For several years, Entrar Afuera has focused on the intersections between public institutions and community lead practices. What happens when an institution opens up and drops its permanent control over processes, protocols, workers and users? It is probably in these rare occasions when people experiment a more expanded, democratic and open relation towards public institutions. When this way of working is not temporary and has become the institutional dynamic of a whole working structure, the sustainability of these extended practices could be on a good path.
Nonetheless, how to identify exemplary experiences that could help us think deeper? Following the living thread of the institutions of care (healthcare, education…), Entrar Afuera came to know the public healthcare system in Trieste (Italy). This experience began when the Basaglian movement closed down the psychiatric asylum during the 1970s and built a strong public and social structure that collectively assumed the responsibility of taking care of each other.
Trieste’s current healthcare system divides the town into four socio-sanitary districts. The whole structure relies on proximity facilities that function according to the values of openness, vicinity and accessibility. The healthcare system works closely with the municipality and the regional public housing office. It might sound comparable to other institutional organizations across the welfare states in Europe, but the way this ecosystem takes responsibility of the community is unique, multilayer and transdisciplinary. An example is the case of the Microareas, a programme developed in vulnerable urban areas where healthcare, social services and housing provision intersect. It is a place where neighbours are listened to: where people´s needs are met by creative solutions, which are developed between the institutional system and the neighbourhood, taking people´s resources into account. Carmen Roll, a former worker for the healthcare system in Trieste puts it this way: “there’s a thread that connects the deinstitutionalisation in mental health and the Microareas as an attempt to deinstitutionalise Medicine”.
In the city of Madrid, where most of the Entrar Afuera collective is based, there was a strong community health experience in Vallecas back in the 1980s. Vallecas, a neighbourhood the size of Trieste itself, is well known for its community and civil rights movements against long lasting poverty and precarious living conditions. However, these threads of former community practices don’t always find living echoes. This is the current context where healthcare professionals, particularly young people specialising in primary and community attention, are seeking ways to reimagine and reincarnate a community health practice that can be transferred to their specialisation programmes and their daily practice.
This is where the Laboratory of Community Health Practices comes in. This Laboratory is a research and action programme organised by Entrar Afuera and the social cooperative La Collina with the support of FundAction’s Rethink19 grant, where professionals from both contexts could meet, share and discuss their experiences, thoughts and future projections over several days.
On the second week of September 2019, a group of professionals working for the regional public healthcare system in Madrid visited Trieste: five doctors and a nurse specialising in family and community care in Vallecas, a doctor who recently finished her specialisation, and a doctor who works as a tutor for specialising professionals. The group was accompanied by two members of Entrar Afuera.
Initially, Entrar Afuera was going to organise a Laboratory that would bring together professionals from three municipalities which currently have community health programmes in place: Madrid, London and, of course, Trieste. This idea was the result of an on-going collaboration with the City of Madrid that terminated a few months before the Laboratory took place. This change might sound trivial, but it is actually key to understand the shift in perspectives: we asked ourselves who had the desire to affect their current practices and sought for other views to identify where to find these interests. Thus, we found a group of young healthcare professionals deeply connected to the neighbourhood they work in, willing to explore community health practices and eager to transform their own specialisation programme so that their colleagues could benefit from a better training in community health.
Over a working week, we met with professionals working in Trieste for La Collina and the regional healthcare system. We visited a mental health centre, where we were confronted with the meaning of working in an institution which, contrary to most mental health services, intends to remain permanently open for people to come and go as they need. We met a group of nurses that spend a great part of their day providing care to people in their homes; we visited a few Microareas and the neighbourhoods where they work; and slowly we came to understand how a large network of social cooperatives is a reliable counterpart to public institutions. We also had time to meet with prominent figures of the Italian Basaglian anti-institutional movement, such as Franco Rotelli.
But, why call this visit a laboratory and not a simple workshop? For most of us, this term was key to give us a different approach to the visit: we wanted to have the space and time to meet and think with others, to share mutual concerns and questions we have towards our practice but have developed from different points of view an experience.
Some of the main questions that guided our encounter and enriched our exchange revolved around three topics: an awareness of the tension between permanently taking responsibility of certain issues and partly delegating it on a community; a continuous tension between political and technical uses of language; and the importance of developing a strong coordinated network between neighbours, professionals and institutions to guarantee the continuity of care.
We can still hear the echoes of the experience several months after the laboratory. In Madrid, the group of specialising doctors who visited Trieste is currently working on a proposal to include specific community health training into their specialisation programme, which is a unique opportunity for change, as it could affect the curricula for specialising doctors and nurses across the region of Madrid and maybe even reach a national level. Of course, there are many other contexts, resources and actors involved in this greater transformation process, but we feel that the laboratory has somehow contributed to it, even if in a modest way.
Partners in Trieste are facing an adverse political context, continuously having to fight to preserve the current healthcare institutions and their dynamic. In such a context, receiving support from other places in Europe and having the time to reflect on their own work and situation is refreshing. External acknowledgement nourishes possible collaborations and maintains the door open for future exchanges. In particular, a couple of specialising doctors from Madrid will seek to spend a period of official international exchange in Trieste during their training program: an output that, in a way, officialises collaborations and opens new paths for future trainees to continue with these exchanges. A future visit from the professionals working for La Collina to Madrid for a second round of the Laboratory is also in sight.