Zero Disease

To organize health care, man began his fight against diseases that in the nineteenth century was focused on therapies against infectious diseases. Around 1850, the construction of the first pavilion hospitals began, which soon showed the potential of hosting and connecting specialized activities that were beginning to emerge. These were mostly surgical, as a result of the revolutionary scientific discoveries and practices of the birth era of the foundations for anesthesia, microbiology, antisepsis and asepsis, but also diagnostic laboratory support, followed by diagnostic radiology (X-ray, 1901 Nobel prize), to which electrocardiographic diagnostics⁷ would be added soon after (Einthoven, 1908).

In order to organize health care in addition to acute patient management and thus urgency/ emergency, you need an increasing ability to manage chronic illness through a holistic vision that includes active handling of the disease, more often chronic diseases to be centered on prevention.

In recent years the traditional and hierarchical health care model that is identified with hospital care has began to falter, not only due to the high cost of energy, technology and management but also because of the profound epidemiological changes in diseases. Traditionally, the cure of acute illnesses has reportedly developed a standby medicine in the top-down hospital context, a facility increasingly dedicated to users, emergency and to the treatment of high intensity and in need of advanced technologies. The hospital has become ineffective for the treatment of rising widespread chronic diseases in need of multidimensional interventions, also linked with social health.

The increase in life expectancy with the progressive ageing of the population has led to the augmentation of chronic degenerative and debilitating diseases, for which the traditional hospital standby model is inadequate.

The attempt to create within the hospital outpatient sectors for specialized external uses has proved unsuccessful for a number of reasons: the structural and hospital management costs are too high for such activities, and the type of performance is completely different since the acute patient must be treated in the hospital and the chronically ill should be treated in the zone, through the enhancement of organizational models characterized by prevention.

Merging the management of activities for acute disease with the management of the activities for chronic illness inside the hospital deviates high-tech and urgency resources from interventions for the acutely ill. The center of gravity of care for chronic conditions needs to be moved into the territory, with the need for increased effectiveness also through avoidance interventions. Prevention becomes the pillar of the distributive model of territorial health care: not only due to its undisputed importance in the promotion and maintenance of health, but also for the better utilization of resources, resulting in cost reduction. The new strategies for the integration of health policies must necessarily take into account environmental sustainability.

After a period of constant evolution and adaptation of the specific structure for increasingly accurate, effective, technically advanced and prognostically favorable treatments, - the hospital - the focus, has opened itself towards the territorial zone for several reasons.

The hospital is a highly sophisticated structure with high technological trends, high management costs only justifiable for performance-intensive care given to a patient in acute emergency and made possible only in a protected environment.

The territory consequently gains importance not only to provide care and treatment to low-intensity patients and to guarantee care continuity and the patient's recovery. But above all, to prevent and anticipate the disease (early detection!). In addition, the territory also represents an important input filter and selector for hospitalization.

The hospital, by vocation, treats (or should treat!) 100% of the acutely ill, while health outside the hospital treats (or should treat!) mainly the healthy to ensure a minimal occurrence of sickness.

The primary care target is therefore made up of 40% of healthy individuals, 40% of healthy individuals with risk factors and the remaining 20% of ill individuals (of which 10% have disabilities).

The hospital's mission is maximum repair and cure of the individual's biological damage, while the mission of the zone is to avoid health damage through multiple strategies on population health, even informing and educating people of the best way to live .

In a distributed model of medicine of the territory, health professionals and family physicians are the central figures in order to achieve a proactive medicine. Proactive medicine is centered on the promotion of good health and the prevention of bad health. The health of a community is determined by socioeconomic and environmental factors, lifestyle and access to services. It is evident that only the model of distributed medicine in the territory with a central role in prevention can ensure the implementation of a wide range of initiatives, projects and policies necessary for effective health promotion.

Hence, the necessity emerges for an integrated strategy between governmental bodies and non-governmental bodies, in the possible fields for regional action. From the action of doctors on the territory and in schools, to interventions by the public authorities through training activities based on epidemiological evidence. The concept of integration is essential and must be developed in a distributed model of Zero Zone, cornerstones of which is home medicine and telemedicine: i.e. trying to bring care closer to the patient-citizen.

Modern medicine (with the exception of acute illnesses) should become "initiative-based", since it must not be the citizen-patient to contact the hospital system but the Zero Zone to take the burden of health in a proactive manner by trying to prevent the development of chronic disease. Proactive medicine has the primary objective of avoiding the disease (primary interception with its information tools, health education, empowerment, control and information on the risk factors). Secondly, its tasks are early recognition of onset pathological conditions (secondary prevention) through targeted interventions and rapid, highly qualified, epidemiological study and monitoring of collective health, determinants of well-being and illness.

To develop the model of Zero Zone, synonymous of active and preventive approach, multidisciplinary, integrated, non-hierarchical, structured network; high computerization (internet of things) is required. Among the tools in exponential development we find apps, increasingly becoming key elements in the communication between doctor and patient (bidirectional energy binomial), essential for effective therapeutic action thanks to i thets significant synergistic effect.

The sustainability of the health system in a distributed model that can not be separated from an integration with the social in the Zero Zone logic (sharing economy).

ZERO Zone is simultaneously a basic and complex operation. The idea is simple: to program a society that tends towards zero entropy. The work to get there is complex since it involves new mental paradigms, new educational models, new business strategies, new administrative measures. Examples are the overcoming of departments of energy, economic development, environment, agriculture, in favor of departments to commons goods or land resources. Smart grids are the digital infrastructures of the Internet of things that allow the connection between energy, communications and logistics. In electrical engineering and telecommunications, a smart grid represents the combining of an information network and an electrical distribution network in such a way as to allow the management of the electrical network in an"intelligent" manner under various aspects or features. In other words, the efficient distribution of electrical energy and a more rational use of energy; thereby minimizing any overloads and variations of the voltage around its nominal value⁸ .

According to the ideological picture of Jeremy Rifkin, a distributed model (Commons) should be applied to the way in which food and energy are produced and the creation of polluting waste at the end of the fuel cycle is avoided. According to the authors, this also concerns the way in which health care is organized in the territory, through the distributed pillar of prevention (Zero Disease) which can only be formed in the Commons. The smart grid digital health is thus being born.

In “The zero marginal cost society" Jeremy Rifkin argues that a new economic system is emerging on the world stage, the rise of the Internet of things is giving life to the "Collaborative Commons", the first new economic paradigm to take hold by the advent of capitalism and socialism in the nineteenth century. Collaborative Commons is transforming the way we co-ordinate economic life opening up the possibility to a drastic reduction in income inequality by democratizing the global economy and creating a more environmentally sustainable society.

In a distributed scenario of the Third Industrial Revolution, it is unimaginable to think of a health care model based on concentration as during the second industrial revolution, which must therefore be overcome once and for all by introducing prevention practices across the geographical zone.

It can not be said that a public health system of a state or region (model "Beveridge") is always better than a private health care system of a state or region (model "Bismarck").

On the contrary, states or regions, in order to have an efficient and effective health service must put in place a model where public and private sectors are in competition with each other.

The ideological framework of Jeremy Rifkin sees three basic paradigms (energy, communications and logistics) complementing each other in a hierarchical and top-down economy, evolving distributively through cost-sharing economic systems. health care is a service, and as such tends to evolve towards the sharing economy and collaborative community (commons).

In the social model indicated by Jeremy Rifkin, can health services also be alternatives to the two historical organizational models of Bismarck and Beveridge?

Even for health services, it emerges that, to appropriately meet the growing and new health requirements, it is necessary to improve the economic system with the best cost/ benefit ratio and the lowest possible entropy. The new route also in health care is the development of the economy of sharing and the development of collaborative communities (commons) where the comparison between institutions, citizens and health specialists will be revolutionized by a new patient-citizen as an increasingly active element and aware of his rights. The intelligent digital networks for health will spread increasingly (Health Smart grid Digital).

The fundamental paradigms of intelligent digital networks for health, which set the new model, correspond to a complementarity between the paradigms of a Zero Zone oriented towards a society at a zero marginal cost, with Zero Disease turned towards an exponential contrast of the disease with an ideal trend of making it null.

Jeremy Rifkin’s prediction is applicable not only to the production of all goods and to all services but even more importantly to service excellence in the protection of health.

The paradigm of energy Zero Zone finds reciprocity with the maintenance of health (to be healthy), of zero disease .

The paradigm of Zero Zone communication finds reciprocity in the evolution of the doctor/ patient relationship through the development of the internet and the strengthening of preventive medicine and predictive zero disease.

The archetype of Zero Zone logistics bares reciprocity in the organizational model of health management (healthcare).

Even in healthcare a third way will come to develop through the use of specific energy elements (consciousness biospheric), communication (empathy, empowerment and assertiveness) and health care logistics; the health Commons or the sharing economy and collaborative communities (commons).

2. Historical evolution of healthcare assistance

2.1 From Hippocrates to the discovery of antibiotics

Hippocrates was born in Greece in 460 B.C. and died also in Greece in 377 B.C. He is considered the father of medicine. Treating disease and the sick has been a necessity formed with the very origin of man; as a spontaneous need of the patient to live in the community while not being alone against an illness. "Medicus" is not only the one who mediates between the patient and the disease, but also who stands between evil and death, often taking over the centuries a mystic or priestly role. The first medical schools were developed in the area of present-day Greece and Ancient Greece, including in Sicily and Calabria. In Crotone, Calabria, the school of Pythagoras (570 BC - 495 BC)⁹ was famous. At the center of the Hippocratic conception there was not the disease but rather a man with an extreme attention towards nutrition and the environment. This was the precursor of the knowledge of the first determinants of disease related to nutrition and healthy air. The writings of Hippocrates (or assumed so) were analyzed in the universities until the 1700. Such manuscripts were oriented towards prudence and caution before intervening with the moderate use of therapy also since in those days there were few remedies available, pharmacology was not yet known and herbal medicine was in its infancy, growing about a century later with Theophrastus (371 B.C. - 287 B.C.), a pupil of Aristotle (384 B.C. - 322 B.C.) to whom we owe an enormous boost of natural sciences.

Hippocrates gave medicine a holistic imprint centred on man and the environment, becoming in fact the precursor of the most advanced modern environmentalist theories, including the economic and ecological ones of our economist of reference, Jeremy Rifkin: our guide in describing the new paradigm of medicine that with this paper we disseminate: Zero Disease.

Hippocrates introduced the first concepts of medical ethics and it is to his school that the doctor's oath is attributed:

 â€œI swear by Apollo the healer, by Asclepius, by Hygieia, by Panacea, and by all the Gods and Goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath: I swear to to honour like I honour my parents he who taught me the art of medicine (concept of pupil-teacher); to share with him my sustainment and satisfy his needs, if he may need it;

 to consider his sons as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture;

 to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else (concept of caste);

 I will apply the diet regime for the advantage of the ill, according to my ability and judgement, I will spread them against anything harmful and unjust;

 I will not administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion;

 I will keep pure and holy both my life and my profession. I will not operate on who sufferers from stone, and will leave such practice to professionals;

 â€œInto whatever house I enter, it will be to help the sick, and I will abstain from all intentional corruption, especially from seducing women, men, free and slaves. And whatsoever I shall see or hear in the exercise of my profession as well as outside my profession that I can hear or see regarding the life of others that should not be divulged, I shall tacite, holding such things as secrets (concept of professional secret);

 I carry out this oath all the way and honour it, may I be able to enjoy the fruits of my life and of this art, forever honoured by all men; but if I transgress it and forswear myself, may the opposite befall me”.

Hygiene, from greek "salutare", is the branch of medicine that deals with health in a holistic way from its earliest conception that studies the wholesomeness of air, soil and water to its most modern conception that studies how to organize in public and private health care the health services as efficiently and effectively as possible. Hygiene has always dealt with how to prevent disease.

Democritus (460 B.C. - 370 B.C.) developed the theory of pores that came to condition the scarcity of hygiene that was found in the Middle Ages. For the school of Democritus, depending on whether the pores were open or closed, there would have been a condition respectively of relaxation or tension. According to this theory, it was necessary to try to maintain the pores naturally open with resulting attention on how to wash and on the water temperature. This concept was misinterpreted in the Middle Ages condemning water as a cause for the closure of the pores.

Fortunately, the erroneous theories of Democritus were uptaken only many centuries later (Middle Ages) while during the Greek and Roman era there was a remarkable development of hygiene. The water was the key element of Roman society that allowed the realization of impressive aqueducts passing through the streets of the empire and considerable construction of spas and saunas with an advanced water and sewage system.

The contrast to infectious diseases was conducted over the centuries especially thanks to the different hygiene techniques that, as we will see, will lead to the development of preventive medicine to the very recent predictive medicine and personalized medicine.

To fight diseases, medical facilities with a high concentration doctors and technology called hospitals, have developed over the past centuries. The modern hospital's origins can be traced back to the early twentieth century and initially it was the wealthy landowners who left a will in favor of places that dealt with poor and dying patients. These were charitable structures, almost always managed and organized by religious people.

Despite the catastrophic plague pandemics and raged leprosy and tuberculosis of the fourteenth and seventeenth centuries there was no awareness that the disease could be contagious to another living organism. The modes of transmission of infectious diseases were unknown and the most accepted theory was that odors carried the contagion, but no one knew how. In the Middle Ages there was no concept of hygiene and the sick were put on the beds with dirty sheets that was recycled without washing.

The hospital of the first industrial revolution can be traced back to the eighteenth century, a large and promiscuous operation between social and health care, where febrile patients were hospitalized with women in childbirth, psychiatric cases, surgical patients at risk of nosocomial gangrene but also the poor in need of shelter and food.

With the rise of environmental health knowledge to counter infectious diseases the pavilion hospital model began its development, built with low buildings separated from each other to avoid to a maximum contagion from one patient to another. Around 1850 began the construction of the first hospitals in pavilions that can still be seen today in the center of ancient metropolitan cities such as the Umberto I General Hospital and the San Camillo Hospital in Rome.

Gerolamo Fracastoro (1478 - 1553)¹⁰ doctor, mathematician and poet, taught logic in the University of Padua. He wrote the latin poem Syphilis sive de morbo gallico (1530), which tells of a young and handsome shepherd who, having offended Apollo, is punished with a terrible ulcerative colitis. Syphilis, a venereal disease at the time newly spreading, took its name from this poem. Fracastoro was among the first to believe that epidemic diseases were transmitted by a sort of seminal entity that carries the contagion (De contagione et contagiosis morbis, 1546).

Carlo Francesco Cogrossi (1682-1769) was the first who noticed that bovine plague had living organisms that transmitted the plague, but his argument fell on deaf ears.

Edward Jenner (1749-1823) was a british naturalist and doctor, know for introducing the vaccine against smallpox and considered the father of immunization.

The use of certain molds and plants for the cure of infections was already recognized in ancient cultures- greek, egyptian, chinese - their effectiveness was due to antibiotic substances produced by the vegetale species or by the mold. However, there was no possibility to distinguish the effectively active component nor isolate it. Vincenzo Tiberio, Molisane doctor in the University of Naples, already in 1895 described the antibacterial power of some molds¹¹ .

Modern research began with Alexander Flemming’s casual on penicillin in 1928. More than ten years later, Ernst Chain and Howard Walter Florey managed to obtain antibiotics in pure form. The three obtained for their merits the Nobel Prize for medicine in 1945.