The scion of a family of doctors, and with an industrial hygienist for a father, Roberto Calisti’s choice of occupational medicine was almost an act of bravado. Family history aside, his hopes for society were what mostly drove him to his calling and nurtured an unflagging passion for his work. HesaMag joined him for a day, going from his understated office into the blacked-out workshops of the global economy.

A smiling Roberto Calisti rolls up to the door of the health and safety at work department where he greets me with a handshake. This diffident and fine-featured fifty-something has a boyish air for his age – lightly greying hair and an easy-going but determined look, dressed in sports gear and carrying a dark blue canvas holdall. We are in Civitanova Marche, a town of 40 000 inhabitants on the Adriatic coast in the Marches region of central Italy. The parking lot where I left my car is half empty; the bar opposite stands closed as yet; opposite it is a primary school where a well-built woman waits looking uncertainly at the locked gate.

And so begins his day: we go up to the first floor and enter a spacious office where he greets a few colleagues – mostly women – and opens the door to his fairly cramped office, dropping his bag in the middle of a paper-and folder-strewn desk. To one side, near the entrance, is a smaller Formica-topped desk with a computer: this is where he writes reports and replies to emails, calls individuals or business managers, and pores over documents.

He is an occupational doctor handling "both pre factum and post factum" he specifies at the outset somewhat eruditely as our interview gets under way, "I mean the risk of work accidents and diseases, situations of maladaptive organization"; he is precise and passionate in talking about his work.

I break in to ask, "what does ‘maladaptive organization’ mean?". Frowning, he explains that this is precisely the most dangerous and complex area: "it is where health, safety and protection proper meet. People get sick because in their work setting they experience situations of harassment, or because insecurity is such that it produces stress. In other cases, it is the result of poorly-designed shift rotations, or generally events connected with work organization", he says confidently.

In past times, conflict was fuelled by the historic clash of capital and labour, I thought. Now, with the Berlin Wall gone and the class struggle ended, the situation often becomes insidious in post-modern societies, like that experienced by Albino Saluggia, the paranoid central character of Paolo Volponi’s novel Memoriale who for years dealt with wellbeing at work in Olivetti; the whole point is that the body revolts against violence by falling sick. In Volponi’s novel, Albino believes the opposite – that the works doctors had falsified the reports to get him the sack. The book was published in 1963, before the era of the big struggles of the Italian workers’ movement, when street protests had a liberating effect, taking the ill-being out of the body to make it a public and collective thing: a real revolt.

A bit of a mongrel

Like Volponi a son of the Marches, Calisti describes himself as a "bit of a mongrel" with a grandmother from the North (Genoa), a Sicilian mother from Syracuse, a father and grandfather both doctors, as was his uncle, too – in short, a calling for medicine very much present in this branch of the family. His father was a laboratory hygienist; as a university student, he chose the only other line of study then possible in that area: occupational medicine. His mentors were a professor from Turin, Mario Governa, and two other members of his faculty: Benedetto Terracini, an epidemiologist from a well-known left-wing Jewish family; and pathologist Franco Mollo. With the 100 000 lira generously donated to him by Governa – there were no scholarships at the time – he went off to specialize in Turin. "My other great teacher was my father, who died young, at 49, and who I still look up to as a professional and ethical ideal", he says emotionally.

After graduating, Calisti went to work at the sharp end in the north of Italy, mostly in Orbassano, an outer suburb of Turin. This was an industrial centre based on metal manufacturing, dominated by Fiat Rivalta, the recently-shuttered historic firm established in 1968, but also comprising all the sub-contracting firms that made the seats and the foundries that produced the wings and doors. "It was very much a traditional view of the firm with a boss who started at the bottom of the ladder, sometimes a former department head, but with an industrial-type mindset and a much more authoritarian attitude with a consciousness of being part of a wider industry set-up", he recalls.

Calisti tells how things were more confrontational, when opposing interests were clearer in a time of contained crisis, and in an era of Japanese-style "total quality" (this is the late 1990s) where work paces were very fast because the need was to produce more and a wider range, while in the Marches region, dominated by textiles and footwear, the reality has always been that of small-, even very small-scale outfits. This was especially so in footwear manufacture where a closed, craft-worker mentality still prevailed, seeing themselves as self-sufficient in production terms and independent of all marketing networks. "In this type of situation, the business owner can also be very hard-nosed, but in the way of a strict father that says you’re being punished because order has to be maintained here, with situations where family members are employed in the firm and human relations are on the whole better".

These first words of his brought to mind a businessman very well known in and outside Italy – Diego Della Valle – and the Tod’s brand: "what is being held out as a new model is a 19th century one. The businessman who says above all – no unions; you all work for me personally; I am your point of reference. Then he goes on: I’ll give you benefits like a nursery, not to mention the other 19th century aspect – charitable works for the community, which gives: I’ll build a community centre where people can come together, whether they work for me or not".

Suddenly I get it: I get what he is saying: it’s like A.J. Cronin’s novel The Citadel. I say that to him and he jumps on it: "Anyone who has read Cronin will see that the main character is a doctor like me, who foreshadows the doctors of Italy’s great industrial reality. And Manson deals not only with work-related illnesses, but all the diseases and misery that workers face". I clearly recalled the novel’s memorable main character, "a man who devoted his life to the ideal of improving the lot of the working class" in the words of a famous socialist doctor of the time. A century on, the job seems basically to have come full circle.

Coming back to the present and the Marches region, Calisti believes that working conditions in companies like Tod’s are good, disputes minor, stress-related illnesses less common; the trend is towards relations between the company and the individual. The owner sees regulatory agencies as a hindrance, populated by overpaid time-servers who go out into factories only to check piles of useless paperwork. "It’s the view taken by paternalistic, generous businessmen who say, 'I already treat my workers so well that there’s no point in you'. This model works fine as long as there are no risks", he says.

He then tells me about a local businessman he had dealings with in the Civitanova Marche industrial area whom he still considers – notwithstanding they have often clashed – a man "who does the right thing" in his words. "Two years ago, there was a fire in the company store which burnt down the factory. Not one worker was laid off for a single day; they all pitched in to rebuild it, which was done at an incredible speed. The fire brigade came out, we checked the workers’ health, and we had a good working relationship with the works doctor. Clearly, things had got lax in the firm. The problem is that this kind of business owner has an abiding belief that they are on top of everything and don’t need help. But the reality tells us that nobody ever has everything under control: "Nemo solus satis sapit, know-it-alls never know it all", he proclaims, quoting something his father always used to say when he was young.

An obsessive researcher

He shows me his collection of asbestos fibres kept in a small cupboard at the rear of the office near the French windows giving onto the balcony. He is an obsessive researcher, but the material is also useful for teaching purposes. The killer mineral – asbestos – is wrapped in small packages of transparent plastic. There is even Eternit asbestos-cement removed from part of the exhaust of a Fiat 639 bus, Montedison Novara’s dark blue asbestos ribbon, and the asbestos-containing aggregate he collected from the Balangero mine where writer Primo Levi worked. In a collection of short stories, The Periodic Table, published in 1975, the author of If This Is a Man describes the environment in which nickel was mined in 1941: "There was asbestos everywhere, like a blizzard of ash: If you left a book for a few hours on the table and then picked it up you found the outline in negative".

We move to the surgery, which is tinier still than the office. A narrow bed is squeezed in up against the right-hand wall; there is also a desk and a small locker. "I think it works best when workers have to tell their own story," he says; in insider-speak, this is known as narrative medicine, a procedure not far off that used by sociologists.

Calisti’s work also used to include site checks on apprentices, but no longer – the works doctors paid by employers now do this, meaning that what once was a medical obligation is now often turned to other ends. "Very often it is about employee selection by stealth, i.e., ruling a worker as unfit for work, or a disabled person not up to it, which at a time of deep crisis like ours is a huge obstacle to getting a job and works to exclude people from the labour market for years at a time". This, he emphasizes, is not a problem unique to Italy because the rule he quotes, "the occupational doctor’s visits cannot be used as a means of personnel selection" is derived from the International Code of Medical Ethics. In Italy, however, the problem had become so acutely urgent that the ethical rule was implemented into legislation in 2008. Often, though, a worker will not accept the private doctor’s verdict and will appeal. "Then the public doctor makes a visit, will see the individual, may perform additional examinations and uphold, reverse or modify the judgment. It’s an important power". Generally, appeals show exponential peaks corresponding to events that are not health-but employment-related, like the pressures of work, and especially the risk of unemployment.

Calisti cites the case of people with disabilities who the medical board passed as fit for work subject to specific precautions being taken, but who were ruled as unfit by the works doctor when applying for a job. "The hardest people to get into work at the moment are those with a learning disability," he says. "Sometimes we have found a solution with the firm. Some paternalistic-style firms may take the attitude that this person is having it rough, we’ll take care of them. Good on them!"

Here in the doctor’s surgery is where patients come to identify occupational diseases. "We get people who are sick or afraid of falling ill, like those who have been exposed to asbestos; then, there is also the epidemiological aspect of it: that’s about figures, where we periodically check changes with different monitoring systems like ReNaM – the National Mesothelioma Register – or ReNaTuNS for nasal and sinus tumours related to the woodworking industry, and the footwear industry from the inhalation of leather dust", he adds before picking up his bag and locking the surgery.

Off to an unofficial firm

It is already 9.30 am when we decide to head out. The first car journey is very short: the workshop we will be visiting lies just outside the town centre heading towards the countryside; we get there in no time. Passing a bar and some terraced houses, we stop near an old building in small undressed bricks bounded by a low wall that used to house farm workers. "This small firm has already been inspected by National Labour Department officials", explains Calisti. "In this kind of place, which is a spin-off of what we find in Prato, there isn’t much to find. But they have blacked-out the windows and that is mainly why they are getting fined, because European law says that the workplace must have natural light. Butyou go in, you fine them, and 3 hours later the windows are blacked out again".

In the days when work was plentiful, this type of house would have many occupants, often related to one another. When the night shift workers came home to sleep, the others would take over in a three-shift system. They tended to rent this kind of house, with one part that served as a dormitory and community kitchens. It is an often an underground operation with illegal or off-the-books workers in an unofficial firm that is not registered with the Chamber of Commerce.

"These situations are less common now; they form pockets of poverty – people who have no way out, partly because they have no roots; they live in poverty with very little work. From a health point of view, we usually act on the hygiene conditions. Not far away, there is an entire building where I don’t know how many live; all they have is a camp bed and skimpy mattress each and a box with their personal belongings. They are like those southern Italians who went to Turin with no money to pay for shelter and slept in sleeping bags in the train station".

Arriving at the gate, Calisti rings the doorbell, which is immediately answered by a young, tall, pale, very thin and frightened-looking Chinese man, who invites us in. "I am the occupational doctor, remember?" asks Calisti scouring his wallet for his ID. At this our host nods his head vigorously with a smile that seems to say, "Sure, I remember". He was fined for covering the windows with black nylon curtains. Inside the workshop, kitted out in an old garage, we find work stations with sewing/stitching machines and an electric fan in the centre. The young Chinese man tries to explain in laborious Italian that they have few orders at present and there are only two of them to keep the workshop going. Times are tough. "Why have you blacked out the windows again?" Calisti asks sternly. The man looks flabbergasted and extremely embarrassed. He makes an elaborate gesture with his hands to shade his eyes and says it is to keep the sun off him. But the doctor is adamant: they have to go if he does not want to be fined again.

We get back in the car and head off to the old industrial zone which dates from the 1970s and still houses some small outfits, although many have closed or relocated to other countries, especially in Eastern Europe. Just down the street we come to another Chinese-owned workshop which Calisti says represents "the future". The firm’s original owner went under; now an old-age pensioner, he still oversees production for the new Chinese owners after the company was taken over; it now employs 14 workers also from China. All are registered, the company complies fully with standards in all respects, and its products are fully "Made in Italy". As we enter, a change comes over the young workers’ faces – their worry and concern are visible, and one anxiously phones through to the owner.

Calisti smiles and tries to put them at ease. "They have taken over a proper workshop and run it very well. Here again, we were called by the labour inspectors to check hygiene conditions, but in practice we have given an absolute clean bill of health on that front; the paperwork, on the other hand, was a disaster. We had to fine them because there was no risk assessment document. That’s why they are scared". When the owner, a very polite elderly gentleman, arrives the doctor reassures him straight away that "everything’s fine" raising his arm and the young Chinese workers resume work with a smile.

By the time we get back to the workplace health and safety department offices it is already almost one o’clock, and the parking lot is now full of cars: today is report card day for the primary school, Calisti tells me. While he looks for a parking space, I ask him, what is the weakest link in the world of work today? His reply is immediate and unhesitating: the isolated worker. "The loss of relations and the resulting isolation are the worst aspects of our modern times for workers today and it’s something that sociology and especially medicine have not looked into much", he says. He repeats something he said to me earlier about the fundamental principles of the French Revolution: "Liberty, freedoms – i.e., rights – are all very well; equality is fundamental; but there is no fraternity and Isolation is killing people".

Calisti then tells me that for him the ideal company does not exist. Even Olivetti – a real Italian icon, especially for the left – the responsible company described by sociologist Luciano Gallino where sophisticated artists and intellectuals worked: "today, it has two problems: asbestos and aromatic amines; the cancer risk for the respiratory tract and bladder has been underestimated. Attacking Adriano Olivetti would be to show mean-mindedness and stupidity, but it shows that self-reliance does not exist even in the places where the culture of vigilance is at its highest".

Leaving his office this morning, I notice two small frames hanging side by side on a corridor wall. Two black and white photos, with the kinds of populist wisdom that I generally loathe or find trite. But this time, one of them surprised me and I thought that by pure happenstance it had a lot to do with the work of Roberto Calisti and courageous doctors like him who have put themselves very much on the side of the weak. The picture shows a cityscape from the sky, with a quote from William Burroughs saying simply: "The most dangerous thing to do is to stand still"•.

This article was written with the valuable assistance of Francesco Carnevale, historian of occupational medicine.

Special report - Occupational health services in need of emergency care

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"Isolation is killing people". One day in the life of an occupational doctor

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