2021-4204-AJMS-HIS – 22 APR 2021

th 1 Public Health Institutions in in the 20 Century 2 3 Only recently studied by Italian historiography, public health is one of the 4 most important sectors of a modern system. During the Twentieth 5 century Italy faced the hygienic and sanitary problem often with different 6 ways and tools than other European countries. The aim of this article is to 7 understand better the attitude and the development of the main public health 8 institutions, both at the central and peripheral level, during the three great 9 phases that marked the in the last century: the liberal age, 10 fascism and the Republic, as well as to highlight the organisations, men and 11 structures that exercised decisive functions in the bureaucratic and 12 administrative State machine. The essay focuses on the most significative 13 legislative measures (for example, the “Testi Unici” of 1907 and 1934) and 14 the turning points that have changed the sector on the institutional plan, 15 from the creation of the Directorate-General for Public Health inside the 16 Ministry of the Interior, and destined to remain for the entire Fascist period, 17 to the birth, in the post-war years, of the High Commission for Hygiene and 18 Public Health, then replaced by the Ministry of Health, until the 19 establishment of the National Health Service in 1978. 20 21 Keywords: , social policies, public health, assistance, 22 institutions 23 24 25 Introduction 26 27 Italian historiography has only recently addressed the field of medicine 28 and public health. Until the 1970s historians had shown a substantial lack of 29 interest in the subject, treating it marginally and episodically by those working 30 in economic history and historical demography (especially modernists and with 31 approaches not always integrable to each other), and which had epidemic dis- 32 eases as their object of privileged research. The only exception is the 1967 vol- 33 ume by Renato Alessi on the Italian health system, published on the occasion 34 of the congress celebrating the centenary of the laws of administrative unifica- 35 tion (Alessi 1967). The increase in attention paid to the living conditions of the 36 lower classes and to the links between political, economic, social and cultural 37 issues led to a broadening of horizons and to the development of a strand of 38 studies on public health which were certainly not very rich in contributions but 39 which had an autonomous distinction. The seventies was a turning point, grad- 40 ual and not linear, accompanied by a thematic expansion and a change in inter- 41 pretative trends. In particular, the research of contemporary historians has 42 evolved according to trajectories conditioned by political history, with an in- 43 evitable reverberation of the modalities and timing of the diffusion in our coun- 44 try of the methodologies of social history. 45 A fundamental contribution to national historiography was made by Fran- 46 co Della Peruta, who tried to focus his gaze on a more institutional direction of 47 the problem, through some very important essays on the administrative struc- 48 tures and health legislation of the liberal state (Della Peruta 1980). Other stud-

1 2021-4204-AJMS-HIS – 20 APR 2021

1 ies (such as those by Arnaldo Cherubini, Giorgio Cosmacini, et al.) have 2 moved along this line1. This direction reached perhaps its highest moment with 3 the publication of volume VII, entitled Disease and Medicine, of the Annals of 4 the History of Italy, published by Einaudi in 1984 and edited by Della Peruta 5 (Della Peruta 1984). According to Maria Luisa Betri and Edoardo Bressan, this 6 work concludes the most vital cycle of studies on contemporary health care 7 (Betri, Bressan 1989: 121). A few years later, in fact, a period of stagnation fol- 8 lowed. It will be necessary to wait until the early 1990s for a partial resumption 9 of research and, in this case the work of the Institute for Public Administration 10 Science of 1990, on the occasion of the centenary of the Crispine reforms, is 11 very important. This publication reserved a whole volume for the Social Ad- 12 ministration, which constitutes an important recovery of institutional issues, in 13 the wake of which other work has resumed, even though numerically rather 14 limited (ISAP 1990). 15 What emerges from the main studies, even the most recent ones, is the 16 predominant interest in the liberal age, which very often represents the term ad 17 quem for Italian historiography, that is, when the political ruling class, this is a 18 well-established opinion among historians, initiated the process of building the 19 Social State. It is therefore thanks to Giovanna Vicarelli that she analyzed in an 20 organic way the health policy implemented by fascism, until then little ex- 21 plored only by the essays of Domenico Preti (Vicarelli 1997, Preti 1982, Preti 22 1987). The more advanced the twentieth century, the publications on health 23 history becomes fewer. Historiography gives inadequate attention to the politi- 24 cal and institutional events of public health in republican Italy, which is quite 25 surprising, especially in view of the abundance of cohesive sources. If we ex- 26 clude the work of Saverio Luzzi, who reconstructs, intertwining social history 27 with the history of the institutions, the set of processes and political battles that 28 led our country to modify in the post-war period the hygiene conditions of Ital- 29 ians and health facilities (Luzzi 2004), the whole output is limited to a few 30 brief hints in works of a general nature, of other sectors or of Cosmacini's 31 works, where, however, the heart of the problem is the history of medicine 32 (Cosmacini 1994, Cosmacini 2005). It was only in the last period, thanks to 33 Chiara Giorgi and Ilaria Pavan, that some short but significant contributions 34 were made to the national health service and its establishment in 1978 (Giorgi, 35 Pavan 2018, Giorgi, Pavan 2021). 36 From this jarring point of view is the comparison with some foreign expe- 37 riences, where the government of health and hygiene policies have aroused 38 considerable interest and in several cases have intertwined the analyses in the 39 history of the institutions with a more attentive approach to the history of med- 40 icine and health. It was Anglo-Saxon historiography that devoted a very im- 41 portant space to this subject, starting with the approval of the National Health 42 Service in 1946, linking it to the construction of a welfare system and the con- 43 solidation of the modern European state.2

1Cherubini 1977, Cherubini 1980, Cosmacini 1980, Cosmacini 1982. 2Among the most significant works on the National Health Service British: Granshow 1988, Honigsbaum 1989, Timmins 1996, Briant 1998, Rivett 1998, Eversley 2001: 53-75, Webster

2 2021-4204-AJMS-HIS – 20 APR 2021

1 Research Objectives 2 3 This article analyzes the development of public health institutions in Italy 4 during the 20th century. The intention is to better understand the attitude of the 5 Italian State and the measures it has taken in the face of the health and hygiene 6 problem during the main stages of its history, the liberal age, fascism, and the 7 republic years, and to highlight the bodies, men and structures which exercised 8 decisive functions in the relevant bureaucratic and administrative machinery. It 9 becomes, therefore, inescapable to answer some questions: what is the legacy, 10 in the field of health administration, of the previous Kingdom of ? Are 11 there any elements of continuity or discontinuity between the three historical 12 periods listed above? 13 This essay inserts this examination into the evolutionary dynamics of the 14 Italian welfare state, which, from the beginning, acquired characteristics quite 15 peculiar to other European countries. It consists essentially of four sections. 16 The first addresses the liberal period, with the measures at the end of the nine- 17 teenth century that gave the Italian State a more suitable administrative struc- 18 ture to face the economic and social challenges linked to the phenomenon of 19 industrialization. These are the years that see Italy, like other European coun- 20 tries, committed to laying the foundations for the construction of a welfare 21 state, with a series of measures to support the most deprived sections of the 22 population. A straight transition occurred at the institutional level with the 23 creation in 1888 of the Directorate-General for Public Health at the Ministry of 24 the Interior, a body destined to have a long life in the Italian bureaucratic sys- 25 tem. During the Giolittian age, the “Testo Unico” on Health Laws was passed 26 in 1907, while at another significant moment it occurred in the immediate post- 27 war period, with the failed attempt to create compulsory health . 28 This objective was achieved by fascism, though only in 1943, when the re- 29 gime was close to falling. It is precisely the fascist dictatorship that is the focus 30 of the second section, which will highlight the inclusion of health policy in the 31 logic of Mussolini's totalitarian project, as well as its relationship, and that of 32 the more general social activities, with the corporative apparatus of the regime, 33 which is intended to significantly change the profile of the liberal administra- 34 tive organization. The proliferation of public bodies initiated by fascism was 35 accompanied by a legislative fervor which led in July 1934 to the adoption of 36 the new “Testo Unico” on Health Laws, which replaced the 1907 text men- 37 tioned above. 38 The third section is reserved for the years of the Republic, which had a 39 very important start with the creation, in 1945, of the High Commission for 40 Hygiene and Public Health, replacing the old Directorate-General for Public 41 Health. This law entrusted the newly established institution with the task of co- 42 ordinating and monitoring the bodies active in the health sector, all in connec- 43 tion with the development of the Italian welfare system. From this point of 44 view, it is almost inevitable to make a comparison with Great Britain, where, at

2002, Steward 2002: 113-134, Rintala 2003, Gorsky 2008: 437-460, Webster 2008: 33-36, Jones 2015: 77-80.

3 2021-4204-AJMS-HIS – 20 APR 2021

1 the same time, Clement Attlee's Labour government approved the National 2 Health Service. In Italy, such a goal was achieved only in 1978, twenty years 3 after another important result obtained by the Central Health Administration, 4 the Ministry of Health, which put an end to the short, but not secondary, expe- 5 rience of the High Commission. 6 The fourth and final section of the article contains the conclusions, which 7 will seek to draw up a final and long-term assessment of the evolution and role 8 played by the main health institutions in Italy during the last century, while 9 seeking to maintain a comparative external objective. 10 11 12 The Liberal Phase 13 14 In 1861 Italy had 22 million inhabitants, most of them illiterate and dedi- 15 cated to an agricultural activity that presented elements of modernity only in 16 the area of the Po Valley, while was dominated by the sharecrop- 17 per, and in the South by the latifundium. In many rural regions of the South, 18 living conditions were at the limits of physical subsistence, with the population 19 often subject to typical nutrition diseases, on all pellagra, and forced to live in 20 small and unhealthy dwellings. The few areas and industrialized areas of the 21 country featured work situations where the use of female and child labor was 22 extensive marked by a high number of work hours per week and in total ab- 23 sence of the most elementary hygiene standards. 24 The fledgling Italian State largely inherited the administrative structures 25 and legislation of the Kingdom of Sardinia, which, as is well known, had led 26 the process of national unification with Cavour in the previous decade. In the 27 field of public health, the Royal Decree no. 3793 of the Savoy State of 20 No- 28 vember 1859 was extended to the rest of the country, and then replaced, in 29 March 1865, by Annex C to the Law of Administrative Unification. The two 30 measures differed little from each other and provided for a health facility cen- 31 tered in the Ministry of the Interior, where a health office, usually chaired by a 32 doctor, and on the outskirts on prefects and mayors, functioned. The system, 33 thus agreed on, favored the repressive side and police functions, aimed at both 34 controlling the health of the population and reporting potential epidemic out- 35 breaks. 36 In these early years of life there was a lot of criticism of a health system 37 that often worked in a cumbersome way, with several elements of uncertainty 38 and contradictory to each other. It will be necessary to wait until 1888 to see 39 the adoption of a measure that completely overhauls the sector. Law No. 5849 40 of 22 December constitutes a fundamental hub in the history of Italian health 41 institutions, so much so that it remains in force, in the main lines, until the late 42 twentieth century. It was an integral part of the program to strengthen the State 43 and the government authority put in place by the President of the Council 44 Francesco Crispi. 45 One of the essential aspects of the measure was the creation of a Direc- 46 torate of Public Health at the Ministry of the Interior, composed of elements

4 2021-4204-AJMS-HIS – 20 APR 2021

1 with the necessary technical capacity and entrusted to the skills of the hygienist 2 Luigi Pagliani, professor at the University of Turin and student of Jacob Mo- 3 leschott. Among the innovations of Law No 5849 are the reorganization of the 4 system of health boards, introduced at the various territorial levels in 1865, the 5 establishment of two new figures of hygienist officials included in the different 6 steps of the public administration, the health officer and the provincial doctor, 7 dependent respectively on the mayor and the prefect, and free medical care for 8 the poor, which was provided by staff paid by the municipal administrations, 9 usually conducted by a doctor and a midwife, or relying on pious works and/or 10 other charitable charities. 11 The reforms implemented by Crispi had the merit of providing innovative 12 solutions to the needs of contemporary society, setting up a hygienic and health 13 system that left, in the words of Giovanna Vicarelli, "a large part of the inter- 14 ventions of health care to the poor [to pious works], after their control and ra- 15 tionalization", channelling “on two main tracks, the public and the private- 16 charitable, the Italian health system" (Vicarelli 1997: 111). Indisputable was 17 the renewal brought to the hygienic state of the Kingdom, culminating in the 18 realization of works for the restoration of cities, rural municipalities and the 19 countryside as well as for the repression of endemic-epidemic diseases. 20 However, for some historians Crispi's health care system did not seem to 21 stray too far from traditional logic. In fact, state interventionism, rather than in 22 direct form, remained conceived in terms of monitoring and controlling the 23 center, i.e. the Ministry of the Interior, and the action of local authorities. Ac- 24 cording to Enzo Bartocci, Crispina law "on the one hand continues to respond 25 to the principles of lassez-faire, albeit with greater flexibility and greater con- 26 trols, on the other hand it pursues the purpose of the painless transformation of 27 traditional forms of assistance inherited from the past" (Bartocci 1999: 180). 28 The conclusion of Crispi's government experience did not interrupt the re- 29 form and renewal of the administrative apparatus. A strong driver was provided 30 by the Directorate of Public Health, who pursued a plan of iron centralization 31 of functions and control over the peripheries, making it an experimental labora- 32 tory of the interweaving of administrative practice and medical science. Over- 33 all, the last glimpse of the nineteenth century is considered by historiographers 34 to be the initial phase of the Italian welfare state. The problems linked to indus- 35 trialization, with the phenomena of proletarianization and urbanization of the 36 popular masses, convinced a part of the liberal ruling class to look with interest 37 at the Bismark experience in Germany and to put forward more concrete pro- 38 posals on the subject of social legislation. The decisive date is 1898, when 39 compulsory accident insurance was introduced, the first organic law dealing 40 with safety at work, and a public scheme, still voluntary, for old age and inva- 41 lidity. 42 It is therefore of great interest to try to understand the relationship between 43 the reorganization of health systems and the random factors usually identified 44 at the origin of the welfare state, namely industrialization, urbanization and 45 the establishment of the workers' movement, which pervaded Italy at the turn 46 of the two centuries. The impression inferred from the scientific literature is

5 2021-4204-AJMS-HIS – 20 APR 2021

1 that health policies were not so much a reaction to the social and living condi- 2 tions of the population as a useful tool for creating the conditions for the pro- 3 cess of modernization. 4 During the Giolittian age, the expansion of social policy continued, ac- 5 companied by the consolidation and extension of health functions and appa- 6 ratus in the public administration, with a tangible increase in staff both at cen- 7 tral and peripheral level. From this point of view, the most interesting aspect to 8 highlight is the strong continuity found at the top of the health administration, 9 all officials trained in Pagliani's time. No substantial alterations were intro- 10 duced into the hierarchy of competencies and the internal articulation of minis- 11 terial offices. This continuity can be extended to the more general role of the 12 public authorities in this field. Despite the commendable efforts made in the 13 social field in the first fifteen years of the twentieth century, the state admin- 14 istration was always rather deflated. Most of the burden of hygiene and public 15 health interventions continued to weigh on local authorities, leaving the central 16 power with tasks of simple superintendence. This situation emerged above all 17 with the promulgation of the “Testo Unico” of 1907, that, in an attempt "to put 18 order in the congeria of decrees, regulations, laws and instructions that had not 19 seen the light of day since 1888" (Cea 2019: 108), strengthened state bodies on 20 the periphery through a better definition of the competencies of the health of- 21 ficer, the creation of consortia for the management of pharmaciesand the con- 22 ferral of additional powers, and therefore an increase in expenses, to the munic- 23 ipal administrations in the field of home care medicine and midwifery of peo- 24 ple in need. The “Testo Unico” of 1907 also had the merit of officially recog- 25 nizing the Directorate of Public Health at the legislative level, who in the 26 meantime was elevated to the rank of Directorate-General. 27 It was the outbreak of war that imposed a more direct role of the State in 28 social policies, which, instead of breaking down, suffered "a multiplier effect", 29 destined to continue in the post-war years, with an even greater flow of legisla- 30 tive measures as to open a new phase in the development of the Italian welfare 31 state. Public health doesn’t seem to participate much in this copious legislative 32 production, with the plan for compulsory health insurance finding no place on 33 the government agenda. The issue had been the subject of discussion in the 34 palaces of politics since the Giolittian period and had its main support from the 35 medical class and the union, both of which were conscious of the undignified 36 health conditions in which the poorest population found themselves. Innovative 37 proposals were tabled in Parliament and working groups were formed to study 38 the problem, but these initiatives, especially the reform provisions envisaged in 39 1919 by the Abbiate Commission3, met with strong opposition from the most 40 conservative circles of society, from the agricultural and industrial business 41 class to hospital administrations, to the political formations very sensitive to 42 the significant financial outlay that the State would have incurred. In particular,

3Appointed shortly before the defeat of Caporetto and chaired by Mario Abbiate, the Commis- sion completed its work in the last weeks of 1919, producing two draft laws, one more innova- tive and advanced, the other of a more limited scope, but which were not taken into account by Parliament.

6 2021-4204-AJMS-HIS – 20 APR 2021

1 the hostility of the clerical world stood out, controlling, in an almost monopo- 2 listic form, the complex system of public institutions of assistance and charity. 3 Against the idea of compulsory sickness insurance there was a large concentra- 4 tion of political, economic and social forces, which prevented the achievement 5 of a very difficult and laborious goal to be crossed even for the fascist regime 6 (Sepe 1999: 190-192). 7 8 9 Fascism 10 11 The physical health of the people must be in first place ... we must seriously 12 watch over the fate of race, we must take care of race, starting with motherhood 13 and childhood ... not fundamental but preliminary data of the political and there- 14 fore economic and moral power of nations is their demographic power.4 15 16 These are the words used by Mussolini in the famous ascension speech 17 given to the Chamber of Deputies on May 26, 1927. The advent of fascism in 18 power, following the march on Rome in October 1922, impressed on the state's 19 health policy a marked ideological curvature in the framework of a totalitarian 20 political project that aimed to bring Italy back to the glories of imperial Rome, 21 restoring it to a central role among the great Western powers. According to 22 Mussolini, numbers were synonymous with power and formed the indispensa- 23 ble premise of a nation's greatness. For this reason, fascism put in place a 24 whole series of initiatives in support of the birth rate and the family. These ini- 25 tiatives did achieve some results. Very visible was, for example, the reduction 26 in the mortality rate in the first decade of the regime. From 1922 to 1933 the 27 rate was reduced from 18.1 to 13.7%, lower than that of the French and Span- 28 ish, and remained constant during the 1930s, until Italy’s entry into World War 29 II, when an increase occurred that reached 15.2% in 1943. In fact, the reasons 30 for such a trend did not seem to be linked to the effects of the health policy of 31 the regime, but to the gradual improvement of people's standard of living and 32 the overall health and hygiene situation of the country. The measures intro- 33 duced by fascism had a limited effect on the health of the population and in- 34 creased impressive social achievements (on all the reclamation works of large 35 national territories and the fight against malaria) based on the propaganda car- 36 ried out by the regime and for representing urgencies largely disregarded by the 37 liberal ruling class. 38 Unfortunately, a favorable trend in the state of health of was 39 matched by an increase in inequalities linked to social position and place of 40 residence. The populations of the Mezzogiorno, the workers and the peasants 41 were the subjects who, over the years, saw a deterioration in the quality of life, 42 especially in urban areas and in certain locations in and Sardinia, where 43 ankylostomysis and echinococcosis maintained high levels of contagion and

4Parliamentary Acts, Legislature XXVII, Chamber of Deputies, Discussions, sitting of 26 May 1927.

7 2021-4204-AJMS-HIS – 20 APR 2021

1 mortality (also in the South where malaria and trachome continued to be very 2 dangerous pathologies) (Vicarelli 1997). 3 If we broaden the horizon of reasoning to the social policy of fascism and 4 its methods of implementation, it is evident how much the assumptions on 5 which it was based, in the words of Domenico Preti, "were such as to empty 6 and frustrate the achievement of many of those objectives that publicly the 7 propaganda of the regime was pointing to as safe destinations of the measures 8 taken ... and for which valuable economic resources were used. The protection 9 of work and in the twenties confirmed "the inconsistency of fas- 10 cist social policy, both with regard to the yardstick of the traditional use of 11 clerical means and with respect to the purposes intended, vehemently when 12 demagogically, to achieve" (Preti 1987: 110). 13 From the mid-1920s, under the pressure of fascist ideology, there was a 14 progressive absorption into the public sphere of social activities and their con- 15 nection with the corporate apparatus of the regime so strenuous that it signifi- 16 cantly changed the profile of the administrative organization of the previous 17 liberal period, up to distinguish the path of the Italian welfare state from that of 18 other Western countries. 19 One of the characteristic features of the health system established by fas- 20 cism was the high degree of fragmentation and the subtraction of competencies 21 from the central authority, which continued to revolve around the Directorate- 22 General for Public Health of the Ministry of the Interior. With this in mind, the 23 ministry that most absorbed health activities was that of the Corporations. In- 24 stead of calling for the improvement of the municipal and provincial hygiene 25 offices, the General Regulation on Occupational Hygiene, approved by Royal 26 Decree No 530 of 14 April 1927, created at that Ministry a medical labour in- 27 spectorate, with the respective organs and factory doctors, for the discipline 28 and hygiene and health surveillance of industrial, commercial and agricultural 29 companies. The Ministry of Agriculture, by reason of the Law of 24 December 30 1929, was reserved functions in the field of integral reclamation, including cor- 31 rective works aimed at preventing the spread of malaria and protecting work- 32 ers. Also in 1929 it was the Ministry of Public Works that was assigned the 33 sanitary and renovation works, for example the construction of social housing, 34 limiting to the simple opinion of the Superior Health Council the intervention 35 on the projects, and not all, of the Health Administration, while in 1938 health 36 service was created at the Ministry of Colonies independent of the apparatuses 37 of the Directorate General. An even more negative impact in 1942 came from 38 the formation of the Directorate-General for Food within the Ministry of Agri- 39 culture, which extended its powers to public health. 40 Fascism created a considerable number of offices and public bodies, out- 41 side the Directorate-General and with budgetary and conduct autonomy with 42 respect to the health surveillance bodies of the Ministry of the Interior, hinder- 43 ing any hypothesis of coordination of the sector. The category included, for ex- 44 ample, the provincial antitubercular consortia, provided for by a law of 1927 45 and assigned diagnostic and prophylaxis tasks. Also in 1927, the fight against 46 tuberculosis was strengthened by the establishment of compulsory insurance.

8 2021-4204-AJMS-HIS – 20 APR 2021

1 Both instruments soon showed significant limits in terms of insurance coverage 2 and financial resources, generating a serious and progressive disparity in treat- 3 ment between those assisted by consortia, molts or often belonging to the poor- 4 est classes, and insured at the Cassa, lower in number and privileged, destined 5 to drag on until the years of Republican Italy. 6 Speaking of public bodies, in 1925 the National Opera for Motherhood and 7 Children was born, with the intention of providing assistance to pregnant wom- 8 en, mothers in need and abandoned, infant and children from families in diffi- 9 culty. These objectives had to be achieved through the creation of institutions 10 on the territory, the financing of existing ones and the coordination of all public 11 and private entities over which the ONMI exercised supervision and control. It 12 was up to the authority to disseminate standards and methods for prenatal and 13 child care and hygiene, a fundamental objective which was well integrated into 14 the demographic policy of fascism.5 15 The process of institutional de-strengthening initiated by fascism through 16 intense legislative production and which diverted the trend towards the reunifi- 17 cation of health activities under the leadership of a single body, the Direc- 18 torate-General for Public Health, also involved local authorities, facilitated by 19 the radical and authoritarian changes made to them in the late 1920s. In par- 20 ticular, the municipalities were taken away from all opportunities for initiative 21 and responsibility in the prophylaxis of important social diseases and narrowed 22 the scope to assist poor citizens, a formal detection of infectious diseases and 23 little else, putting the figure of the health officer in crisis. 24 The legislative fervor of the regime led in July 1934 to the “Testo Unico” 25 of the health laws, approved by Royal Decree No. 1265. The most important 26 aspect, since reading the first article, was the strong continuity of the new sin- 27 gle text with the previous legislation, especially in the way of understanding 28 health, which is still linked to a police function and the protection of public or- 29 der. The “Testo Unico” showed little adherence to scientific progress and 30 changed social conditions, bringing together in a somewhat disorderly way the 31 laws previously enacted by the Ministry of the Interior. The consideration will 32 be confirmed several years later by Giovanni Petragnani, university professor 33 of hygiene and bacteriology and Director General of Public Health from 1935 34 to 1943, in an article that appeared in the journal "Annals of Public Health": 35 36 The “Testo Unico” of the health laws of 1934 was drafted without the mind of the 37 minister of the interior at the time having born the conviction that it was the re- 38 sponsibility of the Health Administration to direct all the services of care and that 39 all activities competing with the defense of health should be under its direct con- 40 trol. The reason for this is that, as recently as 1934, the powers relating directly to 41 the fight against infectious diseases appeared to be pre-important and, I would 42 say, sufficient for the health administration. It was not warned, even by the most 43 senior medical officials, that the health and social progress, which had already 44 been achieved and in impressive evolution, required the adaptation of the health 45 administration to the new situation (Petragnani 1955: 762-763)

5On the National Opera for Motherhood and Childhood see above all: Minesso 2007.

9 2021-4204-AJMS-HIS – 20 APR 2021

1 Together with the drafting of the single text, the other major aspect in the 2 field of health policy on which fascism concentrated, or perhaps it would be 3 better to say did a little, was that of establishing a compulsory health insurance 4 scheme. The problem, as we have seen, had been dragging on for years and 5 was an unsolved legacy of the liberal age, which had not been able to deal de- 6 cisively with the widespread expansion of the mutual assistance funds of the 7 various professional categories, distributed in a disorganic way throughout the 8 territory, with duplication and waste of all kinds. It was the promulgation of the 9 Labour Charter in 1927 that rekindled interest in the issue and opened up a 10 heated political debate within the regime that dragged on until the war years, 11 when Parliament debated, in May 1942, a bill approved by a Council of Minis- 12 ters now beginning to recognize the urgent need for a coordinating body and 13 the unification of sickness funds. Ending a long-running affair, Law No. 138 of 14 11 January 1943 the “Ente mutualità fascista” - National Institute for Sickness 15 Assistance for Workers (INAM) was born. 16 Unfortunately, thanks to a general situation close to catastrophic, with Italy 17 increasingly in difficulty in the Second World War, the ambitious Inam project 18 remained "little more than a simulacrum", devoid of concrete effects (Sepe 19 1999: 217). Moreover, the plan for health insurance had a scope that transcend- 20 ed the sphere of health policy and extended to the welfare sector as a whole, 21 steeped in and hegemonized by clerical forces. For Domenico 22 Preti, the two things went hand in hand and no modernization of public health 23 could have taken place "without a simultaneous refoundation on a lay basis, 24 and no longer voluntarist and charitable, of the welfare system", including the 25 hospital network, which had to be subtracted "from the particularisms, inequal- 26 ities, anarchy in which the legislation on Ipab continued to maintain it" (Preti 27 1987: 251). The outcome of the affair was also influenced by the many uncer- 28 tainties of fascism with regard to the establishment of compulsory health insur- 29 ance. The regime preferred not to deviate too far from the liberal model that 30 had progressively supplanted the system focused on mutual aid societies in fa- 31 vor of one marked by company sickness funds. Fragmentation of interventions, 32 disparities between categories, areas of the country and in the collection of 33 contributions, duplications, customer use and the burden of mutual structures 34 ended up strengthening and becoming almost ordinary elements of a system 35 destined to drag on in the years of republican Italy, heavily conditioning the fu- 36 ture of the sector. 37 38 39 The Republican Years 40 41 A few weeks after the end of the war, in the midst of enormous political, 42 economic and social and material difficulties, a major innovation came to the 43 administrative apparatus of public health. The Italian Government issued a de- 44 cree, number 417 of 12 July 1945, which established the High Commission for 45 Hygiene and Public Health, ending, after almost 60 years of life, the Direc- 46 torate-General for Public Health. The legal system and powers were governed

10 2021-4204-AJMS-HIS – 20 APR 2021

1 by Legislative Decree No 446 of 31 July 1945, which gave the institution es- 2 sential tasks in the protection of health, coordination and supervision of health 3 organizations and bodies set up with the aim of preventing and combating so- 4 cial diseases. The new institution aimed to meet the need, manifested above all 5 by the medical class, for greater autonomy of the health administration and its 6 reconstruction on a basis more in line with the growing development of welfare 7 services and the increasing powers of public authorities in the social field. 8 In truth, the choice made by the executive only responsibly fulfilled the 9 autonomy claims, without significantly affecting the disparity of guidelines and 10 the disorder that resided in the sector. Decrees Nos 417 and 446 reduced the 11 Directorate-General for Public Health to an increase in rank, placing it halfway 12 between the simple Ministerial Division and the structure of a Dicastery and 13 immediately highlighting, for the High Commission, a series of significant 14 shortcomings. It could not, for example, take part in meetings of the Council of 15 Ministers, unless explicitly invited (and in any case without the right to vote), 16 and sign the draft laws which he himself formulated, which were to pass under 17 the Presidency of the Council. Limitations were reserved for the activity, with 18 considerable powers in the field of hygiene and public health remaining in the 19 hands of mini-material apparatuses, certain parallel administrations, prefects 20 and local authorities such as municipalities and provinces. The limited powers 21 of ACIS and the deterioration in the quality of many services provided corre- 22 sponded to an inadequate distribution of financial resources, insufficient to 23 cope with the social and health conditions of post-war Italy. The years saw a 24 gradual increase in appropriations for the High Commission, but these re- 25 mained always less than necessary. The spending of time did not even change 26 the proportions between the different budget items, with a preponderant posi- 27 tion occupied by antitubercular care and motherhood and childhood. 28 The need for its modernization also benefited from the comparison with 29 those countries where there was already a central and truly autonomous entity, 30 in short, a Ministry of Health. Looking more broadly, it was the Italian welfare 31 state itself that was taking on a different appearance than in the rest of western 32 democracies. In Britain, an inescapable post-war term of comparison in the 33 field of social security, Labour Prime Minister Clement Attlee decided to mark 34 government activity with a welfare policy focused on building a free and uni- 35 versal national health system. Italy, on the other hand, continued along the path 36 mapped out by the recent past, strengthening the mutual system, which caused 37 profound differences in treatment between the various professional categories. 38 Protection against diseases remained entrusted to an insurance scheme, without 39 proceeding, in Cosmacini's words, "towards a courageous and responsible 40 choice on the part of the State in defense of its biological heritage", which took 41 into account the epidemiological changes taking place. 42 Public health continued to show major shortcomings in coordination, over- 43 lapping of skills, operational slowness and cumbersomeness, duplication of 44 personnel and equipment: all situations that generated a great waste of energy 45 and financial resources, making healthy organization impossible. The Italian 46 political leadership was aware of the difficulties, but very few measures were

11 2021-4204-AJMS-HIS – 20 APR 2021

1 taken to overcome the existing framework, perhaps because of the technical 2 and financial obstacles that the government saw linked to the establishment of 3 a Ministry of Health. Hundreds of laws and decrees were issued, which, alt- 4 hough important, did not constitute the pieces of an organic and rational project 5 of renewal of the sector, but rather the tiles of an incomplete, disjointed and 6 confused mosaic. The appointment of a considerable number of parliamentary 7 committees responsible for studying certain aspects of health did not lead to 8 any concrete results, apart from the drafting of miles of paperwork (reports, 9 draft bills and various proposals) left in the drawers of Parliament's offices. 10 The 13 years of activity of the Office of the High Commission for Hygiene 11 and Public Health show, in essence, a physiognomy of the institution character- 12 ized by obvious elements of transience and legal uncertainty, almost as if the 13 sector was waiting, and in fact it was, for a definitive reform. And this reform 14 came in 1958, when the approved, after years of political 15 discussions and in the medical press, the law that sanctioned the birth of the 16 Ministry of Health. All parties, albeit with different accents, agreed to support 17 the bill presented by two Christian Democrat senators. The basic idea was to 18 provide the health administration with a technical aspect, in the sense of en- 19 trusting it to elements with proven specialist skills, and to unify the services be- 20 longing to ACIS and other ministries into a central body, while ensuring their 21 sufficient decentralization on the territory. Unfortunately, the measure dis- 22 missed by the Houses was less advanced than the great expectations that had 23 formed in previous months, especially within the medical class, which had 24 fought so hard to achieve such a result. The complex political negotiations 25 linked to the law did not conceal the perplexities and resistance of sectors op- 26 posed to change, starting with the private ministries of responsibilities for the 27 benefit of health. It was a pretty moderate turnaround. The handover with the 28 old management of the High Commission took place gradually, without exces- 29 sive jolts. There were many constraints imposed on the sphere of activity of the 30 new Ministry, indispensable for an effective action to synthesize and regulate 31 what was related to health care. At the local level, several control functions 32 remained with the prefect, i.e. an official of the Ministry of the Interior. 33 It was also true that these limits were the consequence of a situation histor- 34 ically determined in our country, with the old charitable and charitable institu- 35 tions never completely replaced by more modern state organizations, and 36 whose responsibilities were passed on in full to the choices of the past and the 37 current ruling class. Once again, the discourse was linked to the development 38 of a genuine social security system and to the choices made by what was the 39 dominant party on the political scene, the Christian Democracy party. On the 40 subject, in fact, the positions within the Catholic party were never unequivocal. 41 While the members closest to the Church's social doctrine showed courageous 42 tendencies towards universal welfare, the more conservative and major wing of 43 DC persisted in showing reluctance to take an overly aperturist line, in which it 44 saw a danger to the hegemonic role exercised by church institutions in the 45 health and welfare fields.

12 2021-4204-AJMS-HIS – 20 APR 2021

1 This is not the only factor, but it is one of the main reasons for the delay in 2 Italy in training a national health service, approved by the Chamber of Depu- 3 ties in December 1978. This is a very important date for our country, which 4 concludes a long process that began thirty years earlier, capable of involving, 5 but not without difficulty, different knowledge and actors. A boost certainly 6 came from the change, in the 1960s, of the political scenario, with the rap- 7 prochement between the Christian Democracy Party and the Socialist Party and 8 the birth of center-left governments, which distinguished themselves for some 9 significant economic and social reforms. In the field of public health, a marked 10 improvement was introduced by the Mariotti reform of 1968, which transferred 11 the powers of control and supervision of hospitals from the Ministry of the In- 12 terior to the Ministry of Health, putting a minimum of order in the sector. The 13 national health service was also the result of original experiences realized in a 14 decentralized form in the territory (on all the Experimental Demonstration Cen- 15 ter for the health education of the population of Perugia led by Alessandro 16 Seppilli), which contributed to the elaboration of a new welfare model and at 17 the same time to modifying the concept of health. 18 The establishment of a universal system had the merit of finally sanction- 19 ing the practical implementation of Article 32 of the Constitution, which guar- 20 anteed the community, which was burdened by the relevant difficulties, a 21 health service hitherto reserved for individual categories of workers, with the 22 aforementioned inequalities in the case (Taroni 2011: 199). The law assigned 23 important functions to the Regions and created local health units, public, au- 24 tonomous companies with legal personality, which had the task of providing 25 services on national soil. 26 If the national health system represented a goal of considerable depth for 27 Italy, considered for many to be one of the most advanced institutions on the 28 international scene, we must not forget the defects that distinguished it, evident 29 from the stage of discussion in Parliament of the bill. On the other hand, its 30 drafting came after a long and laborious compromise between the different po- 31 litical formations. The text found indeterminateness as to the assumption of cit- 32 izens' participation in health choices and in the management of services, as 33 well as in the way in which the USLs are implemented. Less than a year after it 34 came into force, Massimo Severo Giannini noted that the law was littered with 35 references to future measures by the State and the regions, with the risk, which 36 in fact happened, of creating organizational problems (Giannini 1979). And the 37 situation did not improve in the years to come. On the contrary, the most inno- 38 vative elements were too often obscured by the malfunctioning of the adminis- 39 trative machinery of the State, by the clientele use made by the parties of the 40 management of the various USL and by the progressive, and perhaps exagger- 41 ated, devolution of competences to the Regional authority, a subject, at least 42 for Italy, still very topical (Pavan, Giorgi 2018: 113-116). 43 44 45

13 2021-4204-AJMS-HIS – 20 APR 2021

1 Conclusions 2 3 This essay offers some firm points about the development of public health 4 institutions in Italy in the last century and of the more general process of build- 5 ing the welfare state. In the latter respect, the idea of a development of social 6 policies characterized by numerous elements of continuity, even in the transi- 7 tion from fascism to the Republic, has gradually developed in national histori- 8 ography. In this regard, for Michela Minesso "the choice of the republican po- 9 litical ruling class was not to replace fascist institutions of a social nature, but 10 in all possible cases that of conversion, changing men [not always] and above 11 all the ends" (Minesso 2006: 310). Minesso's reference is mainly aimed at wel- 12 fare policies, and even more specifically at motherhood and children, but it can 13 be without problems extended, even with the distinctions, to the field of public 14 health. 15 In order to try to better understand the distinctive features of health institu- 16 tions in twentieth-century Italy, it is therefore necessary to take a step back and 17 examine the legislative measures and administrative structures operating in the 18 second half of the nineteenth century. A decisive impact was provided by 19 Crispine reforms, destined, in their main provisions, to remain in force until 20 late twentieth century. The Directorate of Public Health of the Ministry of the 21 Interior, founded in 1888 and transformed into a "general" in 1902, went 22 through, almost unscathed, the three final decades of the liberal period and the 23 entire chronological arc of the fascist regime. Men and apparatuses remained in 24 many cases the same, managing to adapt to quite different historical situations. 25 And even when, in July 1945, the High Commission for Hygiene and Public 26 Health was created, the institution immediately appeared more of an elevation 27 of rank of the aforementioned Directorate, than a new subject in the bureau- 28 cratic and administrative landscape of the Italian State. A similar observation 29 can be made for the Ministry of Health, which in 1958 inherited, to a large part, 30 the configuration of the High Commission, which in the meantime organized 31 itself in a more similar way to a Ministry. 32 In the suburbs of prefects, mayors and provincial doctors continued to play 33 a leading role in the sector for decades, certified by both the “Testi Unici” on 34 health laws of 1907 and 1934. There were no major differences between the 35 two provisions. This point is more important when one considers the decidedly 36 antithetical contexts from which those norms came from. In addition, the “Testi 37 Unici” show a similar way of understanding health, still linked to a police func- 38 tion and the protection of public order and far from the progress made by sci- 39 ence and changed social conditions, as well as by an organizational model that 40 reserved to the health administration the management of all care services and 41 activities competing with the protection of health. Lack of coordination, over- 42 lapping of competencies, scarcities, and various awkwardnesses, resulted in a 43 waste of energy and financial resources, which then became issues on the 44 agenda, dragging themselves well beyond the start of the Republican phase. 45 Thus articulated public health ended up contributing decisively to direct 46 the construction of the Italian Welfare system along an axis that differed from

14 2021-4204-AJMS-HIS – 20 APR 2021

1 the experiences of the main Western countries. Moreover, the maintenance of 2 the mutual system and the weight exerted in the health and welfare field by the 3 ecclesiastical world also pushed in an alternative direction from the path usual- 4 ly traveled by a modern welfare state. 5 Not that the passing of the years had not seen any improvement in medical 6 knowledge, hospital facilities (think of the Mariotti reform of 1968), welfare 7 benefits, etc., but this progress remained part of a context where aspects of con- 8 tinuity with the past prevailed, and by far. 9 And then the real moment of breakdown of this structure can be identified 10 in the establishment, in December 1978, of the National Health Service, a fun- 11 damental step that gave effective substance to Article 32 of the Constitution, on 12 the protection of health, and completely reorganized the sector in the center 13 and on the periphery. For Saverio Luzzi, despite certain weaknesses and errors 14 of perspective, it is "one of the most important reforms in the history of repub- 15 lican Italy" (Luzzi 2004: 315). Law No. 833 placed Italy on an equal footing 16 with other international countries, such as Great Britain, and made the Welfare 17 system more modern and democratic, providing those elements of universality 18 that were previously lacking. All this advancement came with a paradox. Italy 19 was coming to the meeting with the National Health Service just when in Eu- 20 rope we were beginning to talk about the welfare crisis and the financial sus- 21 tainability of a system that, in widening public functions in the field of social 22 security, had highlighted considerable problems of bureaucratization and cen- 23 tralization. In fact, between the end of the seventies and the beginning of the 24 following decade, a heated political and academic debate opened on the need to 25 reform and introduce corrective instruments to European Welfare, a dispute 26 destined to heavily influence the application of future social policies and drag 27 on, leaving unresolved several issues, almost to this day. 28 29 30 References 31 32 Alessi R. (edited by) (1967), L’amministrazione sanitaria, in L’ordinamento sanitario. 33 Atti del Congresso celebrativo del centenario delle leggi amministrative di 34 unificazione, vol. I, Venezia: Neri Pozza. 35 Bartocci E. (1999), Le politiche sociali nell’Italia liberale, 1861-1919, Roma: Donzel- 36 li. 37 Bressan, E., Betri M. L. (1989), Dieci anni di studi di storia assistenziale e sanitaria 38 in età moderna e contemporanea (1978-1988), in «Sanità, scienza e storia», n. 1. 39 Briant K. M. (1998), The health of a nation: the history and background of the Na- 40 tional Health Service, Farncombe. 41 Cea R. (2019), Il governo della salute nell’Italia liberale. Stato, igiene e politiche 42 sanitarie, Milano: Franco Angeli. 43 Cherubini A. (1977), Storia della previdenza sociale in Italia 1860-1960, Roma: 44 Editori riuniti. 45 Cherubini A. (1980), Medicina e lotte sociali (1900-1920), Roma: Il pensiero 46 scientifico. 47 Cosmacini G. (1980), Problemi medico-biologici e concezione materialistica nella 48 seconda metà dell’Ottocento, in Micheli G. (edited by), Storia d’Italia. Scienza e

15 2021-4204-AJMS-HIS – 20 APR 2021

1 tecnica nella cultura e nella società dal Rinascimento ad oggi, vol. III, Torino: 2 Einaudi. 3 Cosmacini G. (1982), “Filosofia spontanea” dei clinici medici italiani dal 1860 al 4 1900, in Betri M. L., Gigli Marchetti A. (edited by), Salute e classi lavoratrici in 5 Italia dall’Unità al fascismo, Milano: Franco Angeli. 6 Cosmacini G. (1994), Storia della medicina e della sanità nell’Italia contemporanea, 7 vol. III, Roma-Bari: Laterza. 8 Cosmacini G. (2005), Storia della medicina e della sanità in Italia, Roma-Bari: Later- 9 za. 10 Della Peruta F. (1980), Sanità pubblica e legislazione sanitaria dall’Unità a Crispi, in 11 «Studi storici», n. 4. 12 Della Peruta F. (edited by) (1984), Malattia e medicina, in Storia d’Italia. Annali, vol. 13 VII, Torino: Einaudi. 14 Eversley J. (2001), The History of NHS Charges, in «Contemporary British History», 15 15, 2, pp. 53-75; 16 Giannini M. S. (1979), Introduzione, in Riforma sanitaria come attuarla come gestir- 17 la, Roma: Edimez. 18 Gorsky M. (2008), The British National Health Service 1948-2008: a review of the 19 historiography, in «Social History of Medicine», 21, 3, pp. 437-460. 20 Granshow L. (1988), “Health for all”: the origins of the National Health Service 21 1848-1948: a fortieth anniversary retrospect, London. 22 Honigsbaum F. (1989), Health, happiness, and security: The creation of the National 23 Health Service, London-New York: Routledge. 24 ISAP (1990), Le riforme crispine, 4 voll., Milano: Giuffrè. 25 Jones D. A. (2015), A brief history of the National Health Service, «British journal of 26 health care management», 21, 2, pp. 77-80. 27 Luzzi S. (2004), Salute e sanità pubblica nell’Italia repubblicana, Roma: Donzelli. 28 Minesso M. (2006), Costruzione dello Stato sociale e politiche assistenziali: origini, 29 svolte, fratture nell’Italia contemporanea, in «Bollettino dell'Archivio per la 30 storia del movimento sociale cattolico in Italia», n. 2. 31 Minesso M. (edited by) (2007), Stato e infanzia nell’Italia contemporanea. Origini, 32 sviluppo e fine dell’ONMI 1925-1975, Bologna: Il Mulino. 33 Pavan I., Giorgi C. (2018), “Un sistema finito di fronte a una domanda infinita”. Le 34 origini del sistema sanitario nazionale italiano, in "Le Carte e la Storia", n. 2. 35 Pavan I., Giorgi C. (2021), Storia dello Stato sociale in Italia, Bologna: Il Mulino. 36 Petragnani G. (1955), La legislazione sanitaria e l’amministrazione sanitaria viste in 37 ordine storico, in «Annali della sanità pubblica», vol. XVI, fasc. IV. 38 Preti D. (1982), Per una storia sociale dell’Italia fascista: la tutela della salute 39 nell’organizzazione dello Stato corporativo (1922-1940), in Betri M. L., Gigli 40 Marchetti A. (edited by), Salute e classi lavoratrici in Italia dall’Unità al 41 fascismo, Milano: Franco Angeli. 42 Preti D. (1987), La modernizzazione corporativa (1922-1940). Economia, salute 43 pubblica, istituzioni e professioni sanitarie, Milano: Franco Angeli. 44 Rintala M. (2003), Creating the National Health Service. Aneurin Bevan and the med- 45 ical Lords, London-Portland: Frank Cass. 46 Rivett G. C. (1998), From cradle to crave. The fifty years of the NHS, London: King's 47 Fund. 48 Sepe S. (1999), Le amministrazioni della sicurezza sociale nell’Italia unita 1861- 49 1998, Milano: Giuffrè. 50 Steward J. (2002), Ideology and the process in the creation of the British National 51 Health Service, in «Journal of Policy History», 14, 2, pp. 113-134.

16 2021-4204-AJMS-HIS – 20 APR 2021

1 Taroni F. (2011), Politiche sanitarie in Italia. Il futuro del SSN in una prospettiva 2 storica, Roma: Il pensiero scientifico. 3 Timmins T. (1996), A history of the NHS: NHS 50th anniversary, NHS National Liai- 4 son Group. 5 Vicarelli G. (1997), Alle radici della politica sanitaria in Italia. Società e salute da 6 Crispi al fascismo, Bologna: Il Mulino. 7 Webster C. (2002), The National Health Service. A political history, Oxford-New 8 York: Oxford University Press. 9 Webster C. (2008), Origins of the NHS. Lessons from history, in «Contemporary Brit- 10 ish History», vol. 22. 11 12

17