Models in Healthcare

#### **Chapter 6**

## For a Model of Revision, Assistance and Care of Identities

*Federico D'Angiolillo*

#### **Abstract**

The global crisis scenario has highlighted the weaknesses of advanced personal assistance and care systems, based on the absolute primacy of technical knowledge. Almost all health organizations have been challenged by the new Coronavirus. The universal system because it is realistically unable to reach everyone efficiently and effectively. The private model, albeit moderated by intentions of global care, because it is onerous and, in fact, not very inclusive. This study, without any pretense of completeness, thanks to an examination of the most well-known documents published by the organizations for the promotion of human health, both EU and international, highlights the essential aspects and purposes of some of the main models of health care, also identifying the critical issues and the remedies prepared. The main purpose of the text is to highlight and reflect on possible alternative solutions to the current strategies to combat the pandemic, implemented by the states. The probable contributing causes that have contributed to the spread of the new coronavirus and its variants globally and that have their roots in now dated issues are then analyzed. The lesson that the Pandemic teaches us is that "no one is saved alone" and that the problems of each family, social, national etc., represent the problems of everyone. The document concludes in the sense that, only through a new approach to individual and collective health care, marked by greater solidarity and respect for individual, specific identities and frailties, starting from those "hidden" in society (adolescents, elderly, of handicaps, immigrants, etc.) it will be possible to promote welfare systems that are more attentive to the needs imposed by the challenges of globalization and therefore really more effective, economical and efficient, and therefore more humane.

**Keywords:** Pandemic, identity, health, fragility

#### **1. Introduction**

The global pandemic crisis shakes the situational equilibrium on which our realities are founded.

The pandemic shows the difficulties of modern social organizations to take care of the most disadvantaged and fragile people (elderly, people with disabilities, immigrants without residence permits, children and adolescents) [1] starting from each single identity [2].

As has been acutely observed [3], health promotion, understood according to the World Health Organization, as a state of physical, mental and social well-being, represents a productive factor of growth and development of the entire community.

But in recent years, governments attention has waned and produced a dismantling of the welfare state that has removed the social protection net of the most vulnerable people.

In this scenario, the pandemic caught us fundamentally unprepared, unable to oppose a reaction on the ground even of a cultural nature.

At the beginning of the crisis, the only serious collective defense tool was to take time by suspending fundamental freedoms, individual and collective, waiting for the vaccine.

On the now essential need for a common preventive strategy of defense against the danger of contamination by biological agents, and on the consequences produced by the pandemic, see, by way of example, the documents published by the World Commission for the Ethics of Scientific Knowledge and Technology Unesco (https://en.unesco.org/themes/ethicsscience-and-technology/comest) and the technical guides published by the WHO (https://www.who.int/emergencies/diseases/ novel-coronavirus-2019) to which reference should be made.

Faced with today's crisis scenario, shared responses are necessarily urgent. In this context, the use of vaccination represents, however, only one of the possible means of protection, not the only one, being by itself, unable to prevent the re-emergence of the elements favoring the current crisis situation on a global scale (which could be repeated) exposed (s) below:


If these factors did not immediately trigger the pandemic, they almost certainly have favored and, in some cases, accelerated its propagation with the consequences in terms of the cost of human, social and economic lives, which we know well.

For these reasons, the task of this chapter will be to investigate the factors that have contributed to the current pandemic crisis without neglecting the teaching that it brings with it: that of a great opportunity for rebirth.

#### **2. A society of situational balances**

The current pandemic crisis has shaken the balance of our life from the ground up. It has been estimated, in fact, according to a negative type 2 scenario, [7] that not before the end of 2020 the cost in terms of loss of human life in the United States alone would have reached 300,000 units. Unfortunately at the time of this writing the number of deaths it has exceeded, in the US, the 500,000 units, while globally far exceeded 3,000,000 deaths, [8] and is a number destined to grow.

At the end of the pandemic, the victims of Covid-19 - currently not quantifiable even through the use of the most advanced artificial intelligence algorithms - will be underestimated, even in the worst forecasts, with a large margin of deviation from reality.

Faced with such a scenario, it is therefore necessary to take a step back, questioning the reasons for the current social, economic and human vulnerability or at least explaining the anthropological and relational reasons that have given rise to this condition of generalized weakness.

In analogy with the great epidemics of the past, [9] the contagion has spread from east to west, affecting all the countries of the world.

The long and, unfortunately, cyclical wave of the pandemic (we are now in the 3rd wave) has changed our lifestyles, social habits, logical and relational patterns, both from the working point of view (employer-worker), but also personalfamily (parents-spouses-children), behavioral, affective, personal-individual (man-woman).

A reflection is therefore required on the individual specific areas in which the pandemic has affected, in order to highlight not only the critical profiles, but also any positive aspects that this state of emergency has triggered.

#### **3. Face-to-face work is not always good**

Due to the pandemic, the massive use of new technologies made it possible not to suspend certain types of work services (for which it was not essential the physical presence of workers), which paradoxically appear to have strengthened in terms of organization and performance.

In particular, the spread of smart-working on a global scale that has been shown to be a useful, economical and sustainable remedy from the point of view of impact on the environment. Not only that, in the time of the restrictions imposed by the pandemic, it has also represented a formidable resource for employers who have achieved equal (if not higher) productivity results with less and better allocation of human and financial resources.

Remote work has made it possible to reduce physical and temporal distances by ensuring a large margin of time for the care and attention to fundamental relational interests (family, emotional and friends), but also to improve the quality of life and, in some cases, to devote personal time to volunteering [10].

According to a survey conducted by the American channel CNBC in collaboration with the online survey tool Survey-Monkey, people said they were happier doing their work remotely and an increasing percentage said they wanted to continue doing it even after the pandemic [11].

In conclusion, the experience of remote work successfully experienced during the pandemic could turn into a formidable tool for the transformation and reorganization of the world of work and society in order to make them more simplified and humans, not only for some social categories (workers, consumers, savers, etc.) but for all citizens.

#### **4. Family relationships at the time of Covid: the role of women**

According to a study conducted by Eurostat, the Pandemic would have burdened the work of women in the social and family contexts in which it is required with greater responsibility and affliction. According to Eurostat, the restrictions deriving from the lockdown would have had a greater negative impact on the female

component, determining in particular in domestic contexts, the conditions for a significant increase in physical and moral violence, a complication (unpaid) of family duties and responsibilities, an extensive decrease in the employment rate of women, exclusion from top decision-making processes due to of the pandemic.

In particular, in the European context [12], it was observed how "the pandemic has separated families and friends, disrupted everyday life and even endangered democracies. It has affected every aspect of our European way of life. The crisis, however, has not been felt uniformly by every individual in our societies. Income inequality, geographic location, age and, in particular, gender, have determined, separately but also together, the way how the crisis has affected and will continue to affect citizens.

Gender and sex dominated not only the clinical aspects of the COVID-19 pandemic, but also how we responded to it. From urgent and pressing issues such as domestic violence and an alarming male mortality rate, to more structural and fundamental questions about the perceived value of different roles in society, it has become clear that gender has been an essential aspect of this virus and of relative crisis.

The competent Commission for women's equality of the House of Commons [13] of the United Kingdom Parliament also reached similar conclusions, who denounce how the Pandemic has triggered a significant increase in gender inequality, with particular reference to the percentage of requests for use of the sick state, and benefits also expected due to the pandemic, an increase in domestic violence against women, an increase in situations of poverty and female unemployment, an imbalance in the weight of domestic work and the burden of responsibility between genders, the request for a greater state economic support, professional retraining and reintegration into the world of work by women.

In conclusion, both of these studies conclude that the economic and social weight caused by the restrictions introduced due to the pandemic was brought especially to women, who would therefore have paid a heavy bill, both in terms of physical and moral health, and in terms of job insecurity and worsening of unpaid domestic responsibility situations, with a general condition of weakness and suffering, not only economic, suffered.

More generally, however, it should be remembered that the female "world" does not constitute a homogeneous humus, for which appropriate and more in-depth analyzes on the effects of the pandemic should be carried out precisely starting from the individual specificities of race, culture, religion, social and economic position of each woman (child, adolescent, elderly, handicapped, etc.) of the consequent damages received [14]. At the time of writing, there are no specific investigations on these particular aspects.

#### **5. Affective relationships: the relationship between genders**

The emotional relationships have been strongly affected by Covid [15]. People have been afraid, both for internal and external reasons, by choosing to lock themselves up in homes or by limiting their relationships in the home. So many people have poured their affection on the web in search of virtual hugs and relationships. However, there are distinctions between states. In Europe there has been a balance of physical relationships and virtual entertainment, (but for example in China virtual relationships have prevailed over reality). And in the UK? According to a United Nations study [16], the rapid spread of Coronavirus, on a global scale, would have occurred more in men (50.9%) than in women (49.01%) and probably also sexually. In fact, the British charity for the fight against AIDS - Terrence Higgins Trust - has repeatedly highlighted an increase in family relationships (84%). The restrictions on individual freedom caused by the lockdown have in fact pushed government bodies

*For a Model of Revision, Assistance and Care of Identities DOI: http://dx.doi.org/10.5772/intechopen.98415*

to more effective and accessible communication on the risks of infection with the new coronavirus even through safer options for avoid the risk of contagion, suggesting, for example, to book free exams [17] or promoting rules of responsible conduct and suspension of personal contacts to avoid infections and not recommending the taking medications due to the risk of exposure to HIV [18].

In conclusion, Terrence Higgins Trust argued that "the best way to fight the Pandemic, even from an emotional point of view, was to take care of themselves and protect each other. The best defense against the virus is to stay home as long as possible, follow government advice on limiting social contacts, keep two meters away from other people when you go out, wash your hands regularly, isolate yourself if necessary, and take care of the most vulnerable and isolated people" [19].

In the studies cited, the isolation resulting from the lockdown has produced pejorative effects of stable coexistence relationships between genders, male and female, fueling tensions, misunderstandings, relationship difficulties that have resulted in physical or verbal litigation, violence and in many cases, requests of divorce.

The consequences of the physical and psychological stress produced by Covid restrictions have been extensively studied [20] and the results obtained suggest public decision makers to adopt a temporally limited approach, maintaining a clear and effective communication capable of anticipating the negative effects that would inevitably have occurred in the medium and long term on the health system.

#### **6. The limits of social health organizations**

Historically, social health promotion and protection organizations have been of two types: public and private. Public health organizations have represented a flagship of the way to do health care, first of all in those States where the person has been really allocated at the center of human health care and assistance systems (e.g. in European countries, in Japan, in Brazil etc.). However, these advanced public social systems have shown profiles of dubious financial sustainability due to the high payment costs (tax levy) and the operational difficulties of ensuring the essential levels of assistance on a territorial basis [21]. In particular, the major aspects criticalities [22] that emerged, for example in Italy, concern: the care and assistance of people with comorbidities and chronic diseases; the inability to manage and treat and share health information flows; the poor interoperability of databases; the methods of taking charge of the assisted persons; the relationship with local communities [23].

From the universal health coverage system, the private health coverage service (adopted in the USA) is distinguished, on the basis of which health services are not provided mainly by the public health system, but by private structures, financed with health policies paid by patients assisted.

In this second case, access to treatment is only possible for citizens who have taken out private insurance. While the State concentrates, more or less incisively, in assistance and care programs for frail people (eg Medicare; Medicaid). In reality, even this system is not stable and suffers from political and economic conditions having been strongly influenced by the alternation of well-known politicalgovernment events which, in particular in the USA, have compromised it stability [24].

#### **7. Universal and global health care systems at the time of Covid**

Healthcare systems are characterized by two performance purposes: universal (UCH) and global (GHS). In the first case, the universal health coverage system

#### *Bioethical Issues in Healthcare*

tends to guarantee quality health services to all citizens regardless of financial problems [25]. From the universal health care system (UHC), the systems of health organization with global mandate (GHS) are distinguished that are focused on the prevention, detection and response to threats to public health, in particular from infectious diseases (USA, Africa).

According to the health security assessment mechanism [26], both of these systems would be in crisis as a result of the Covid-19 Pandemic for the following reasons:


According to a study published in the *Lancet* [28], countries that have invested in measures to adapt to international health security and access to treatment have been more effective in tackling the pandemic (eg South Korea, Singapore, Taiwan, Thailand, Cambodia, Kerala, Veneto Region). The *Lancet* study concludes on the need for nation states to promote concrete support and health security policies and actions for the future thanks to global health care systems of a universal nature that are perfectly integrated and aligned with common indicators that ensure for all integration, financing, resilience, equity.

#### **8. Health as a productive factor for growth and employment: three strategies compared: European, American, British: the Italian universal health system**

In continental policies, investments in public health represent a productive factor of growth and social development. The health protection and promotion strategy is also a testing ground for federal and parliamentary governments due to the growing emergency situation that has imposed severe revision policies. Below are some examples of health organization strategies and plans/programs launched to overcome the current crisis situation.

#### **8.1 European Union**

In the strategic documents of growth of the European Union [29], the right to health is almost always considered a fundamental driving force for growth not only social and intergenerational, but also economic. The European Union has in fact

#### *For a Model of Revision, Assistance and Care of Identities DOI: http://dx.doi.org/10.5772/intechopen.98415*

argued that thanks to efficient and innovative systems of care and assistance for people of productive age, it would be possible to achieve the objectives of containing public spending, improving the health of EU citizens by protecting them from international and transnational health threats.

The European Union has therefore launched a program for sustainable and inclusive growth, based precisely on the promotion of individual and collective health articulated on four fundamental pillars:


The impact on a global scale of the current pandemic emergency has had an undoubted conditioning effect on the action strategies for health promotion within the European Union.

In particular, the European Parliament approved a new EU Regulation no. 2021/522 establishing a Union action program in the health sector (so-called EU4Health program) for the period 2021–2027 and repealing regulation (EU) no. 282/2014.

Under the EU4Health program, the European Union for the next seven years will implement actions to combat the main cross-border health threats by creating:


• support the prudent and efficient use of antimicrobials as well as promote medical and pharmaceutical innovation and greener manufacturing.

According to an INAPP research study, [30] as part of the actions already undertaken by the European Union for the promotion of health, the new European program "EU4Health" would establish a different and more effective system of connection of health measures within the European states integrated, also from the outside, with the protection instruments adopted at a supranational level.

In the new scenario outlined by the "EU4Health" program, the European Commission will exercise a leading role in the implementation of the planned actions. In particular, the EU Commission which can go as far as the exercise of a delegated legislative power, implementing in detail the indicators of the progress of the program (Annex II of EU regulation no. 2021/522) in compliance with the principles of precaution, complementarity, consistency and solidarity.

#### **8.2 United States**

In the United States of America, the federal government has approved a health reform plan "The Biden-Harris plan to beat COVID-19" articulated in seven key points.

In practice, the US administration [31] has focused its action to protect public health with the preparation of a plan to overcome the pandemic crisis - in the United States alone there are about 579,000 deaths - which aims to:

1.to give a greater voice to science.


In addition to the health strategy of the US plan (*Biden-Harris*) for the escape from the crisis, it should also be remembered the adoption of a specific directive on national security aimed at recovering the "Global leadership of the United States to strengthen the international response COVID-19 and promote global health security and biohazard preparedness" [32] as well as the numerous executive measures (presidential actions) adopted for the protection and response to the spread of the coronavirus.

#### **8.3 United Kingdom**

Similar actions to respond to the pandemic threat (in the United Kingdom there are more than 128,000 deaths due to Covid) have been undertaken by the British government (British Public Health Plan - PHE 2025) which identifies at least 10 strategic priorities for the next five years and that the National Health System (NHS) is committed to supporting. In particular, there is also agreement in the United Kingdom on the need for greater internal collaboration and participation by the competent British Department of Health, including with the European Union, and the rest of the world, for the prevention of future pandemic scenarios. However, health protection in the British recovery program is not only achieved through the functioning of the national public health system (NHS), but also through the promotion of social and economic conditions that allow people to enjoy a life of dignity, prosperity and aware of the risks associated with bad eating and behavioral habits, improper and unbalanced lifestyles. (sedentary lifestyle, alcohol consumption, smoking, lack of social relationships). In conclusion, the British public health strategic program for the next five years (PHE 2020–2025) intends to implement the set of knowledge and skills to support better physical and mental health in the population. Improve the organization and the quality of the work of decision-making processes. Use cutting-edge tools and techniques to increase organizational efficiency and propose new solutions and virtuous approaches to public health problems.

#### **8.4 Italy**

Italy was one of the first countries in the world to be affected by the pandemic and to have recorded the highest percentage index of the number of deaths in relation to the population (about 120,000 deaths due to Covid). Specifically, the health emergency has revealed many structural and organizational weaknesses in the response to the growing demand for care and healthcare following the pandemic [33].

It should be borne in mind that the organization of the public health service in Italy is entrusted to the Regions (while it is the responsibility of the State only to determine the essential levels of assistance), and for this reason, it shows evident territorial disparities in the provision of health services, in particular of specialist services, in the prevention and management of comorbidities and chronic diseases, in the activation of a coordinated response to pathologies resulting from climatic, environmental and local alterations, also through the use of modern information and digital technologies. To counter these deficits (while we are writing, the National Recovery and Resilience Plan - PNRR has been approved) [34]. Italy over the next five years will allocate 15.63 billion euros for the creation of proximity networks, structures and telemedicine for territorial health care, innovation and renewal of existing digital technological structures (FSE, LEA) as well as staff training.

In particular, by 2026 it is intended:


In a nutshell, the Italian government, thanks to the "Next Generation EU" European aid program, intends not only to implement the standards of universal care and assistance currently in place, through the use of modern communication and digital information technologies, but also to enhance the network of medical and territorial assistance services, with the creation of 381 new community hospitals for short-term hospitalizations.

#### **9. The consequences of the pandemic**

If even today there are no unambiguous certainties about the real origin of the current global pandemic crisis [35] we are certainly able to indicate with an appreciable degree of reliability at least seven negative effects, direct and indirect, which have occurred at the level:


g.seventh, the loss of jobs and economic initiatives [42].

All these effects describe the high price caused by the pandemic, both in terms of human lives, and in terms of social and economic costs that will have to be incurred for reconstruction and which are borne by future generations [43].

#### **10. The real reasons for the crisis**

From the indicated list of negative consequences determined by the pandemic, it is clear that the global crises has made vulnerable almost all our certainties (life, health, work) and lifestyles [44], strongly questioning the agendas, projects, habits and priorities [45].

After all, as the Holy Father correctly pointed out, what really highlights the pandemic is "*the evident inability to act together. Despite being hyper-connected, there has been a fragmentation that has made it more difficult to solve the problems that affect us all. If someone thinks that it was just a matter of making what we were already doing work better, or that the only message is that we have to improve existing systems and rules, they are denying reality*". Faced with the pandemic, the Holy Father concludes, the fragility of world systems has highlighted that not everything is resolved with the freedom of the market and that, in addition to rehabilitating a healthy policy that is not subject to the dictates of finance, "*we must restore human dignity to center and on that pillar the alternative social structures we need must be built*" [46].

But this lack of unity on a global level is also reflected at the internal level of individual states. "Similarly," the Pope reflects, "*the organization of societies around the world is still far from clearly reflecting that women have exactly the same dignity and identical rights as men. In words certain things are affirmed, but decisions and reality shout another message. It is a fact that women who suffer from situations of exclusion, mistreatment and violence are doubly poor, because they often find themselves with less chance of defending their rights*"[47].

It is evident that if society is in imbalance, if it is difficult to affirm and promote the rights of every person to participate in the human consortium (women, children, elderly, disabled, etc.), all the more this imbalance will reflect at a global level, that is, in sharing and promoting effective development policies even for the most disadvantaged nations. This is why it is essential to rethink the ways of identifying places, tools and opportunities to bring out and affirm the rights of these "hidden" identities which, on the other hand, can contribute to the civil and democratic progress of every social structure [48].

#### **11. For a possible way out**

So, if we assume that the true stability of the civil consortium has not yet been achieved and indeed has worsened due to the pandemic, in this perspective they will have to be positively welcomed the three recommendations of the United Nations to overcome the global crisis (global health care needed; common socio-economic and humanitarian policies; a recovery plan that rewards gender equality) [49].

From an economic and employment point of view, particular attention will be paid, among other things, to the strategy of social dialogue (so-called fourth pillar of the ILO strategy) between governments and individual social partners, both at national and transnational level, for the identification of a conscious common strategy for resolving the crisis.

Finally, from the health point of view, in this phase of the pandemic, it is necessary to guarantee effective, efficient and resilient global immunization services, that is, accessible to all people through basic health care of a universal character [50].

In the near future, on the other hand, the international, national and supranational recommendations on prevention of zoonoses and arbovirosis [51] must be scrupulously followed and applied through the implementation of epidemiological intelligence actions, training and information for operators and citizens, prevention and control from the risk of exposure, contamination and transmission of biological agents.

In a globalized way, the measures and actions for the control and contrast of the pandemic must necessarily be shared and coordinated with strategic actions and agreements of States and communities of States that privilege the centrality of the human person on the economic interests of production [52].

We must be aware of the planetary significance of the factors that have conditioned this crisis, which require shared responses. In an overall logic, therefore no longer based on partisan interests, it will also be possible to face and defeat the next global crises that have their roots, in hindsight, in issues that have not been resolved for years, if not for centuries and which, here, they can only be mentioned in summary: the fight against hunger in the world; the cultural, economic and civil divide between rich and poor countries; the sharing of scientific and technological advances, the promotion of fundamental human rights, respect for nature and the environment.

In this direction, there has been a significant change in the steering strategy of the World Trade Organization (WTO) regarding a possible suspension of the so-called "TRIPS" agreements, which govern the protection of intellectual property rights under international customs law, in this case, resulting from the production of vaccines and treatments anti-Covid [53].

The dialogue initiated within the WTO, regarding a possible suspension of the TRIPS agreements, had a first favorable echo from various states, including the US Administration [54] and was the subject of particular attention also in the EU context on the occasion of the G20 World Health Summit, on 21 May 2021, held in Rome [55].

The hope is that, also thanks to this important international forum of the main world economies, this year under Italian leadership, common actions and policies can be implemented to fight the pandemic, founded on solid ethical foundations about the need for a common strategy to overcome this crisis [56].

#### **12. Conclusions**

As a consequence of the current global crisis scenario, this chapter has shown the characteristics, but also the criticalities, of the main and most advanced systems of care and the promotion of human health.

The examination of some of the most well-known Western health organizations has revealed a scenario of crisis that has sharpened as a result of the pandemic, which are no longer able to respond effectively and promptly to the new challenges caused by globalization.

For this reason almost all systems Western health care and protection are under review.

This is good. However, the new organizational structure will have to be more attentive to the real needs of society.

In some crucial areas of medical research, the interests of politics do not have to prevail and we need to give more weight to science.

The challenges of the next years, even in the health sector, therefore require better and more prudent skills protection and information on possible risks to the health and safety of any personal identity, in particular children, the elderly, the disabled, immigrants, pregnant women, with a spirit of greater solidarity [57].

History teaches us that, only thanks to integration and authentic respect for specific cultural, social and religious identities is it possible to create a generous and peaceful coexistence that nourishes conditions of shared well-being and development.

In order for all this to be concretely possible, however, it will also be necessary to treasure the teaching that the Holy Father gave to the current pandemic, which reminds us that:

*For a Model of Revision, Assistance and Care of Identities DOI: http://dx.doi.org/10.5772/intechopen.98415*

"Where nature and, even more, persons are involved, another way of thinking is needed, one that can broaden our gaze and guide technology towards the service of a different model of development, more healthy, more human, more social and more integral" [58].

#### **Author details**

Federico D'Angiolillo# National Institute of Statistics, Rome, Italy

\*Address all correspondence to: federico.dangiolillo@gmx.fr
