Medicina per "stranieri", questioni etiche per un approccio interculturale. Esperienze degli ambulatori di strada.

The research is composed of 4 chapters and investigates the operational methods of doctors and health workers who work in street clinics. The first chapter "Epistemological Aspects Characterising Social Research: Methodologies of Analysis in Applied Ethics" analyses the main theoretical and operational problems of intercultural medicine in street outpatients' clinics, a reality to which most of the time, irregular foreigners and foreigners in a situation of fragility turn. The second chapter "Intercultural Aspects in Health Communication" highlights the importance for doctors and health workers to know how to practise intercultural medicine even in the most difficult contexts: intercultural medicine is fundamental for a good development of the doctor-patient relationship and for facilitating the trust of the patient towards the health professional. In the practices of intercultural medicine, narrative medicine occupies a place of primary importance: it has a fundamental role because it makes it possible to explain the different meanings of illness and to build a personalised care relationship capable of increasing patient compliance. The training of the physician and of all health care personnel, starting from the university preparation, cannot today disregard the awareness and the responsibility that this reality entails: the contribution of social ethics and, in particular, the development of ethical competence, is, therefore, fundamental for every professional who intends to deal with his work in a responsible and conscious manner. The work of health professionals takes place within diversified structures, but which, at an organisational level, must take into account the new needs induced by a society increasingly characterised by ethnic and cultural pluralism: health professionals must therefore be placed in a position to work on the multiple existential meanings of illness, on the possible conflicts generated by this multiplicity, and to activate the resources and other services present in the area in a coherent manner: the ethical space is an organism in the process of being structured also in our country and modelled on the example of the Espace éthique dé l'assistance publique, operating in France for about thirty years, which could constitute a place, institutionally recognised, in which to bring together and develop the experiences gained in the practices of the street clinics and give greater vigour to an intercultural and narrative approach to therapeutic relationships. In the elaboration of the chapter, I carried out a comparative analysis of theories elaborated by scholars from various disciplinary fields (moral philosophers, anthropologists, physicians) regarding intercultural medicine, noting and describing the main limitations and ethical emergencies implied by the use of multiculturalist criteria and the exclusive reference to EBM. The analysis conducted allowed me to detect both the need for training, for care professionals, in intercultural medicine, in ethical competence, and the need, at the level of clinical governance, for the establishment of Ethical Spaces. The third chapter 'The right to health in the national context for regular and irregular foreign citizens. Analysis of regional cases' highlights how, although the right to health is a legal obligation of states, recognised at international level, it encounters numerous implementation problems, often making these rights 'rights on paper'. As widely recognised at the European level, at least from a formal point of view, immigration policies adopted by individual states must recognise migration not as an exceptional phenomenon to be managed according to emergency criteria, but rather, as a structural process connected to the very existence of society and tend to promote and implement wide-ranging actions aimed at promoting effective, humanitarian and safe actions that promote the integration and well-being of all citizens. All public and relevant institutional bodies, which interface daily with citizens and regulate the democratic life of society, are key players in integration processes, since they are the main producers of goods and services that are not for sale, but determine people's wellbeing: the public health sphere is one of the main providers of services to citizens and the promotion of integration also implies diversification both in terms of delivery and organisation of health services. At the national level, regional policies have two different approaches: bottom up and top down. On this basis, I have analysed and compared the health policies of six regions, highlighting their main strengths, limitations and ethical implications in relation to health policies and services aimed at migrants, with particular attention to irregular foreigners, who constitute the weakest and, for this reason, particularly significant group. The fourth chapter "The Right to Health for Irregular Foreigners in the Municipality of Genoa" examines three historical and consolidated experiences located in the Municipality of Genoa: their genesis, characteristics, organisation and functioning. In order to examine these three realities I conducted a quali-quantitative analysis by first examining the medical records of the people who go to these outpatient clinics and then administering twenty-five semi-structured interviews to all the volunteer health professionals involved in the street clinics investigated. Examination of the files allowed me to identify a substantial overlapping of clinical data and pathologies with respect to the surveys carried out at a national level, confirming the weight of determinants and confirming the healthy migrant vs exhausted migrant effect contemplated in the literature. I chose to devote special attention to the dental problem, which is recurrent and widespread in the most fragile segments of the population and which has a major impact on health even among foreigners: the right to oral health is recognised globally as an integral part of people's general wellbeing, but to date it remains largely unenforced At a national level, regional policies do not contemplate interventions dedicated to oral prevention in a coordinated and continuous manner, but only emergency interventions. I subsequently analysed the material using the NVivo programme with the aim of drawing a profile of the volunteer doctor, understanding his motivations, his attitude to intercultural medicine, and his degree of awareness. With the collaboration of the non-profit association Fondo Scuola Italia, I launched an oral hygiene education and prevention project in 13 primary school classes of the Istituti Comprensivi of the I, II, VI Municipio with a high frequency of foreign students. The course involved teachers and at the end of the course each pupil received a dental hygiene kit and a multilingual oral hygiene education guide. In addition to this project, with the collaboration of the Genoa City Council's Department of Social Policies, I had joined the oral education project for adults "The Right to Prevention" aimed at fragile citizens of the Genoa City Council and STP migrants. The project, financed by Mentadent and Unilever Italia Mkt Operations S.r.l. with the collaboration of the Italian Red Cross, the ANDI Onlus Foundation, Mentadent and a number of Rotary Clubs in District 2041 (Milan metropolitan district) through a mobile equipped unit, aims to guarantee even the most fragile categories of society the right to receive basic dental check-ups and treatment, thus promoting prevention, a correct dental hygiene routine and taking action to prevent numerous oral cavity pathologies and promote people's general wellbeing. Genoa was supposed to be the lead city for the initiative and operations were to be carried out in the period between April and May 2022: the outbreak of war in Ukraine and the intensification of migratory flows on the Balkan route meant that this mobile clinic had to be sent to Trieste so that, to date, it has not been possible to schedule its deployment for the project, the drafting of which can, however, be viewed on the sites of the promoting Associations. In summary, the analysis conducted in this thesis confirms the initial working hypothesis, i.e. the need to develop an intercultural approach in a society increasingly characterised by ethnic and cultural pluralism, overcoming the albeit laudable voluntarism that has characterised many significant experiences. In fact, organisational limitations of the NHS emerge, but also related to the actual awareness and ethical competence of doctors and health workers in dealing, from a non-emergency perspective, with cultural otherness, with particular reference to therapeutic and, more generally, care relationships. Two possibilities appear to be effectively feasible and interrelated today. One concerns staff training which, by placing ethical competence at the centre, could take as a model the one elaborated by J. Tronto, with the five phases of care identified by her, starting, however, from a biographical approach based on the awareness of otherness, of the incommensurability between cultures and the flexibility of languages. The second is the constitution of ethical spaces in the NHS structures which, using doctors, health professionals and ethics experts, constitute a place where it is possible to implement intercultural paths of common knowledge and co-responsibility in the management of the therapeutic relationship.