2021-4204-AJMS-HIS – 22 APR 2021 th 1 Public Health Institutions in Italy 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 Welfare 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 history of Italy 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: Welfare State, 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 Sardinia? 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 insurance. 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.