Maria Giulia Marini: Professor, I brought with me a copy of my book, ‘Non-violent communication and narrative medicine for a sustainable health‘, published in 2024 by Springer, where I describe not only overt violence, but also what I call slow violence, the invisible violence, diluted in time, often not perceived as such, with words.
Silvio Garattini: But also with deeds: take for example what happens with the elderly. It is a real form of violence to give an 80- or 90-year-old person 12 to 14 drugs a day. That’s not the way to achieve longevity.
MGM: Precisely on the elderly I wrote a chapter in the book about ageism, discrimination against old age. You are an ambassador for longevity, in your interviews and in your book ‘Living Well. Physical activity: what, how, how much, when… and why’ published by San Paolo Edizioni in September 2024 indicates how to achieve a ‘healthy long life’: what are the basics?
Silvio Garattini: Three elements: having a strong interest, something that motivates, a purpose, eating little, and above all not drinking: the alcohol market is powerful, but it remains a great enemy of health. By now the correlation between alcohol and cancer is obvious, it is not a question of how much alcohol, all alcohol is carcinogenic; it is uncomfortable to talk about it because the economic interests are considerable, especially in Italy, a land that makes wine one of the biggest sources of income. The WHO itself has expressed itself in the document addressed to journalists ‘Reporting about Alcohol’, where it is debunked that a glass of red wine a day is good for you. It is still a risk factor and as such must be eliminated: but as with smoking it took thirty years, here too we will have to wait a long time. The third element is exercise: I walk 5 km every day, it’s a walk that allows me to think, to meditate.
MGM: I think of the first element, the purpose, and I think of eudaimonia, the reason for getting up every morning, and I think of your walk, and I remember the philosophers of the peripatetic school, the very ones who first spoke of eudaimonia, the happiness that is achieved even after a struggle, a sacrifice to carry out one’s mission. Speaking of missions, of purposes, in my book I also wrote about the violence of this world on young people: I see their narratives blocked, stopped, just as if they lacked a purpose. Few have a glimpse of hope, of the future.
Silvio Garattini: We need to refound the school. That’s where we have to start again: it can no longer be a shrine to the past, which stops at teaching history up to fascism and nothing about international geopolitics. What we need is a contemporary school, which yes, maintains solid roots, but which teaches experimental science, mathematics, statistics, and links them to art, philosophy, literature. Sew up the parts. And then not just educate on the details, the small notions, but the big picture. And for young people we have to bring the generations together: we are carrying out projects where we motivate grandparents to spend more time with their grandchildren: longevity is also gained this way, by wanting to live for the other, and precisely because of this you take more care of your own lifestyle.
MGM: Again, on young people: we also need to re-educate them on language: young people today know about 800 words, very few compared to the 1500 words of previous generations: the fewer words we know, the more our mental map shrinks. Words are thought, reflective, creative, imaginative. If language becomes impoverished, so does the ability to analyse the present and imagine a future, even if it may be frightening. Language, science, art, and the law should be safe havens precisely to calm fears and to be able to forge that purpose we wish to achieve. Those needs to be realised should be carefully distinguished from absurd claims, as Marshall Rosenberg, the creator of non-violent communication, explained. But there is not only violence of words, but also of system, one for all in healthcare, the great Leviathan with its public administration.
Silvio Garattini: There is considerable systemic violence: how can a general practitioner with 1,500 patients follow each one of them accurately? There is an abysmal fracture with the territory, sometimes irremediable, where general practitioners go their own way and hospital doctors ignore the existence of the territory. We must work to really build community houses, centres for listening and proximity: there is something in the usual regions, Tuscany Emilia, but these examples of health virtuosity are too rare. Yet, we citizens can do a lot to make ourselves less sick and not invade GPs and hospitals: about 50 per cent of chronic diseases such as type II diabetes, hypertension, heart, kidney and respiratory failure, and even more than 50 per cent of cancers if we did without alcohol, ate less and moved more. With much less waste for our planet.
And then the pharmaceutical market does not help, nor does it advertise the validity of diets, because fewer drugs would be sold, every year a new one arrives for the same indication. Maybe there are already 22 in that therapeutic area, sometimes even more. But we cannot be sure that the three criteria for a new drug, such as quality, efficacy and safety, are met.
MGM: Why is it that data from clinical studies are not indicative?
Silvio Garattini: Often the comparisons are only with placebo. And we also know that in many situations using placebo is unethical: it is a violation of the Declaration of Helsinki.
MGM: This injustice is also violence. This touches the pillars of the UN Agenda on Sustainable Development Goals 2030, especially Pillar 16: ‘peace, justice and strong institutions’. There is no justice if there are therapies that can soothe and cure that are denied because we end up on the ‘placebo’. I am also reminded of the many therapies denied to women because they are not believed: ‘Madam, you are stressed, go and see a psychiatrist…’ and sometimes after six months the diagnosis of a tumour appears. This is the knowledge we derive from our thousands of collected narratives. A continuous source of narratives where people are quoted as not listening and unfortunately also by female doctors, this is the ironic side of it.
Silvio Garattini: This is another very serious problem. Men almost always participate in clinical trials. Future medical students prepare their exams on texts written for a healthy and sick male population. And then we give the same dose to men and women, without considering that the adipose tissue in women influences the metabolism of the drugs, and therefore the doses must be lower because the drug may still be present. I have just published a book with St Paul’s on this subject: A medicine that penalises women. Evidence of an inconvenient truth and some proposals for a solution, drug protocols are still male dominated.
MGM: Pillar 5 of the UN Agenda talks about gender equality, and so we see how far we are in facts and behaviour: I come back to the violence of not listening, of being ignored in one’s pain, indeed there are studies that show that on physical pain scales women do not feel pain, but then from the narratives it emerges that many of them think it is right and proper to live with pain, and always wear a mask of happiness to be socially included. Paradoxically, Artificial Intelligence listens more: in a study by Ayers published in Jama in 2023, Chat- GPT was statistically 9 times more empathetic than forums with live doctors.
Silvio Garattini: I’m not surprised, these systems know how to dilute emotions perfectly. For imaging, it’s a great ally, also for training young people on a new procedure: virtual reality is beautiful, it’s like being inside the human body. But I am worried about the scientific journals: nowadays many clinical studies are written by AI, and we can no longer recognise whether it is human thinking or artificial algorithm thinking. We need transparency: we need to know how the algorithms think, how they are designed and above all where they are, who has the data, the information, this knowledge.
Last: The future
MGM: Professor, in my practice with narrative medicine I ask people to write their own illness narrative according to a mindset that goes to the body, emotions, thoughts, desires, values and relationships, but I never stop at the present, or only at the past like the prevailing models on pathology, illness autobiographies (also called illness memoirs). Remembrance is important but the gaze must go to ‘the future’. Even if there are diseases, winds of war, environmental and economic crises. Some stop at the present, others can also glimpse a future through legacy to future generations.
Silvio Garattini: We never lose the ability to hope, I was 17 years old at the end of the Second World War in Milan, in ’45: there is still the possibility of coming out of the dark moments. To give meaning, to think big, to plan, to try, to widen our gaze.
He kindly accompanies me to the exit. Outside the Mario Negri, I see the ball given to me by the recently deceased sculptor Gio’ Pomodoro that is the globe. The professor then shows me a rebuilt Lombardy farmhouse: ‘that’s a campus for all PHDs and students from other countries’ and shows me the Politecnico building: ‘we have collaborations with them too’.
A citadel of international science, built in Milan: surrounded by his continuous entrepreneurship, awareness and lucidity, I feel not only intellectually stimulated but energised. The professor’s will be the thing that stays with me the most. That Latin voluntas, which derives from vis, strength, absolutely without violence.
