We publish the second chapter of a book on the workers’ and patients’ struggles at the university clinic in Rome in the mid-1970s. The introduction of the book can be found here and the first chapter can be read here. We recommend watching this inspiring documentary about this historic movement in tandem. 

This part provides a very sharp  critique of a doctors’ strike that was going on at the time, by analysing the complex hierarchy within the doctoral profession and the divergent interests. This type of analysis is still relevant today!

The polyclinic collective formed part of a wider network of political committees in major workplaces and working class areas; you can read more about them in these articles on Magneti Marelli, on Senza Tregua and the political committees in Veneto. The collective’s outstanding character was based on the fact that it included medical students, nurses, porters and doctors, and aimed at the socialisation of the divided knowledge within a project of workers’ control of the clinic. Patients were participating in the regular assemblies of the collective. Workers fought for equal conditions between permanent and precarious staff, they imposed free health services for local workers against the private interests of the bosses of the clinic. The collective supported the occupation of administrative buildings for the establishment of a children’s nursery for hospital workers. They also joined a feminist occupation of an operation theatre for free and safe abortions. The collective was locally linked to similar collectives within the energy sector, railways and various working class neighbourhoods.

In terms of understanding, the comrade uses the word ‘barons’ to describe the very elitist, if not semi-feudal character of the medical and university hierarchy at the time. Many of the bosses of the university clinics were embroiled in corruption and had close links with conservative, religious and sometimes fascist circles. She writes about the ‘university workers’ struggles’ for equal wages with the workers directly employed by the hospital – at the time university contracts were used as a form of subcontracts within the hospital, in order to pay less for the same work. So the ‘university workers’ are actually medical workers in the polyclinic.

 

The workers between trade union and autonomous struggle

Which unity of workers?

In Spring 1971, the trade union SUNPU started a dispute according to their usual approach: they propose an adjustment of pay and conditions of workers employed in the clinics in relation to those of the hospital workers, based on the pending university reforms. This adjustment is supposed to take into account the “presumed greater specialisation of the university personnel in comparison to the hospital workers” and the “function of higher education and research of universities within society” (July 1971) [1]: meaning, we are supposed to reward the workers in the clinics because… they engage in research activity! The initiative of SUNPU provides an occasion for a first confrontation between different positions. 

At this point in time the Collective was not yet organised as a structure that could have led a struggle itself. Various times the collective repeated that “it did not intend to replace the trade union”: rather the collective tried to foster all those tendencies of rank-and-file democracy and the refusal of delegation, also focusing at organisational structures, such as the official ‘Council of delegates’ [1], which the collective attributed with the task to control the functioning of the hospital from below. For example, the collective states that: “with the department delegates we should immediately create department assemblies, together with the patients, the doctors and the students in order to stabilise the increase of staffing levels according to the real requirements; we have to control the modalities of patient admissions from below, we have to make sure that every worker in the area can use and then manage the infrastructure to prevent and finally eliminate the reasons for becoming ill. To make it short, with the department delegates we have to realise the self-management of the workplace and of health” (22nd of October 1971)

It turned out quickly that these hopes were misplaced, given that the ‘Council of delegates’ never took on such a role. [2] However, this did not stop the collective from taking on the responsibility and developing their own activity, which evolved on two levels. 

On one side, the Collective criticised the trade union platform which divided, rather than united the workers: the result of their proposal would not be unity, but the division of the working class. The workers did not want an economic and formal adjustment based on a presumably higher level of qualification, but aspired for an improvement of wages within the political unity of all workers employed in social services. [3] The proposal of the unions highlights the discrimination towards the workers in the clinics (in comparison to the rest of the workers with university contracts – the translator), but at the same time it creates a privilege for them which would harm the rest of the hospital workforce. In this way the unions maintain the very system of discrimination, placing the workers in a permanent rat-race against each other. 

In contrast, the unity of workers in social services can only be established by abolishing the classist structures which are the fundamentals of discrimination. In consequence the collective criticised the trade union proposal, also because it relies on “the university reform, which maintains the class character of the current school system, which churns out post-grads who are even more able to exploit the working class and to maintain the centres of power of the barons, such as the university clinics”. (11th of November 1971) 

Beyond that, the trade union proposal went well together with the proposal of the barons to transform the entire hospital into a university clinic. The Collective started to denounce this as being against the interest of the people and in the interest of repression against worker and student struggles (16th of July 1971). The union did not mention that this platform would accentuate in a negative sense the division between these specific clinic workers and all other categories of precarious workers in the clinics (contract workers, day labourers etc.). By focussing on the ‘research’ element, which causes some of the major problems in the hospital, the proposal would aggravate the conditions for patient care in general. 

On the other side, the Collective also put forward their own proposal: there is a way to achieve a real unity with the rest of the hospital workers, which is “the transfer of all hospital personnel (and therefore also that of the clinics) to the regional hospital administration (based on article 5 of the DPR, 28th of March 1969)” (11th of November 1971) This article states: “The clinical institutions which are directly managed by the university constitute in their entirety a poly-clinical university hospital which is equivalent to the regional hospitals”. The argumentation of the Collective is as follows: if the university poly-clinic is equivalent to the regional hospitals then the workers of the university clinic should also be treated like the regional hospital workers, and given that in the very university clinic there is already a part – the pavilions – which comes under regional administration of St.Spirito, also the workers in the clinics should be added to this administration (which is basically the demand for ‘regionalisation’ of all workers who undertake hospital duties and are referred to as such). 

The ‘regionalisation’ has two advantages. 

Primarily, it introduces a real unity, without any detrimental discriminatory elements: it starts from the fact that the workers do the same job and that their equal treatment follows from this (rather than having two different ‘adjusted’ treatments, which can create divisions in future, e.g. through the introduction of new laws or improvements that have been won for one category, but not the other). For the same reason this proposal can be understood immediately by the workers, it is an easy and clear proposal within which you cannot hide any loopholes. This is true to such an extent that when the Collective presented the proposal during a SUNPU meeting “given this justified demand, the union saw itself forced to verbally agree with the transfer of all university personnel to the hospital administration” (25th of November 1971), except that actually they continued to oppose the transfer vigorously and re-proposed only a wage adjustment. 

Secondly, it is a proposal that expands the social base of the workers that struggle for unity. If all those workers who work in care (which includes the workers employed for the maintenance and administration of the hospital) would become part of the general hospital workforce, then also those divisions would be superseded that ensue from the current fact of having various employers (the university, the ministry, the boarding school, the subcontracting company). Also those divisions would be superseded that stem from the various precarious forms of hiring that these administrations practice (the clinics hire people as self-employed, the university gives them contracts etc.). With the proposal of ‘regionalisation’ the workers would find a general solution for thousands of diverse problems of all groups of workers. Even a unity with workers in other social services would be achieved (such as schools, transport etc.), given that they are also supposed to transfer the regional administration. [4]

Furthermore, it’s the principal aspect of this proposal, when it comes to the organisation and direction of the social services, which allows the workers to intervene in the general questions of  the care sector. Here it becomes clear that what happens in the Policlinico is relevant to all popular masses.

The doctors, the care work and the wages

July 1971. The doctors of the university clinics go on strike, the wards empty themselves, the patients are discharged or transferred. Why? “Certainly not in order to denounce clearly and decisively the extreme lack of resources with which the doctors have to work”, proclaims the Collective. “Certainly not in order to actually improve the service in favour of the patients and the citizens. They went on strike in order to get higher wages, because, as the doctors say, although they are paid for teaching and research work, they are not paid for the care work they are doing”. (19th of July 1971)

Their only goal, in fact, was to pay themselves the ‘wage adjustment’ for hospital doctors that had already been determined in the De Maria law (from the 25th of March 1971, no.213). During the three months of strike which paralysed the university clinic, none of the authorities asked themselves what it meant to deprive the population of Rome of nearly 3,000 hospital beds. The upper hierarchy of the state, the hospital management and the promoters of the strike really didn’t give a toss about it. It would be a whole different story when the workers would start their struggle and put the issue of “the lack of resources within which we have to work” right at the centre of their mobilisation, trying to “improve the service in favour of the patients”. In this case, all authorities would be ready to reproach them of “depriving patients of care” and load responsibilities on their shoulders that the workers certainly don’t have.

Let’s return to the doctors strike. The Collective felt the need to have a clear position to present to the masses when it comes to the demands of the doctors. In a leaflet to the patients and their relatives the workers denounced this strike as corporatist (“we cannot allow that the doctors use the strike, the weapon of workers, for their dirty interests in money and power to the disadvantage of the workers”, taking into account amongst other things that at the end of the month “they will cash in their full stipend, thanks to their research and teaching work. Where will they cash it in? Probably by the sea?”). They attacked the strike as sectorial which only aims at the ‘economic’ recognition of the care tasks, which is in fact a “maneuver that is inclined to keep things as they are, to keep on producing doctors who are external to the reality of factories and working class areas, and all that under the banner of ‘neutral science’ that actually only serves the interest of the bosses!” (19th of July 1971)

Beyond this, the Collective maintains that within the declared goal of an increase of the stipend for care work “the half-hidden aim of the strike is to transfer the entire Policlinico to the university” (26th of July 1971), in order to reinforce further the power of the university barons over the public health system (in fact, for the barons the two objectives follow the same logic: public health services are of such little interest for them that they need further material incentives; on the other side, their true strike aim is not to be paid for care tasks, but to engage only in ‘research’ work”). [5] It is paradoxical that they try to achieve this goal by saying that they actually work ‘too much’ in public health (in relation to how much they are paid for it). 

The most obvious question that the Collective poses to the proletarians in order to help them understand what their interests are in this struggle of the doctors is the following: “What kind of health care is it about? Do doctors dedicate only that time to the care for the patients on the public wards that is left over from their work in private clinics? Is it about health care that uses patients as guinea pigs in order to make themselves a name? A health care that snatches patients from the often filthy wards of the hospital of ‘high research’ in order to subject them to fatal experiments? Is it health care that administers drugs without looking at the true reasons for the illness and that limits itself to patching up the ill worker so that the bosses can exploit them even better?” (19th of July 1971) The doctors who have initiated the wage dispute had no intention to discuss these central questions, instead they demanded more money for that type of health care.

Actually not all doctors agreed with this trajectory. It’s only the university barons and the senior doctors who strongly believe that the care work is only an appendix for their high research. They see the care element as a way to get cheap access to patients to experiment on. The other doctors relate to the dispute according to their position within the hospital hierarchy (although they all participated solidly in the strike due to clan solidarity). Only a small group of precarious doctors disassociated itself, actually because they demanded “a new type of medicine that is not subservient to the pharmaceutical industry, to the private clinics, to the hierarchical and feudal structures”. [6]

Perhaps it is helpful – at this point – to draw a small flowchart of the hierarchy of doctors in order to understand how health care is subjected to the profit interests of the medical barons, as denounced by the Collective.

Although rife with struggles between different clans and threatened by the permanent discontent of the lower grades of doctors who are eager to ascend to the top more rapidly, the university doctors form a closed and restricted group. The noteworthy ideological homogeneity is due to the recruitment via cooptation amongst those who have shown the right attitude (the training to become a doctor is long and it is always possible to exclude those who express ‘divergent’ ideas). On the other hand their internal authoritarian regime is the direct result of the enormous power that the higher grades hold.

At the top of the pyramid we find the barons (it would be more appropriate to call them superbarons), namely those professors whose influence spans from their own clinic to the entirety of the health and university structures of the country (and even to the ex-colonies, e.g. in the case of Stefanini, who placed his students at the university of Mogadishu).

Their time is certainly very precious, and to waste it by providing healthcare on the wards… no way, this is not going to happen! But how should the time be spent instead? Hardly ever in the operation theatres or the cubicles of the research units (they leave this to the subordinates), but much more often in meetings of the highest directive and advisory organs of the national health system, such as the Superior Health Council, or the National Council of Research, the special parliamentary commissions etc. where they weave the lines and intrigues of the government’s health policies of which they are the prime beneficiaries. 

Another share of their precious time is dedicated to local entities (the Regional or Provincial Health Council etc.) where they create and undo hospital units, fashion new decentralised university departments, new faculties for the main universities, centres for hygiene and prevention etc.. All of this follows the precise logic of creating new extravagant hospitals and departments in the region where they can place their protegees, who provide the barons with ‘academic studies’ and ‘publications’, and who thereby expand and consolidate in capillary form the power of the barony.

By privileging the ‘specialisation’ of decentralised medicine, this logic creates holes in the public health care system, which is supposed to be sacrificed in favour of the ‘superior needs of research’ – and these holes are immediately filled by the private medical sector, always under the benevolent approval of the barons, who use their public sector position to provide (themselves with) recommendations to give licenses to private clinics. This is how the commercial relationships with the local political elite are deepened. The political elite can show off with their policy of social intervention (which is actually composed of all the favours that have been granted to the barons) and collect votes, while at the same time enjoying the fruits of the development of the private medical sector by speculating on the tendering process of public contracts. These ties between the barons of medicine and local powers have tightened first of all in the South of Italy, and is one reason for the continuous stream of patients from the periphery to the centre of the country (and vice versa), which is a system that is preferred by the barons to extend their reign beyond the confines of the university. 

Descending the hierarchical ladder we encounter the little barons, who are professors whose limited political power won’t allow them to participate on the top level of decision making. They divide their time between research in the university institute and health work in the private clinics, where they have space and equipment at their disposal (we will soon find out how they managed to get hold of these!) in order to extort heavy fees from whoever comes their way. In general they accompany the activity of the super barons, they support them in the clinic council, they praise them in their speeches at congresses, they become the spokespeople of the super barons’ interests in the administrations of various hospitals and represent their political and speculative aims: they are, in short, the sub-government of the barons. 

Further down the ladder are the assistants. They are indeed present in the hospitals and deal with the patients: they are in fact the main executors of the most undignified experimentations on the human guinea pigs. They are also big squanderers of public resources, given that they are the most staunch and vocal supporters of highly technologised medicine of the anglo-saxon variety. They promote enormously costly machinery (which is either only rarely used and/or needed), which they see as instruments to boost the reputation of the clinic (and the barons) and to move up the professional ladder towards a professorship. Their career is in fact their main occupation: they know that there are only few vacancies for professorships which makes them particularly belligerent. They shadow each other, they hide from each other what they are doing and create sealed departments of secrecy and favouritism within the clinic – and they do all of this with complete disregard towards the needs of the patients.  

Up to this point we have dealt with those medical professionals who are already part of the official ‘category’ of doctors, who belong to rival clans and obtain various grades within their clan. Given their knowledge about mutual benefits, the relationships amongst them are regulated according to precise behavioural codes: they do each other favours and give each other presents, they don’t ask for fees if they treat each other or each other’s relatives etc.. 

Below them we encounter the large segment of people who have not yet acquired the professional status, the various precarious doctors: volunteer assistants, interns, specialised medics; these are the only ones that work in the hospitals fulltime. Their task is to perform the routine tasks on the wards in an effective manner, without losing too much time, because even for them the main activity is supposed to be research related. They engage in research that has been ‘signed off’ by the assistant doctors, for whom they are a cheap workforce (they actually work for free, except from those very few fortunate or recommended people who benefit from a study bursery). They help the assistant doctors towards a professorship or to climb up the institutional pyramid (when they are not busy as errand boys for the electoral campaigns of the barons who are looking to obtain posts in the state administration) and perhaps manage to earn a few merits that help to distinguish themselves from the swamp of their equals. They are a vast ‘reserve army’ for the professors without any contractual power and exposed to major blackmailing. Often these precarious medics become aware of the futility of their work, or worse, of the dangerous nature of the research that they are subjecting the patients to, but if they want to advance in their career they have to adapt and fulfil the tasks that they have been entrusted with. They have to abstain from any critique when engaging with the institutions and have to be ready to serve the barons in any which way.

Still, it would be wrong to say that all the doctors who work at the university hospital (in particular the youngest amongst them) are all hardened reactionaries or careerists without scruple. Apart from the fact that the subordination to the power of the barons leads to a lot of complaints amongst the lower ranks, which are often expressed with a ‘democratic’ veneer, it is possible to make out another dividing line amongst the precarious doctors. On one side there are those (either because of their proletarian background or because they participated in the student movement) who combine their critique of class medicine with a direct experience of what health care looks like. They refuse to dehumanise the patients and try to establish a different kind of relationship with them and their relatives, with the workers and the students. But there are too few of them for having any actual weight. On the other side there is a group of precarious doctors who pose the problem of talking sides in a different manner: they have already started to climb up the ladder, but sooner or later they come to a crossroads, in particular when they see themselves obliged to accept the ‘rules’ of the pyramidal structure and to quieten their ‘conscience’. Usually they end up playing the role that the structure assigns them to, but it should not be underestimated that this acceptance is often felt as forced and that it leaves traces of a conflict. These doctors constitute something like a ‘quicksand’, a weak point of the entire hierarchical structure; a strong mass movement that knows how to wedge itself into this gap and to act upon these contradictions could perhaps separate them from the higher-level doctors and weaken the front of the barons. 

Concluding this digression we can say that in the university hospital the relation between actually performed care work and position within the hierarchy (and therefore the relation between care and remuneration) is proportionally inverse. The barons and little barons, who are not even present in the hospital receive high incomes from the private clinics [7], research contracts, participation in various scientific-ministerial activities, in addition to their state stipend, which is, although much higher than that of the rest of the hospital employees, only a minor factor in the total balance sheet. The assistant doctors ‘who direct the research programs’ are not content with the good stipends they receive; while the precarious doctors, who are the only ones who actually do care work, do not even get a single lira for it. 

How can such a situation be rectified? For the barons who, amongst their other positions, also lead the professional associations, the answer is evident: don’t pay for the hours actually spent doing care work on the wards, but rather for the official position held, and thereby paying most to those who do the least. 

Given that the barons are used to wield absolute power over the entire hospital they also didn’t hesitate to seek… the solidarity of the workers in order to achieve their goals during the dispute. The doctors alluded to the possibility of’ a common fight between doctors and non-teaching staff’ over wages, which was something that the workers refused fervently, saying “they allude to this because they need the workers, they want to make use of them and then ditch them again, like always. We have to counter every attack in a decisive manner!” (19th of July 1971)

As we have already seen, there is only one voice amongst the doctors that doesn’t sing in tune with the rest, which is the ‘nuclei of precarious doctors’. These linked up with some other doctors who are in a minority position within the ANAAO (Associazione nazionale aiuti e assistenti ospedalieri – National Association of Hospital Assistants) and with medical students and workers at the Policlinico. They fought for the question of care becoming a central issue of the dispute, also hoping that the future university and health reform would transform the sector. For example, they argued for the introduction of an ‘integrated doctorship’, which would overcome the division between teaching and research on one side and care on the other – and the subordination of the latter to the former. Unfortunately, this position remained weak and didn’t manage to influence the progress of the dispute in any way.

After three months of ‘hard struggle by the barons’, the desired concession was granted. The outcome satisfied the barons, as it left the question of the structure within which care is performed untouched. Furthermore, the agreement didn’t deal with any of the problems of the precarious doctors (“employment at the university continuous to be dependent on the precarious doctors’ offer of unpaid labour, upon which the institution rests historically; the university thereby eludes the issue of permanent work contracts, including pensions, compensation for work-related risks etc..”) [8]

In the meantime, the barons were happy for the hospital to ‘function’ again.

 

Footnotes

[1] “The election of the ‘Council of delegates’ on the 3rd of May 1971 was a confirmation for the fact that the hospital workers want to establish a ‘rank-and-file structure’ that expresses all of their categories [components] and which represents a fundamental step towards the self-management of the structure of work. They consider this as the only concrete way to eliminate the exploitation of the working class. The delegates of the departments – in contrast to the official works council [commissione interna] – are related to the actual place of work, and therefore will be invested in all issues that can spring up in the department, from the situation of dismay in which the patients find themselves every day to the oppressive pace of work of nurses and health care assistants to the insufficient amount of doctors.”

[2] Early on the Collective denounced that, by decision of the hospital hierarchy, the ‘Unitary council’ had replaced the ‘Council of delegates’, which had been an expression of rank-and-file democracy (30th of August 1971)

[3] On the contrary, the trade union proposal created problems between university and hospital workers once it came to its practical application. When university workers were threatened with injunction after a strike, and the SUNPU appealed to the solidarity of the FLO, the hospital workers did not follow the SUNPU call “because a real unification with the hospital workers cannot emerge from such a platform”. (11th of November 1971) 

[4] In March 1972, when non-teaching staff at the university were in dispute, the Collective proposed the unification of this particular struggle with the workers at the clinics and pointed towards regionalisation as an objective for the unity of service workers. “They want to make us believe that to unite all service workers is an impossible or at least very distant endeavor. Nothing is further from the truth than that. We know that a law, which has been published in the Gazzetta Ufficiale on the 19th of January 1972, allows for the transfer of university staff to the regional administration. The speeches of various trade union leaders, in which they state that the political orientation of the various regions is the determining factor, are wrong; we say that the opposite is true, that wherever there is a unity of the rank-and-file there is an unfailing victory of the working class” (7th of March 1972)

[5] So much so that at the beginning of 1976, during the discussions about the Mariotti law, which imposes on doctors who work ‘on a contract with fixed working times’ to choose whether to work within public hospitals ‘full-time’ or to work in private clinics of the university barons – and they obviously would not like to have to make such an ‘either or’ choice – they advanced a very simple proposal: “Let’s withdraw the De Maria law and let’s only engage in research; in this way we would get rid of the double position of working both for the public and the private health sector”. They really don’t want to work in the public care system! When it comes to the private one, on the other hand, they don’t hold back!

[6] A leaflet signed by “a nucleus of precarious doctors” (8th of October 1971)

[7] The income from the private clinics stem from the capital that the barons have invested, rather than being a share of the tax income of the state. Still, it is necessary to remember that the quantity of that income is always proportional to the position of the barons within the university, who thereby uses his academic title for the purpose of his own enrichment. 

[8] Leaflet of the 8th of November 1971 by the ‘nuclei of precarious doctors’. The second issue that was not addressed by the settlement was the demand by the precarious doctors to be incorporated into category 6 of hospital doctors ‘with the statutory right to full-time contracts, the abolition of unpaid labour and the registration of the actually performed hours of labour’.