free download in: Arabic / العربية, Chinese (Simplified) / 中文(简体), Chinese (Traditional) /中文(繁體), Czech / Čeština, Danish / Dansk, Dutch / Nederlands, English / English, Finnish / Suomen Kieli, French / Français, German / Deutsch, Hebrew / עברית, Hindi / हिन्दी, Italian / Italiano, Japanese / 日本語, Norwegian / Norsk, Portuguese / Português, Russian / Русский, Spanish / Español, Swedish / Svenska , Tagalog / Tagalog, Vietnamese / Tiếng Việt