Almost a manifesto
If it weren't so long, this text would (like to) be a manifesto. It is not an analytical essay that interprets a site or a critical history of the movement lead by Franco Basaglia. Rather it is a deriva, an unplanned itinerary through and with a number of reflections, events, and objects I have encountered in my relationship with the contemporary healthcare system of Trieste. It is a result of a long engagement with the agents that inhabit and build this system every day, with the memories of a collective practice of care, the artefacts and places that constitute the material possibility of a practice of caring with each other, an engagement with what Franco Rotelli (2013, Cogliati 2018), one of the protagonists of the Trieste's trajectory and director of the Mental Health Department of Trieste during the 1980s and the 1990s, has called una città che cura, a city that heals, a city that cares.
This text has two areas of concern. First, it is an attempt to contribute to the critique of (and the reinvention of) institutional analysis by proposing it as an ecology: a practice of organisation “in the middle of troubles” in Donna Haraway’s language (2016), rather than an external diagnosis of someone else’s problem or an autonomous practice far from the contradictions of actually being engaged in the work. An ecology deals with time in a diagrammatic rather than linear way, instituting a relationship between social dynamics and the political imaginary as a concrete exploration in constant tension with the present, both as it is and as it could be.
The singularity of Trieste began in the general turmoil of the 1970s, but is situated today in the frame of contemporary patterns of governance in (the South of) Europe: the dismantling of the welfare system has affected not only the provision of services, but also the legitimacy of public policy’s role in taking care of society. The space of Trieste does not escape this scenario. Basaglia’s revolution is now immersed in the conditions of precarity and austerity, the mud of privatisation and institutional counter-reform, and the consequences of the neoliberal understanding of care as a project about the individualisation of affects, and the commodification of lives.
The choices of prior generations constitute our contemporary spaces of possibility. And the space of possibility today is that of the collapse of welfare. We live in a damaged world: the past pushes upon the present and the contemporary thickens at the precarious brink of modernity, in the crisis of the paradigm that announced (prematurely, yet again) the end of history. In order to escape the trap of infernal alternatives (Stengers and Pignarre, 2011), of having to choose between market-driven welfare destruction or state-driven authoritarian paternalism – I will attempt to institute a space of storytelling and fabulation that can, I hope, push Trieste’s singularity as a practice of concrete imagination beyond its boundaries.
The second issue this essay takes up is the role of caring in constituting the social modes of organisation in an ecology. The contemporary engagements with care are multiple and sometimes contradictory: care is a disputed category in the critical analysis of social reproduction, but it has also recently become omnipresent in moral marketing and neoliberal governance, marking, as Maria Puig de la Bellacasa calls it, a “pervasive order of individualised biopolitical morality” (2017). Aware of this second meaning, I nonetheless try to stay and participate in the critical debates, especially in/given the plural spaces of feminisms that have been constructing a complex understanding of care over the last (at least) fifty years.
Care is an ambivalent territory. It is crucial in the analysis of contemporary forms of capitalism as a micro and biopolitical machine that organises social reproduction: care perpetuates exploitation, dispossession, and abstraction (Barbagallo, 2016; Federici, 2013; Fraser, 2016), especially (but not only) beyond the sphere of the production of commodities by means of commodities, in Sraffa’s terms (1975). At the same time, care is a space of autonomy and organisation that is capable of instituting new grounds of possibility in and against the processes of annihilation that the capitalist mode of social organisation of reproduction... triggers (bell hooks, 2009; Precarias a la Deriva, 2004).
Amid this tension, recently new chains, dynamics and agents have gotten involved in the analysis of care – intertwining the geopolitics of power and the processes of articulation of race, gender, and class with the continuous cycles of social production that care, as ontology, sustains. Moreover, the critical analysis of care today engages with the more-than-human and more-than-social dimensions that care involves: on the edge of other worlds, it is made by the sensible agency of matters and by the urgent temporalities of sustainability and catastrophe (de la Bellacasa, 2017).
On the waves of these multiple debates and approaches, I will try to balance along a different edge, crossing institutional analysis with the complexities and the singularities of care, as the molecular processes that configure the material functioning of care, as well as with the logic of organisation that reproduces the institutional rationale, that is the molar lines that order the institution. To put it more concretely, I am trying to stay with care at the point where it intersects with an instituent critique of citizenship.
Historically, industrial citizenship and social welfare constituted the utopian horizon for the 20th century struggles (of white and male workers): the goal was a homogeneous image of civil society organised through the nation-state. The Basaglian movement constituted another conception of the citizen, starting from the existing institutional denial of the matto as a citizen, Loon, as linguistic re-appropriation of the pejorative term, and from the assertive formulation of the question of citizenship through the lenses of singularity and fragility.
Today the question of citizenship can become something else: how can we produce a quotidian practice of democracy in the current situation? How can the loonies (we as loonies), society’s internal outsiders, affirm their social, civil and political rights, without being trapped in the double-bind of exclusion-vs-normality? How can the welfare state support the constitutively difficult freedom of singularities within urban life, instead of constituting/normalising the citizen as a homogeneous identity entitled to and recognised by rights?
Citizenship, in other words (in Precarias a la Deriva's word cui-dadanía, 2004; a pun that we could tentatively translate as care-zen-ship), revolves around the constitutive role of caring in the making of social and urban life. In Trieste, this question was initially articulated in two ways: as an institutional problem, that is how to dismantle the institutional tendency to objectify sociality; and as an institutional challenge, that is, how to invent transformative practices within the institution, practices capable of sustaining the freedom of those in a moment of fragility.
De-institutionalisation was a practice meant to reclaim alter-subjectivation against the objectifying mode of the total institution: an objectivation that not only affected the confined bodies of the sectioned, but also those of the workers who served as technicians of oppression. The objectifications practiced by psychiatry can usefully be seen as the limit in the tendency of all institutions to reproduce themselves, and their power over society, rather than sustaining the social reproduction (and permanent invention, Rotelli, 1988) of the collective means organised to respond to social desires (as Gilles Deleuze, 2004 defines, more or less, an institution).
In Trieste, this practice of citizenship as emancipation has been articulated in the molar dimension, the attack on the order of the institution: through social movements, medical critique, media campaigns, legal trials and urban conflicts, through legal regulation and institutional production and a long et cetera of strategies, all aimed at defending the invention of a different practice of care. At the same time, this practice has been, and continues to be, an experiment that deals with a radical understanding of citizenship, as an endeavour of care that involves users and citizens within the molecular politics of caring.
In the attempt of contributing to this experiment, I engage with an ecology of care (or caring ecologies, since care is a process, and is always plural). Ecology of care means, then, making care (and making sense) through the permanently unresolved and unpredictable modes of social reproduction; making care through the composition of different processes of subjective transformation; making care “with the surroundings” (Stengers, 2013, but also Harney and Moten, 2013, or Deleuze and Guattari, 1988), i.e., acknowledging the interdependence of care within the social, mental, and environmental organisation of everyday life.
Caring ecologies move through the living tensions and compositions of care, within, around, and outside institutional practice. Using the space of Trieste as the ground for this concrete imagination, I will use the next pages to try to sketch the ecology of care as an assemblage of concepts, materialities, relations, and experiences.
Trieste, città libera?
This story takes place in a singular space, Trieste. Throughout the 20th Century, Trieste has almost always been a frontier before the unknown: the edge of the crisis of the Austro-Hungarian empire after the Great War; the limit of expansion for the Italian Fascist regime; the last markers of Western 'democracy', along the edges of the iron curtain.
Although, Trieste has been a boundary for centuries: a place of global exchange and cultural conviviality among religions, communities, and cultures. The fall of the Austro-Hungarian empire and the inclusion of Trieste as part of Italy caused the collapse of the city as a financial centre, as well as the rise of identity conflicts among Italian, Slavic, and other ethnicities in the city. Since the 1950s, waves of relocation from Yugoslavia sustained the development of steel factories and other industries. After the industrial crisis of the 1980s and the fall of the iron curtain, Trieste has been in a long economic and environmental crisis made more difficult by the demographic reality of an aging population.
In this place of inertia, the Basaglian movement has constituted a plural and global rupture since the late 1960s. The story starts in 1961 in the city of Gorizia, where Franco Basaglia and his equip transformed the mental asylum into a therapeutic community, while simultaneously contesting the relationship of power embedded in their own practice of institutional reform, until the crisis of the Gorizian model in 1968 when the impossibility of a collaboration with local government moved Basaglia to resign. Already in 1964, The destruction of the Mental Hospital as a place of institutionalisation (Basaglia, 1964) defined a new framework for critical and radical psychiatry, including a self-critique of the same therapeutic community model they were experimenting with.
A phenomenologist, Basaglia distinguished the temporary mental distress and fragility of persons needing care from institutionalisation, which he identified as the main problem. It was the dramatic and violent role of psychiatry (and medicine) in the delivery of care that had to be, in the first place, ended and transformed.
In the traditional asylum, the phrenologic asylum, Basaglia and Franca Ongaro argue (1987), psychiatry is a practice of violence that roots its legitimacy in a totalitarian understanding of the relationship between the state and society. In this framework, caring is not an option (and care becomes a practice of repression and control). However, the discovery and use of new pharmacological approaches after the Second World War allowed Basaglia to argue for a radical refusal of the traditional means of the asylum and propose a new approach to care. In this new pharmacological, institutional and political frame, de-institutionalisation, institutional psychotherapy, radical and anti-psychiatry, ethno-psychiatry and the likes gained a renewed centrality, first in England and France, later in Italy, Germany, Spain, Brazil.
Originating with the followers of the critical institutional practices of John Connolly and others in the late 19th century, this debate arose around the experience of Saint Alban and La Borde in France, the Northfield Military Hospital and the anti-psychiatric practice of Kingsley Hall and the Philadelphia Association in the UK, as well as the anti-institutional Italian movement, especially in Trieste, Trento, Reggio Emilia. In Italy, some of the key participants in these debates were Franco Basaglia, Franca Ongaro, Mariagrazia Giannichedda, and Franco Rotelli. Also important were and are the publications of Giovanni Jervis, Mario Tommasini, Assunta Signorelli, Giovanna Del Giudice, Giovanna Gallio, Mariagrazia Cogliati, Peppe Dell'Acqua. At the same time, thinkers such as Michel Foucault, Mony Elkalm, Robert Castel and artists such as Marco Bellocchio, Silvano Agosti, Dario Fo and Franca Rame, among many others, were expanding the space for critique beyond psychiatry.
There were and are many individuals involved, but, most of all, this new practice of care in Trieste has been possible thanks to a new generation of users, nurses, doctors and citizens who, seeing the asylum as a space of experimentation and discussion, inhabited it from the 1970s on: hundreds of volunteers, artists, activists, students throughout the 1970s and 1980s who forged the material realisation of a collective imagination of freedom and emancipation as the ground for caring. Together these people, allies, parts, and counterparts of the institutional management, imagined and sustained an intrusion in the institution that brought a new understanding of how to approach mental health, but also an invasion that was able to resist the conservative counterattacks and the restoration of traditional models.
Some historical facts to ground my reflections around the caring ecologies of Trieste: in 1971, Franco Basaglia was named Director of the Asylum and given the political mandate by the Christian Democratic provincial president, Michele Zanetti, to permanently close the Psychiatric Hospital. There were 1300 inmates in Trieste at the time; more than a hundred thousand people were sectioned in Italy. After a profound social, medical, political and media effort, in 1978, the Italian legislation ordered a structural reform, forbidding detention, recognising the inalienability of users’ civil, social and political rights, and defining a protocol for the dismantlement of all psychiatric hospitals and the institution of local and community services and psychiatric wards in general hospitals.
However, deinstitutionalisation in these debates and practices was not intended as a practice of reform that would establish a new, perhaps less violent, power relation that would be articulated through negotiation around new drugs and open services. Instead, the strategy of the Italian radical psychiatric movement in the 1970s was to destroy the institution in such a way that the asylum's deinstitutionalisation was part of a wider critique of medicine and the welfare state.
“Con l'ospedale alle spalle, non vale”, Alessandro Saullo, a young psychiatrist, recently said me, explaining the logic of destruction back then: mental health cannot be a practice of emancipation if the psychiatric hospital is maintained as a threat of discipline for the person in distress. The journey of recovery cannot be just one of healing; it is one of emancipation, of the appropriation of the places and objects of life as autonomous ground for the production of new social relations, both in and out of the institution, and thus can only occur through the welfare system and, at the same time, in the open dynamics of urban life. Mariagrazia Giannichedda (2015) summarises this effort as the capacity of the public healthcare system - i.e. the state - to sustain the constitutively difficult freedom of urban life. At stake is the process of subjectivation as opposed to the institutional objectivation of the person in distress, but also through the politics of things, as an active engagement with the question of how to enrich, in material terms, those lives reduced to bare existences: breaking the locks, dismantling the caged-beds, choosing furniture appropriate for places where people lived, and generally thinking politically about the places and the objects of life.
This process of emancipation implied not only a cultural transformation and a political struggle, but also collective disobedience of existing laws and the production of new jurisprudence that recognised the social, civil, and political rights of people confined in the asylum. And though the 1978 law forbade institutionalisation, the application of the reform was uneven throughout the 1980s and ‘90s. The last Italian asylum closed officially in 1999, but the practices and protocols of healthcare that have the stated aim of helping people in distress remain problematic in most of the country.
After Basaglia’s death in 1980, via grief and the profound commitment of Basaglia's equip, the radicality of this process was reconstructed and translated into the affirmation of an urban logic of care. In Trieste, when the asylum closed in 1981, care was already decentralised. Centres in each district of the city were open 24/7: doors were unlocked; since the late 1980s, tens of social cooperatives had been organised with the support of the Department of Mental Health which also supported educational grants, community budgets, and other forms of economic support. Nowadays this ecology involves apartments, neighbourhood services, mechanisms for family integration or for users’ independent lives. Starting from the creation of the local districts of health in the early 2000s and the local programmes in 2005, both of which I discuss later in this text, the spread of Basaglian critique into the general medical practice has transformed community healthcare and the general hospital, leading eventually to new legislative regulations like the Regional Law of Healthcare System Reform of 2014.
But to understand the complexity of the ecology of care, it is also useful to understand the subjective configuration of the workers in Trieste’s public healthcare system. It is heterogeneous and can be sketched as follows: a part from the Basaglian equip of the 1970s (nowadays retired from work, but still very active) a first group, in executive positions, proceeds from the long trajectory of the Basaglian movement. Some in this group maintain a political engagement with the whole system of health and care, some focus on the development of radical but disciplinary practices of care, in psychiatry and beyond it. The second group of professionals have come via a typical career path and is fairly distant from the ethics of the Basaglian movement. A third group, younger and smaller than the other two, was drawn to Trieste by the Basaglian legacy, and work in experimental services in mental health and urban health. At the same time, the space of social cooperative enterprises around care today involves hundreds of people as carers and users, which have an affective and moral attachment to the Basaglian movement. Most of the younger workers in the healthcare system (which employs around three thousand) are not aware of the singularity of the system; many locals are aware of the exceptionality of Trieste’s model of care provision and of Basaglia's legacy, but the majority is not.
The permanent ongoing reinvention of the Basaglian process is built on these muddy grounds, constituted on the everyday level by the appropriation of (and failures to appropriate) institutional spaces. This attempt is to dismantle the separation of the places of care from social life by displacing care from institutions and centring it in the life of the city (“la cura dei luoghi, invece de i luoghi di cura,” the care of places instead of the places of care, as Ota De Leonardis and Emmenegger put it, 2005).
What is at stake is the fragile possibility of affirming a different common sense as an activating practice through institutions (a common sense not with its Kantian connotations, but rather next to what Christoph Brunner, 2018, calls an “activist sense”): a common sense of emancipation that can sustain a different and radically democratic instituent practice that is immersed in the dynamics and the contradictions of urban life. And, finally, a common sense of the state as a site of crystalized resources that can be used to sustain the commons. As Franco Rotelli puts it, “What if we recreate these crossing points, this new alliance, between the designated institutions and the people? We could then really imagine that the citizens constitute themselves as those that have the right to care, and that this care is a responsibility of the city: a city that cares for every single one of its citizens and that, by doing so, constitutes citizenship and constitutes itself as a city” (2019).
This common sense responds to the possibility of being stuck with, as Nic Beuret (2018) has beautifully paraphrased Donna Haraway, the vulnerabilities of social life. It offers a way to displace the operative resources of the state into the richly multiple processes of social reproduction. This attempt, and its permanent failure, is the starting point of this journey through caring ecologies where concepts, materialities, relations and experiences flashing up from the Trieste experience can hopefully allow us to think through our present, “at a moment of danger” (Benjamin, 2009).
Through the ecology of care
What runs through the text, or so I hope, is an investigation of the ambivalences of a more than institutional ecology of practices, knowledges, objects, and relations. An ecology that lives along the limits between society and the state, that sits on the edges and connects different modes and experiences of institutional care, but also an ecology that makes it a practice to stay with the trouble, in the middle of the complexities and difficulties of social reproduction.
This ecology is assembled by juxtaposing fragments, concepts, materialities, relations and experiences, which means as well memories, tales, animals, objects, plants, and so on, all these social worlds that interact with each other. I will start by enumerating the fragments I am using in this text to sketch this interconnected system of reciprocities and conflicts, of mutations and compositions, that is the ecology of care.
My starting point is the threshold, the site where I begin to explore this singular mode of institutional engagement with care; second, the proposal of perceptions as an operative guide in the invention of alternative institutional practices; and third, the space of translation as a practice to critically engage from my singular position with this ecology’s ability to propose a different understanding of institutional reproduction. Fourth, the catalogue as an array of practices, which I propose here as an affirmative critique of, and escape from, the institution’s tendency to procedural crystallisation; fifth and consequently, transition is analysed as a practice for contrasting crystallisation and for the proliferation and the mutation of critical institutional practices through the encounter with the life of the city. Sixth, I examine the practice of the enterprise, by which I mean here the singular social cooperative movement of Trieste, as an invention of the commons on the ambiguous edge that separates the public from the private sphere; seventh, within this material ecology, compost becomes the concrete allegory for the composition of care in Trieste. Last, I deal with the practice of reclamation as a way to engage in a committed way with care within the social reproduction of a damaged world.
My first gateway into the complex ecology of Trieste is a specific programme that operates within the general healthcare system itself. I will move through it in dialogue with the voices and practices of those who run it, as my thoughts and reflections on the local integrated care program (and on the caring ecologies in general) rely on an ongoing collaboration with Margherita Bono, who works in the Micro Area Programmes and who in the last few years has led action research projects to redefine their functioning. This analysis discusses a distinctive element of the caring ecologies, that is the way things can happen differently when the institutional practices sit on the edge or threshold between the state and society rather than being projected from the state onto society.
I explore the threshold by drawing lines of flight. A flight from the logic of the state into a logic of caring, a flight from a closed institutional frame into an open urban system; a practice made of contradictory elements that tries to make sense not of the realities around it, but with them, as Isabell Lorey (2019) has proposed in her contribution to the project Entering Outside. An institution that goes outside, leaving its safe ground and getting lost (Newey, 2019) in the, sometimes nonsensical, reality outside the walls of the hospital or the consulting room. But also, a flight from ethnographical truth: I will use a series of narratives that fly away from facts to explore the space of imagination.
The Micro Area Programmes is a set of interventions in several vulnerable urban spaces of Trieste in which healthcare programmes, social services and housing policies intersect to involve local social networks in designing public care policies for these sites. Each Micro Area cares for a population of about 2000 people, but it is also a space, a small apartment, normally on street level, where a range of activities take place – social and cultural collective practices, and services such as home visits, check-ups, public health sessions and so on. This space is open five or six days a week; the core working group of the Micro Area is three to six people who work different schedules, volunteers who take care of activities that are not directly mandated by the public institutions, plus a variable number of inhabitants who both participate in and organise activities.
One of the most interesting aspects of this programme is that the healthcare is not provided through protocols, rules and duties that see the citizen solely as the object to whom resources, attentions, benefits are given: as a recipient. Instead, the programme supports the citizens in exercising their rights, helping them to know and use state devices and resources to gain full liberty – the same dynamic and conflictive difficult freedom of urban life that Giannichedda described.
In this framework, the story of care constructs itself as a narrative, constitutes itself as a space. Perhaps it involves a woman who lives alone in a small council apartment, with a small dog. Every day she watches the sea from her balcony; she is going through a stressful period, losing her memory and her autonomy. She is old and her husband died some years ago; she came to the attention of the Micro Area coordinator (or community manager) because of the old ladies who pass on local rumours as they visit neighbours and shops. The idea being – with all the ambivalences it holds – to use gossip for the common good. Within this framework that falls somewhere between control and care, the ladies have found out that this resident is losing her memory and becoming more and more vulnerable.
So the community manager contacts her and begins imagining a series of resources that could be activated to respond to the situation, those that form part of the public institutional services of the welfare state and those that are part of the business and social network of the city. This requires the community manager to deal with a multitude of tiers and norms, authorisations and hierarchies, logics and values, to find her way through different agents, allies, tools within the state and the wider social configuration.
The old woman, let us call her Feste Puck (Shakespeare, Foucault, 2003, reminds us, uses some agents as points of entry to a critical perspective about reality), refuses to engage with the services the community manager proposes, and she is generally suspicious of all welfare workers. She claims she has seen her general practitioner stealing milk from her fridge; probably he does it quite often, since almost every day she has to come to the Micro Area to ask for milk and sugar.
Every day the story is the same: Feste comes around noon, when the social lunch is arranged; she asks for some milk and sugar and is invited to join in the lunch. She sits and tells the community manager about how they never allow her to visit her ex-husband in the clinic where he is cared for. The community manager then reminds her that he died almost five years before; maybe Feste should think about visiting her general practitioner and asking him to give her some permanent support. Feste starts to cry; she is aware of her fragility, but she is afraid of being hospitalised. Who will take care of her dog? Will she be able to come back home?
And her suspiciousness about the general practitioner stealing the milk suddenly makes sense. She is providing us with a situated analysis of the ecology in which she is immersed. The general practitioner is the gatekeeper, or the funnel, to a general system of care: he embodies all the ambivalence implied in “being taken care of”. Normally care also involves the risk of being constrained in your autonomy: move to a care house and lose your dog, lose your small apartment and the few social ties you have in the neighbourhood. Also, I think while Feste cries remembering her husband, you never know if you will be able to look at the sea in the morning, while drinking a cup of coffee, in the care home. At the end of the day, maybe it doesn’t matter so much if someone steals your sugar, now and then. It is still your home and your neighbourhood.
A vécu, lived experience, from the end of the world, to say it with Francesc Tosquelles (1986, cf. Foucault 2003), Feste Puck is well aware that institutions tend to disempower the citizen in relation to the organisation of care. To change this tendency, the language of the institution, “la langue de la tete,” Tosquelles calls it, has to displace itself and enter a dialogue with “the location of perception.” In this dialogue, “what counts is not the head but the feet: knowing where you put your feet. The feet are the great readers of the world” (Tosquelles, 2012). In this sense, the ecology of care is composed through the situated perceptions made by all the feet that have read the city, that produce it as a common oeuvre.
Henri Lefebvre counterposes this ecological approach of perception to the ideological ordering of politics: “Public policies subordinate reality to a strategic system of significations” that take away most of the population of the city’s ability to use public space, but nonetheless, collectively residents constitute the city as an ecology through reception and transmission – a composition of social life that is based on perception (1996). Aware of the antagonism between institutional abstraction and social practice, and in alignment with Feste’s seat-of-the-feet-critique, Federico Rotelli, District Medical Doctor, explains the logic of deinstitutionalisation in a pamphlet intended to defend the Trieste Healthcare System from possible reforms:
“When [chronic pathologies appear], the tendency in healthcare is that of institutionalising the person (in a care home, a retirement house or in a healthcare residence). This gives substantial form to the dichotomy illness-exclusion vs health-community. But maintaining the citizen at home, even if she is ill and disabled, allows for the support of her personal dignity and affective relationships, while keeping a cultural conception of disease and death as among the events that are a natural part of life.”
Although Feste Puck and Federico Rotelli have different backgrounds, they both aim to institute situated policies based on perception by looking at (and acting through) the effects that institutional practices have on the concrete life of society (Mitchell, 1999).
The Micro Area emerges as an ecology of proximity, to use Andrea Ghelfi’s term (2016). A proximity of the politics of care to the open ecology of the city, where the practice of caring is a co-creator of the urban fabric. In our imaginary journey, the concrete life around Feste is complex, and the community manager is facing a difficult situation: the resources she was going to activate cannot work in this context, given Feste’s worries, and she has to invent something different. She starts by inviting her to different activities in the Micro Area; once a space of commonality is built, the manager negotiates a series of visits with Feste, promising that she won’t be hospitalised unless it is strictly necessary, and guaranteeing Feste the final say. The negotiation is not about the formality of this freedom: constitutionally Feste always has the right to refuse a medical or healthcare option, but the community manager underscores this by reassuring her that she, as an institutionally recognised agent in the ecology of care, will support Feste in exercising her rights even when a doctor or care worker insists on doing something “for her own good.”
In this ecology of caring, the provision of care happens on the threshold, on the limit between the state and society, or between the worker and the citizen; it is a device that destitutes and institutes the norms of care. In a workshop, Monica Ghiretti, the coordinator of the Ponziana Micro Area, explains that this programme, “has no barriers that discriminate access, the service is there, the space is there to be inhabited.” In the Micro Area Programmes, the state’s boundaries are concretely contested through the trespassing of those thresholds that the state institutionally constitutes. Instead of going along with a system that pits the citizen – all alone – against the mighty resources of the state, they create, around and with the citizen, a collective ethos based on reciprocity, responsibility, and inclusiveness.
The community manager calls the social services of home support, a specific person who may be better able to find a solution; this contact connects her with the youngsters of the “solidarity service,” secondary school students who receive a small municipal grant to participate in local solidarity networks. They will meet with Feste to see how best to help; at the same time the network of local businesses can deliver her shopping, and the community manager talks with the people who attend the vegetable garden nearby: every week, they will bring Feste a box and check on her. The community manager also visits weekly, as do the youngsters of the solidarity service. The gossip team will also knock on her door now and then. Sometimes, a solution is achieved and the situation stabilises; other times, however, the drift of institutionalisation is stronger, and the effort to sustain the right to health within urban life fails.
The story of Feste Puck confronts this essay – this practice of knowledge production – with the first contradiction: that between fabulation and truth. If few critical scholars still aim to tell the truth, still fewer would feel comfortable when one of their interlocutors (or participants or informants, as some call them) tell them, as happened to me, “you are telling tales about Trieste.” The question arises: how much can we imagine when telling a story? What is the role of fabulation in constructing a concrete imagination of a social and political practice? I hope the fragments I present in this text can get us closer to responding to this question.
The imaginary story of Feste Puck could end in many ways; so many we could lose our minds in trying to imagine the possibilities: the effort to support her difficult freedom may be successful for a longer or a shorter time; she might end up needing a care home, or, instead a system will be organised to sustain her; or she will be hospitalised. In that case, the Micro Area will take care of her small dog Billy, (or Billy-Boo as those now caring for it will rename Feste’s friend). Who knows, perhaps Feste Puck will become Billy Boo, she will become her companion in order to escape the tendency of institutionalisation. Chissà?
What is important here is not which of these stories is the truth – any of them could be true – but rather that each carries pieces of contradictory and ambivalent truths of loss, pain, vulnerability. Feste Puck and Billy Boo allow us to play with our imagination: they tell us about true worlds that are not always real. And Paulo Freire's (2018) definition of truth is useful here: “a true word is one that changes the world.” The truth therefore is pedagogic and conflictive practice against the institutional abstraction of life into protocols: truth does not describe the world as it is, but takes part in the world and participates in making the world anew. This perspective lets us escape from the double-bind that opposes the realistic inferno of the neoliberal world to the romantic utopia of something that has not nor ever will happen (cf. Echeverría, 2000). For example, with our feet on the site of the Micro Area, we can affirm that the social organisation of care through the state can do things differently, it can sustain a different life of the city. It can imagine an ecology of care.
The Micro Area is thus the threshold at which the process of incorporating a different logic into the dynamics of public services can begin; this occurs when provision of care is deinstitutionalized through the emancipation of all the people in all their different positions truly participating in the endeavour of care. This encounter between different actors and different knowledges is mediated by an effort of displacement, by the politics of translation, as I try to make clear later in this section.
Thinking of caring as an ecology allows us to acknowledge that “the reciprocity of care is rarely bilateral: the living web of care is not maintained by individuals giving and receiving back again. But by a collective disseminated force” (de la Bellacasa, 2017). In a similar sense to that proposed by Maria Puig de la Bellacasa, the processes opened in the Micro Area experiment blur the artificial limit between society and the state and contest the boundary that separates individuals and the social dimension of illness, the distress, or, more concisely, all that is contained in the word ‘problem’. When the logic of the threshold is enacted, the process of care stops being about one person and becomes an ecology of things, practices and affects, thus transforming the institutional limit into an open boundary.
To return to Isabel Lorey, the practice of caring with “is based on knowledge accumulation, on knowing the social situation of the people that need support and for that reason it is important to be aware of the tendencies of control and surveillance [and] build together a common modality that allows each person to again take control over their lives in the midst of the neighbourhood, in the midst of the (new) relationalities in the urban territory” (2019)
The Micro Area’s proximity to everyday life goes along with the insertion of a de-institutionalising practice within the interstices of the state. The same story we recounted above needs now to be inserted in the functioning of the state. Institutions and procedures come into play but they are translated out of their logic and into social life.
The community manager mediates with the Mental Healthcare Local Centre to arrange mechanisms of support for Feste; with the Healthcare District for home visits; with the Electricity Company and the Public Housing Trust to arrange and support bill payments and other bureaucratic problems. The assemblage of programmes, spaces and actors becomes an ecology through which the public worker and the citizen together advocate for rights. The public worker’s role is both to share knowledge to allow the citizen to access her full rights and to agitate the state to reconfigure the functioning of the institution around and along the citizen’s singular life.
The transformation of institutional practice into an open boundary, a threshold, is crucial in the Basaglian trajectory. The dismantling of the mental asylum in the 1970s created space for the urban affirmation of a system of mental healthcare that puts the institution (and its actors) always at risk, destroying the locks, the fences and the chains and establishing the 24/7 neighbourhood centres, the social cooperatives, as well as mechanisms of economic sustenance and of voluntary-based support.
The destruction of the asylum as a place, Franco Basaglia says (2005), is the limit to be inhabited in order to produce another space, together with all the agencies in the endeavour of care and in the city. It is not enough to formally abolish the fence; it must also be destroyed. The radical deinstitutionalisation of the Trieste Psychiatric Hospital was a practice of violence, an appropriation of the incident’s risk by those to whom the ability to act and take responsibility for their actions was denied, sectioned in the realm of the “force of things” (Gramsci, 1971).
But trespassing the asylum wall to build always-open institutional sites in the city was not only about destroying the psychiatric institution. It was about breaking apart the institutionalisation of life driven by healthcare as a system and medicine as a knowledge. Once the walls are breached, there is the problem of management: how can we make this freedom something durable and sustainable? Commenting on Frantz Fanon’s resignation letter from an Algerian mental healthcare department, Franco Basaglia affirms that in a time in which the political revolution is “for obvious reasons” not possible, “we are forced to manage an institution that we deny” (2005).
This ambivalent state remains for the community manager trying to design an ecology of care for Feste Puck, but because of the Basaglian institutional transformation, she is confronted with a plastic system rather than with a rigid one: a system that aims to destitute and institute itself every day, as transversal and transformative force of the instituent practice, in the term proposed by Gerald Raunig (2009).
This tension between destruction and invention is one of the elements that brings Irene R. Newey, a nurse and researcher from Madrid, to Trieste in an early December in the middle of the Bora and the Christmas markets. She is helping design community healthcare practices for the municipality of Madrid, and she is in Trieste because of the instituent practices continuously happening here. I am here as an accompanist and translator and as part of my not always effective effort to make my research useful to the spaces in which I have been involved for so long, proposing concepts but also opening bridges with other healthcare workers around Europe.
In this way, I discover translation itself as a practice of research, a method that allows me to listen to conversations I would not normally hear, to pose, in my role as Irene’s voice, questions I would never have imagined. Translation lets me disappear as a ventriloquist’s puppet into the narratives and conversations, lets me explore the realm of the imperceptible politics that happen below the surface of discourse.
“Listen to the stories,” Franco tells us in an informal conversation, “and try to grasp how each story is both shared,” when it crystallises memories in a narrative, “and extremely differentiated” since everybody looks at it from her own ground and position. Which story should we believe? I ask. “None of them,” Franco says. “We should make memory into a critique of the present, rather than a history about the past, and bring together these plural gazes in a common challenge to keep our present open and invent new modes of action. Even if we will keep failing,” he concludes.
Keeping this in mind, Irene and I get lost in the system and encounter different agents doing different work. Those in the Micro Area Programme explain how it is to see things from their position, close to urban life; the doctors and administrative staff at the Healthcare District, where the reinvention of the institution is systemic rather than artisanal, tell us their perspective; and so do those in the Mental Healthcare ER in the general hospital, where the inertia of traditional psychiatry is constantly attempting to close the open door, to re-institutionalize the practice of care in the name of exceptional situations.
“If you are a nurse, we can understand each other, not like with these sociologists!” Federico jokes (or not?) with Irene. In their conversations, there is a shared set of knowledge and competencies, not only linguistic, but, more importantly, in the concrete experience of modes of action and logics that govern the ecology of care. We are in the core of the caring ecologies of Trieste, the Distretto Sanitario (Healthcare District) located in the old general hospital, now almost dismantled (another, more modern one is up the hill, in a less central area).
The Healthcare District is the device through which the healthcare system tries to move the practice of care from the hospital to the spatial dynamics of the city, moving technical practices as well as human resources from the institutional site to urban life, and responding to the challenge of taking charge of the complex life of the citizen in relation to the plural ecology of care. In sum, the district contests protocols as the tool to organise care and proposes a catalogue of practices that can be arranged differently according to each situation.
There are four Healthcare Districts in the city, each tending to a population of approximately fifty thousand people. The Districts coordinate with general practitioners (who in Italy have a private contract with the state, although their consultancy is free for all residents), and provide home-care and personalised care through a system of resources including people, objects and assets: nurses, specialists, physiotherapists, and other professional figures; ambulatories, temporary care residencies, rehabilitation sites, cars and consultancy facilities; and, finally, grants, specific budgets, and social benefits, managed by the Districts in coordination with other institutions.
Although it acts through the hierarchies of institutional healthcare, the Healthcare District aims to disrupt the institutional logic as separate from social life and to re-knit the fragmentation of the different parts of the institution itself. The District is a device that simultaneously acknowledges and manages the boundaries between the different agencies in the system and contests and destabilises them.
Calling these practices territorialised medicine (medicina di territorio, in Italian) irritates the categories and presumptions of healthcare intervention in two ways. First, it grounds the idea of primary healthcare in spatial rather than communitarian dynamics, thus placing the practice of care in social reproduction rather than making it dependent upon an identitarian membership in one community. Territorialised medicine helps sustain social reproduction by investing public resources to hold together a system of common living. Second, territorialised medicine actively contests the separation between public health and medicine, which rarely meet and collaborate. Territorialised medicine makes the endeavour of care, and importantly doctors and other healthcare professionals, into an ecology, one in which different resources, agents, sites, objects move and adjust to temporary balances, unstable equilibriums. It is an ecology of perceptions, knowledges, and negotiations, of actions and durations.
Federico tells us, and Ofelia Altomare enriches his description the next day, about some of the Healthcare District’s activities. He starts the story from the moment in which the citizen enters into contact with the totalising experience of the hospital and therefore when the critical practice of care joins in the effort of disarticulating the institutionalisation: the moment when the practice of territorialised medicine encounters its nemesis, the general hospital.
Healthcare District staff are already present at the site of most intensive care, as a few workers from each district follow inhabitants when they are hospitalised. They visit the patient in the ward, contact the doctors to follow the patient’s hospital stay, and discuss the situation with the rest of the Healthcare District staff and the patients’ relatives or friends. Their presence allows them to start mobilising the resources that will guarantee the patient/citizen’s dignity and the right to health after discharge in the context of her life. This involves mobilising social and economic resources to support her, configuring caring and healing devices in her apartment, thoroughly and safely displacing the practice of care from the institution back into social life. Finally, Federico stresses how important it is that everyone involved understand the specificity of each technical practice and the web of knowledge and actions that allow it to be most efficient: “Reading a radiography or putting in a pace-maker does not involve a permanent relation with the patient, or any continuity. The patient expects his radiographies to be promptly executed and correctly interpreted […]. Your general practitioner on the other hand has to act in the opposite way, leaving the technology to the specialist, but taking charge of all the aspects of care that affect your life.”
The practices of the Healthcare District cannot be normalised into a fixed set of protocols: there is not one practice, but an ever-shifting set of practices that intervene and develop in a living world. This permanent destabilisation/organisation challenges the institutional tendency to segmentation so that the citizen has a better chance to enjoy her “right to health.” This is not a formal entitlement, but a relational experience immersed in social life and sustained by the coextensive action of the various agencies of the healthcare system. “Care is organised as an existential experience for both poles of the binomial carer/cared, and therefore contaminations and cross-overs are continuously constructed through the contradictions of normality” (Signorelli, 1998).
Contradictions, yet again. If earlier, we have encountered the contradiction of fabulation, here another matter emerges. This contradiction is that created by being part of the apparatus that institutionalises while trying to be a radical and responsive agent in the ecology of care. The question is how to maintain this tension, as a transformative “care for the past”: one that acknowledges the existing institutional practices not as something to be destroyed altogether but as the starting reality one has to confront to transform them. This implies thinking of them as ecologies that perform a certain way of living, but that can transition to new forms of social and material organisation.
Another way to think about instituent practice is as a critical denial of the instituted and the governing of the contingent equilibriums of transition: a subsistential territory (Raunig, 2016). Instituent practice aims to compose care around/with all the singularities involved: the pathology, the life of the citizen, her social networks, the political, institutional and administrative resources around care, or the knowledges, cultures, technologies and individual singularities (of the workers as well as the citizens) involved in the enacting of care. In other words, composing these material, social and institutional agencies is not about ordering, but about encountering.
In an interview with the research group Entering Outside, Franco Rotelli says: “I am always astonished when I speak with a young doctor and I ask him what he does, and he tells me his actions. If I ask him about the context in which he enacts this practice, either he knows nothing, or he refuses to know. Sometimes he has a vague idea about it, but there is nothing more overdetermined than what happens in the field of health: huge institutional assets, big economic interests, powerful professional corporations shape all. But the citizens as users should also matter. There are enormous issues on the political, organisational, administrative and cultural levels that play around this doctor who does these actions. But he ignores all this. In the best scenario, he cares about enacting a scientifically correct practice; his competence starts and finishes there. We think this is deeply wrong” (2019).
The caring ecologies are a plural and multiple logic of care. They are plural as far as they combine seemingly simple objects – always composed in a different way – according to their singular properties, until they perhaps find an unstable, temporary and partial equilibrium of competences, experiences, contingencies. This composition, this combination, is multiple in the sense that this plurality of competences would be destructive if it fragments the ecology of care. The responsibilities of care overlap, collaborate and conflict; the ecology of care is intersection of worlds, processes of interaction, where change emerges out of collaboration and conflict, in the simultaneous and intertwined acting of many worlds, each with its own culture, population, history, but still interdependent with the rest.
As Dimitris Papadopoulos proposes when speaking of technoscience, the ecology of care “is continuous with instituted [care] and vice versa, a continuation that unfolds across disparate and fragmented worlds” (2018). A network of possibilities that is the crafting of desiring, technical, social, and administrative dynamics that act around the contingency of care into a living system that takes care of singular and multiple parts of itself. A city that heals, an ecology that cares. All of this is the challenge the Healthcare District tries to organise: not by ordering prescribed protocols, but by enriching the open catalogues of the caring ecologies.
“It is about guaranteeing the right to health of the citizen, not about responding to the needs of the patient,” Ofelia says. “I don’t understand the difference,” Irene responds. “It is about taking charge” Ofelia offers. And the ball goes back and forth a few times before a common language re-emerges: not a technical one, but one made of ethics, experiences, politics, doubts, efforts and failures. Ofelia Altomare is the director of a Healthcare District on the periphery of the city. She is a nurse, the first appointed to this role. Along with other executives who come from the nursing profession (usually highly subordinated and gendered in the governance of care), she plays a significant role in Trieste's contemporary ecology of care.
The incomprehension between Ofelia and Irene is powerful, a shared wrestling with the matter at stake, rooted in the intention of understanding the full meaning of words and the materialities attached to them. Irene is not interested in understanding just the molar signification of “presa in carico” (take charge), but in confronting the molecular unfolding of this expression within the ambivalences of reality. The molar understanding would open a different conversation about the linguistic and material implications of paternalism and objectivation. The molecular thread instead takes us through concrete assemblages, continuities, transversalities, a discussion of how this practice respects the patient’s privacy, how it becomes a habit for staff and the citizen, how you reorganise the ecology of care around the guaranteeing of rights, as a relational experience, rather than the covering of needs, which so quickly leads to the objectification of the person as illness.
Ofelia first refers to the continuity of care as the model that allows the District staff to construct the transition from the hospital to the patient’s home, but what is difficult to grasp is how this process happens concretely. The molar “naming” and the molecular “acting” intertwine in Ofelia’s explanations: some of the actions cannot be solidified into one example, because the action is related to contingencies and is always a singular production. Nonetheless they need to be enunciated as statements, to be affirmed and constituted, even if they will inevitably be manipulated according to each situation. This is catalogue, not protocol.
Ofelia talks about how they are managing a situation right then. Someone has been hospitalised and after the home care team visited the apartment and talked with the family, it is evident that biomedical attention alone will not be sufficient or sustainable. Her account resonates with Federico's words the day before, but this time the account takes up the material details. The question is how to bring people together, coordinate their actions, organise the different objects and subjects of care. In other terms, instead of segmenting the practice of care, for example calling the social care department so they can take charge of their specific area of competence, the Healthcare District aims to knit the different competences into a common responsibility. Call the care workers, find somebody to refurbish the house according to the new needs and dignity of the person, help the family find a way to afford a carer. All these separate acts work to break down medical care as independent and univocal, or, at best, bilateral: the patient and the doctor alone in the consultancy room.
This common effort, this common hold on the ecology of care, is the result of a long transition, the forging, negotiation and affirmation of a different institutional practice. If the space of the asylum was one of violence and rebellion, the Healthcare District is one of molecular revolutions, of moving from competence to response-ability, a shared ability to respond (Haraway, 2016). Irene asks how this can happen, how the material culture of labour can change. How do the commons unfold in the endeavour of care?
“Slowly” Ofelia says, and through experiments, discussions and negotiations. Franco Rotelli refers to this process as a process capable of enacting a minor practice and making it hegemonic, building autonomy inside the state through material consistency, and by opening spaces of radical instituency. In the relation of capitalist-determined antagonism, “non possiamo vincere, dobbiamo convincere” (We cannot win, so we must persuade) (Basaglia, 1979).
The possibility of the common effort is constituted in the technical; the polity is located in the “operative” dimension, shaping the enactment of policies. Words, statements and questions circulate in a space of discussion rather than vertically ordering practices. It is a space of “minor hegemony,” that is the capacity of constituting within the institution a certain culture and a certain capacity of acting together. This minor practice is not oppositional to a majoritarian process, but it sheds light on the effect, rather than the rationality, of the state: how can we enact emancipatory public policies, staying in a contradictory way in the state?
This transition is always at risk of being reversed, Rotelli cautions, if it is not sustained by a practice of continuous and common engagement with both the inside, the institutional practices, and the outside, in urban life.
It is not only the patients who need to be guaranteed a process of de-institutionalisation. Ofelia Altomare recalls her own journey through de-institutionalisation in relation to the practices within. First, it is about putting oneself at risk as the leading group aiming to change the institution’s functioning (“sharing our doubts and our challenges, democratising the space of decision, disrupting hierarchies, especially because we were the ones at the top”); second, it requires affirming new ethics and discussing their importance, not only in principle, but in most material terms (“for example one of the issues we raised was the time table of nurses: if the citizen is the core of care, you cannot provide home care just from 8 to 14; it must become a 24/7 service. But this raised a number of concerns around which we had to negotiate and reorganise institutional practices”); thirdly, “it is a matter of crafting how each worker is going to participate and work in the Healthcare District, taking into account his or her singular situation and knowledges: one is a single mother; the other has to take care of a relative, and so on; one can work in a certain area or on a certain issue, etcetera.
However, the boundaries of the institution are not the limits of care. In fact it is the opposite: thinking of the ecology of care implies affirming a dispersive engagement of the institution throughout urban life and requires the institutions to invest to support the city’s commonwealth. The care “for the past” – that is the work of changing existing institutional practices and investing in open dynamics – is accompanied by a care for the present. Care is a relational experience that overflows the dynamics of healthcare, that participates in the city, and sustaining the right to health sustains social reproduction and urban life as well.
The term “presa” is an interesting one for understanding what is at stake here: it means seizure, grasp, hold. Prise in French. It holds the moment and a variety of possibilities folded through experience and unfolded each time in a different configuration. Presa involves having a catalogue of practices and tuning them in with the situation, configuring spaces made of contradictions and ambivalences. The seizure holds a complex reality together, displaying a collective effort in a contingency in which the healthcare institution is just one actor among many, and where a “continuous folding of the private, the public, and the commons into each other creates a condition where designating one of these three domains as the primary force […] becomes almost impossible” (Papadopoulos, 2018).
The word they use in Trieste is im-presa, Impresa Sociale (Rotelli, 1992). Not just a common seizure, but also a common enterprise. The enterprise as adventure and challenge resonates with Leigh Star and Griesemer’s (1989) conceptualisation of the entrepreneurial effort as a common, affirmative and composite practice that deals with institutional dynamics as an ecological assemblage: a collection of limits, memories and practices, a complex overlapping of points of view and perceptions. Such a collection allows the institution to enact the broken equilibrium of its own reproduction in its permanent transformation, thus preventing the institution from being drained by its tendency to autonomy and separation from society.
Inventing institutional practices therefore means acting in the changing institution, aware of the institutional drift to internal reproduction, but also feeding the molecular tensions that move a common enterprise to organise and respond to needs and desires. In Trieste, the common enterprise found its organisation through the 1991 Italian law on social cooperatives that guarantees economic support and fiscal privileges to cooperative enterprises in which at least a third of the members have disadvantages of some kind.
One of these common enterprises is the tailoring cooperative Lister. It is configured as a space of up-cycling where broken umbrellas, old textiles, out-of-date banners and other objects can be reused: it is organised to be inclusive, not only in its management, but throughout the production process. The production processes are organised to allow people with diverse mobilities to participate: for instance, the pace of production can be regulated to correspond to the rhythms of the people working, their distress and anxieties. The principles of up-cycling, the attention to places and to aesthetic qualities, are also used to construct a narrative around abandoned objects: the production of the objects becomes a ritual that embodies the practices of deinstitutionalisation, as Pino Rosati calls it, that reinvent the objects’ role in social reproduction.
Housed in the premises of the former asylum, today the Cultural Park of San Giovanni, Lister is an artistic, political, economic and institutional reality that participates in the common enterprise of care, along with other social cooperatives and associations, including Agricola Monte San Pantaleone, which manages the most beautiful parks of Trieste and the city’s seven-faith cemetery as well as the rose garden of San Giovanni, one of the most important in Europe. There are others, too, cooperatives and associations: CLU Basaglia, La Collina, Radio Fragola, Reset, Articolo 32 and more: a cooperative, associative, entrepreneurial movement that employs hundreds of people and accounts for almost 1% of the local gross production.
The first social cooperative in Trieste was born in 1972, as the first act to dismantle the asylum and give back civil and economic rights to the people sectioned there. It was an invention, in Basaglia’s terms (2005), a machiavelli, to trick the law and avoid forced internment. It started from a common sense: that of paying a stipend to the sectioned instead of imposing unpaid labour on them through the logic of occupational therapy. This gave patients a salary and a legal membership in a cooperative, helping to rebuild their social, civil and political rights in (and beyond) the asylum.
At the same time, the cooperative movement is a practice of health and care, because making beautiful and useful things makes you feel better, as Giancarlo Carena, president of the Social Cooperative Agricola Monte San Pantaleone says. In the 1980s, in fact, new enterprises were needed to build institutional practices in the derelict space of the asylum, to invent new forms of care not only against the return of segregation, but also privatisation, abandonment, and misery.
What was at stake was, and is, the invention of institutions as common enterprises, or commoning enterprises, in the middle of social reproduction: in the middle of troubles. Felix Guattari described the rise of social cooperatives in Trieste as opening not just the psychiatric practice beyond the asylum but also inserting them in social and urban life, “no longer artificially separated [from social life and] moving in the direction of a general desegregation”. “One can create light psychiatric facilities in the midst of the urban fabric without necessarily working in the social field. One has simply miniaturised the old, segregative structures and, despite oneself, internalised them. The practice being developed today in Trieste is different. Without denying the specificity of the problems posed by the mentally ill, the institutions created, like the cooperatives, concern other categories of the population that are also in need of assistance [like] drug-addiction, ex-convicts, troubled youths, etc” (1984)
But when this practice of emancipation is in the neoliberal city, another contradiction emerges. In this uncertain unfolding of the common enterprise within the urban ecology, un-commoning is also always going on (Papadopoulos, 2018) and the social cooperatives are part of that. The common enterprise is immersed in precarisation, because its workers have temporary contracts and difficult conditions. It is trapped in the process of privatisation of care, since the cooperatives can become the tool to outsource the public delivery of services. If entrepreneurial practice is appropriated to unfold the commons in the life of the city, alertness must be taken to ensure that it does not become a gateway to privatisation. The common enterprise needs to think of itself as a garrison in open social space. A manifestation against the processes, pushed by private economic interests, that can annihilate the caring ecology.
In this process of annihilation, privatisation gains its full meaning as a biopolitical and micropolitical process. It deprives each person of the capacity of enjoying the common good by making the disposal of care an exclusive good doled out in the name of scarcity. At the same time, the privatisation of practices disrupts the social responsibility around care and makes it a matter of competence and consumption, imposing the linear logic of choice in the asymmetric spaces of caring (Mol, 2008).
The social cooperatives movement can be a space that counters the growing privatisation of care, that opens new ways to manage the public endeavour of care. But this happens only by staying in the troubles of social reproduction; not by separating the endeavour of care from the urban ecology, but rather by immersing the enterprise of care in the struggles of the city.
This tension between enterprise and commonality is always at risk of tipping either toward enterprise, by the accelerating logic of the market that expels singularities through economic competition, or towards the institution, by the entropic logic of institutionalisation that tends to organise care around the efficiency of the institution rather than the effectiveness of care. But the productive tension of social transformation can be sustained by making cross-cutting institutional programmes (transversal), by offering public resources to sustain the difficult freedom of vulnerable times and people within the social life of the city.
The ecology of care can find the most fertile sites on the edges where different worlds intersect, not only breaking the separation between the different parts of the institutional assemblage and between the state and society, but also sustaining the empowerment of social life in the management of the enterprise of care.
“Stand up and walk around your desk. And go out of your office, and feel the fresh air of the city.” Gardener, psychiatric nurse, artist, long-time social co-operator, and president of the Trieste Association of Artisans Giancarlo Carena is often theatrical when he tries to explain the singularity of Trieste’s social cooperatives movement. He starts by arranging the narrative around your perceptions, to make you settle in the analytical journey that he asks you to undertake with him. “How can a place where such horrible things happened in the past today be a space that triggers beautiful projects?” he asked me in 2014 when we first met walking in the blossoming gardens of the former asylum.
Once opened, the asylum becomes part of the city and then a park. A park that lives on the limit between management and refusal, between institution and society, between nature and city. The caring ecology is a space of composition and expression, a practice of sensibility and transformation within the circuits of production and accumulation of capitalism; it lives amid the dangerous tension of capitalist dynamics that domesticate nature in order to profit from it. The practice of the common enterprise aims to deal with health care within (and against), rather than outside, these dynamics.
“Care is too important to give it up to the reductions of hegemonic ethics. Thinking in the world involves acknowledging our own involvements in perpetuating dominant values rather than retreating to the sheltered position of an enlightened outsider who knows better” (de la Bellacasa, 2017). This means that the practices of utopia can be challenged, dis/assembled and, in Basaglia’s term (2005), immersed in reality.
Also caring ecologies as a text, in this sense, aims to operate here as a conceptual gateway for an institutional critique that reconfigures health and care practices in the contemporary, understood as a critical edge of modernity. Caring ecologies is therefore an abstract machine, one that operates using concepts to produce knowledge inserted in, and possibly useful for, social change. In doing so, the analysis of the material dimension of the ecology intertwine with the ethics of those operating in it, crossing different layers of institutional analysis and subjective enquiry. The practice of research holds together the analysis of the ecology and the diagrammatic proposal of an action – it tries to open a dialogue between the signs and the things that make the ecology, in order to make critique into programme. In this machine, molar and molecular are always intertwined.
The entanglements of caring are constituted as a system of values and significations, as rationalities of governance, but they must also be interpreted as bearers of a series of lateral possibilities that need to be interpreted and re-enacted so that they can invent new institutional forms capable of participating in sustaining a distributed ecology of caring, in a present that is more precarious every day.
While I get lost in these thoughts about my text, Giancarlo is drawing on the paper placemat at Il Posto delle Fragole, the Place of the Strawberries, one of several restaurants managed by another social cooperative, La Collina, and the first public space opened in San Giovanni. Back then, in 1973, it was run by the people sectioned in the asylum. He is explaining the three contradictory utopias that have been unfurled in this place, and how the three of them still survive today. The first utopia in the 1907 mental asylum, when Trieste was part of Austro-Hungarian Empire, was part of the Empire’s impressive public investment in its four main metropolises to sustain a new conception of mental healthcare based not on punishment, but on the construction of a separated and serene community. Although this first utopia was one where beauty and serendipity were represented through idealism, normality and discipline; and it was ultimately a utopia of violence and segregation.
The second utopia emerged through the 1960s and the ‘70s. When Franco Basaglia closed the asylum in 1979, he said “the only good thing to do here is to throw salt, so that nothing can grow, ever again.” Destruction was not just a metaphor; it was a concrete practice. To bring an end to violence, the doctors gave the formerly sectioned the tools to destroy the fences and supported them in their exodus from the asylum into the city, through institutional and activist practice, including disobedience and occupations. This second utopia was one of destruction and liberation.
“We disobeyed”, Franco Rotelli often says. The third utopia is the park today. It lives in the same (still public) premises of the Austro-Hungarian therapeutic garden, which is also where the soil, filled with salt during the utopia of destruction, became a cross-contaminated forest, nurtured since the 1980s by many unstable, sometimes hidden, and almost always informal practices: raves, arts, occupations. The third utopia is an allegory rather than a representation or a metaphor. The park is a symbol of care and diversity, as well as a place of well-being. It is not an exaggeration to say that it has been the morphology of the park that has put together cultures and generations, integrating cultural life and economic enterprises in the space of the ex-asylum.
“This process of reconstruction and redefinition has involved everything and everybody. No one component (and it could not have been otherwise) has been able, or has tried to, avoid this process. The very physical places of the asylum have affirmed a new “being”: not any more as a space to be forgotten and left behind, but as a crossing point. An urban trajectory used for the neighbourhood: a road to be crossed. Another piece of the city (one of the few with a lot of green) to be enacted and to be questioned” (Assunta Signorelli)
In this sense, the composition of a certain capacity of acting, a certain trajectory of empowerment, resonates with the reflections of Italian autonomous Marxism on the term class composition, a metaphor borrowed from the chemical composition of elements to represent the subaltern’s autonomous capacity of analysis and organisation.
In the 1960s debates, composition acted as a counter name for class consciousness, which would separate the class in itself from the capacity of the class to struggle (the class for itself). In the autonomous approach, the technical and political composition of the modes of organisation directly constituted the capacity of acting and speaking, as workers against capital.
But there is a difference here. Ecology of care may be like class composition, but it is compost: it makes things grow. The park is a plurality of sites and a multiplicity of perceptions, composed in the process of care: it is symbol, but also material space. A combination of agents: the university, the cooperatives, the healthcare system, the public services; the soil, the users, the students, the workers; but also a multiplier of relations: contracts, conversations, concerts, screaming, laughing. A park made of roses, earth, memories, gardeners, saws, lovers. The ecology of care is a compost of organic matters that reclaims care by building the city in common.
The park reclaims care in the same place that the asylum imposed a practice of constraint. I use reclamation here in an effort to explore tensions like those addressed by Maria Puig de la Bellacasa in putting ambivalences at the centre of her work around caring: “To reclaim often means to re-appropriate a toxic terrain, a field of domination, making it capable of nurturing; transformative seeds we wish to sow […] acknowledging poisons in the ground that we inhabit rather than expecting to find an outside alternative, untouched by trouble, a final balance – or a definitive critique.” “Reclaiming care keeps it grounded in practical engagements with situated material conditions that often expose tensions.” (2017)
In this ecology of care, refusing a certain mode of organisation is only possible when another is invented. This means affirming sustainability, resilience and durability as vectors of another logic of caring. Destroying the asylum while at the same time “reaffirming the right to asylum, as a fundamental right for the person in a moment of distress” was and is one of the core principles of the Basaglian revolution, as Giovanna Del Giudice explained to me in our first conversation in 2014.
In Giovanna's practice and conceptualisation (2015, 2019), the care for the past and the present is always the edge of the care “for the future”: the destruction of the asylum and the transformation of the institution needs to happen continuously and simultaneously. Every day we work to dismantle the institutional entropy and the opportunistic mentality of care as control, but in order to do that, we have to ceaselessly invent new modes of organising care, as a practice of encounter, permeability, cultural crossing. A practice of social permaculture, as Starhawk (2016) calls it in her translation of the ecological practice of permaculture as a tool for political action.
Dimitris Papadopoulos refers to the process of commoning as one of creating generous infrastructures. In his analysis of techno-scientific practices, “what counts as invention is not primarily the individual experimental achievement that gives coherence to traditional experimental scientific practice (although this might be sometimes part of it); rather, it is a form of dispersed experimentation: distributed invention power. If science as experimental achievement ever existed, this achievement of invention is now dispersed in society and matter” (2018). The ecology of care is immersed in this dynamic invention: it is more than social, more than an enterprise; it is more than institutional, more than personal; it is mobile and dispersed, yet it persists.
For Papadopoulos, commitment, accessibility, engagement (and words that resonate with reciprocity, responsibility and inclusiveness, which are the words we saw in the analysis of the Micro Area at the beginning of this deriva) are joined in the infrastructure to make possible an ecology that constantly challenges institutional entropy, that transforms urban life and supports the emancipation of those agents that build the city. These generous infrastructures “are autonomy made durable: transparent, unnoticed, and persistently present spaces that incorporate political practice in their workings. Infrastructures allow more-than-social movements to politicise ontological practice in the absence of consensus [...] without the need to start again and again from scratch” (2018).
Commoning becomes a practice situated in a non-sovereign relationality: it creates a space of instability and contradiction, where the politics of the commons become a practice through which society can occupy “the very contingency of non-sovereign standing” (Berlant, 2016) rather than resolving ambivalences (or, again, contradictions) through affirming of a new sovereignty, one that always exists on someone else’s back.
Compost for the future, on the edge of the present, the rose garden is the material sign of the utopia as it exists in reality: both failed and continuously being renovated. “[We have five thousand roses], but five thousand roses are still missing, and they are for me the sign of the city that is uncertain; they are the cypher of what is possible, of what has not become true in that true life that we wanted to live, for us, for the loonies, suffering brothers and sisters with whom we have taken a long walk. A walk that took us far, but not as far as we hoped we would get (but much farther than their Lordships could even imagine). The rose that still does not exist calls for another time, another generation, another energy, another love. And no one today, especially today, make any secure prophecy about this: a prophecy of men and women that can look, and listen, and watch, and touch, and smell, and use all their senses, and cultivate the concrete signs coming out of them because they are capable of hearing the noise of life, of touching the earth, watering the roses, and changing the things.” (Rotelli, 2015). E bagnare le rose e cambiare le cose.
Toward a conclusion
Trieste is an ecology of practices where knowledge comes together across many tangled registers. It is a palimpsest of codes and operations in which different discourses, affections and compositions define an unstable and plural mosaic of voices. The ecology of care stands continuously on the edge of the present: it escapes the narrative of care as autonomous space and affirms one inherent to social life by forging a city that cares and heals.
Go back to the park, Giovanna told me once, when I was telling her where my research was taking me. And back in the park, I add one more thing before concluding, an experience in which I have been actively involved during my time in Trieste: a show of Radio Fragola, the autonomous and cooperative radio born in the early 1980s, at the intersection of social cooperatives and counter-cultural radio stations. “The Universal In/Corporate, leader enterprise in the production of symbolic matrixes, presents Eschuchame [Listen to me, in Spanish], a sporadic case of someone’s ingenuities.”
Every week with these words, Margherita Antivulgaris opens a space of imagination and discussion where different agents participate in creating a common sense of listening, in which the ambivalences of a plural reality are not resolved through the linearity of discourse, but instead exploded as a multiple ecology of caring. Escuchame is a cosmicomic ecology of voices coming from different sites of mental health and the city, meeting in the park every Friday, at 5.30pm, for many years.
In Escuchame, the radio narrates every time, “voices get stuck in smoking nucleuses of sonorous matter, where meanings are untied from objects, through the foolish certainty of eloquence, without fulfilling their own finality.” A world-making microphone that works through intimate expression; that affects the modes of existence of bodies; that challenges the prejudices and roles that even the distributed and emancipatory institutions of Trieste tend to reproduce. The voices on the radio, separate from the body’s stigmatised identity, give us back a palimpsest of expressions, in which the boundaries between deviance and normality are disrupted by waves of sound.
Escuchame follows its own rules and rituals, instituting a resilient space where the singular modes of existence can find a contingent consistency, a quivering normality. The mathematician Ferdinando repeats his questions on the genealogy of families, week after week; the artist Diego Porporati reads his “Short Chronicle of Time in Twenty Four Chapters,” never getting past the third chapter: the history of wine. The Titolare Ignoto, at the mixer, fades out the signature tune of the show. It is 6.30pm.
Then the ritual of care continues: a fizzy drink from the soda machine in the corridor of the former pavilion of calm patients. Next, each of us adds a little bit to the salutation protocol: the procedure lasts an undetermined amount of time, summoning a composition of gestures and stories that evolve, and, by growing, repeat themselves endlessly, until the voices of the show begin returning to their factual form, bodies again in the twilight that enshrouds the park.
Stuck in the middle of the trouble, the ecology of care comes together as matters, gestures, memories, across the park, through bodies, plants, artefacts, along and with social and institutional relations. It stands as an interdependent dynamic of intrusion and perception, transition and repetition, denial and invention, composition and insistence that plays with the materials and relations that constitute social life, with the intersections of partial singularities and partial commonalities and their thick specificities, sometimes immersed in the contradictions of the institutional field, sometimes lost in a moment of fragility and freedom.
Imagination can be a space to craft this ecology of care, through contradictions, ambivalences, or discontinuities. Imagination as a materialisation of plural worlds. Thresholds, perceptions, translations, catalogues, transitions, enterprises, composting, reclamation have been just eight stories for my deriva through this ecology. A fabulation of care that I hope can contribute to thinking about social practices of emancipation and reproduction that are capable of responding within this current dangerous moment and contribute to crafting practices for making life, in a damaged world, sustainable.
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Quando S. distrugge le fotografie della mostra del P, egli compie il gesto impopolare: nega, rompe l'armonia della fiaba: è “cattivo” e aristocratico. Nega la verità del cavallo, vede la mistificazione: non c'è uno spazio in cui la fiaba possa realizzarsi.
In città i sottoproletari caracollano dietro il cavallo come i proletari dietro la carretta di Madre Coraggio: ma il cavallo, inutile e bello, sarà sempre la mercé, l'oggetto prodotto: il sottoproletariato diviene qui produttore di mercé e quindi accettabile, accettato a circolare per le vie della città. La produzione ha le sue leggi, la legge custodisce e sostiene la produzione. I fuorilegge producono per un giorno, e per un giorno sono ammessi a circolare con la loro macchina cavallo, ancora una volta macchina desiderio e non macchina politica. Si pavoneggiano nei loro vestiti di stracci: è l'eterno carnevale dei poveri: c'è spazio per porsi ma non per opporsi. La lotta ha altre date altre sedi altre piazze: la vacanza continua, lo spettacolo ha vinto un'altra volta, l'oggetto si pone ancora una volta impenetrabile: il cavallo-liberazione si morde la coda, il matto ritorna ai circuiti normali della sua distruzione.
Dietro al cavallo c'è l'orrore di sempre, la sporcizia, la violenza, la penuria del manicomio, la condizione sottoproletaria dentro l'“ospedale” dove l'“aggressività” del “malato” può scomparire solo per ricomparire trasformata nella docilità handicappata del cavallo garantito dai suoi cavalieri: gli “ippocrati” appunto. Asettico, privo di virilità, il cavallo garantisce alle vittime la possibilità di sognare; ma questa unica chance è socializzazione di un desiderio che, svincolato dal bisogno, è pura negazione di storicità. Desiderio di essere in quel luogo specifico: il “fuori dal manicomio” che ti tiene esso stesso fuori: di essere in quel luogo della grettezza nel quale è improponibile, per la strettezza dell'abito, la vita per chiunque desideri vivere.
La gente del manicomio ha prodotto un oggetto di inconsueta bellezza, segno consolatorio che anche nella merda (il manicomio) nascono fiori. Questo fiore ci piace, a tutti. E il segno di un ottimismo nell'uomo che non riesce mai a morire anche se assurdo.
Solo ad S. questo fiore non piace. Rigido e solerte difensore di un'istituzione organica, S. distrugge, come un bambino cattivo, “psicopatico”, il gioco degli altri bambini: il trastullarsi di chi gioca a far fiabe. La sua violenza verbale è sgradevole tanto quanto inesplicabile: il camerino d'isolamento sarà il luogo ove meditare la sua asocialità.
Ma: popolare è e rimane la maschera.
 I have been engaged with the ecology of care in Trieste over a number of years and in many different roles. I arrived the first time in 2014, as a researcher in the Minister of Public Health of the Ecuadorian Republic and participated in an intensive workshop along with a delegation of psychiatrists from China. It was then that I met Giovanna Del Giudice; I went back a few months later, in 2015, and began collaborating with Giovanna and the Conferenza Permanente per la Salute Mentale nel Mondo “Franco Basaglia;” I also organised a series of debates and workshops in Barcelona, with Radio Nikosia. In 2016, I spent the spring and early summer in Trieste with the financial support of Rosa Luxemburg Stiftung and the mentoring of Isabell Lorey, developing a frame of action research at the Mental Health Centre of Domio, with the Peer-Support Group and in ‘community’ healthcare in the neighbourhoods of Ponziana and Zindis. After this, in collaboration with Marta Malo, Marta Perez and Irene R. Newey, we articulated Entering Outside, a dialogue among social, care and healthcare workers and activists in Europe, with the collaboration of the Azienda Sanitaria in Trieste and the Municipality of Madrid, and the support of the National Museum Centre of Arts Reina Sofia in Madrid. At the same time, with a group of Trieste workers including Margherita Bono, Paola Comuzzi, Michela De Grassi, Sari Massiotta, Monica Ghiretti, Federico Rotelli, Federica Sardiello, Alfio Stefanich and Davide Vidrih and the support of Kent Law School, at the University of Kent, we started to collaborate with the community healthcare programme Well Communities, in London. Other smaller collaborations have also been happening in these years with Cooperativa Sociale La Collina, Radio Fragola Gorizia, Dipartimento di Salute Mentale (both in Trieste and Gorizia), Cooperativa Sociale Agricola Monte San Pantaleone, and many other individuals and groups in Trieste and its vicinity. My thinking about the ecology of care has come into being in these discussion spaces, along with other practices, views, interpellations from a range of groups, including Entering Outside in Spain, the Vessel Project in Bari, the Radical Psychiatry Network in Nottingham, In Spite of Everything in Athens, Raum Station in Zurich, the Casa Azul in Malaga, the Kent Law School, the School of Political Sciences in Kassel, the School of Art of Zurich and the School of Management in Leicester (as well as some academic conferences): of course it is not the institutions but the people in them, and many others have been the chats, the nights and the encounters that forged these reflections. Martha Schulman has been not only the editor but a friend in conversation when reviewing this text, and I am extremely grateful to her mordant wit.
This array of practices, configurations and trajectories constitutes the messy ground I try to synthesise here as my own point of view on a complex, open, and collective work that is the caring ecologies of Trieste. Luckily for me, encountering Giovanna in 2014 meant engaging with a number of voices and opening a multiple, critical and plural space of conversation with people in different sites. Although one Adam, two Alessandros, Andrea, Beatrice, Carol, Claudia, Davide, Ecaterina, Elena, Elisa, two Fabios, Frida, Grazia, Guillermo, Lara, Letizia, Marco, Mario, Michela, Naomi, Nicole, Patricia, Patrick, Pina, Sandro, Valentina and Yulia are not named in these pages, they have been my interlocutors in these years, have framed my conceptual and material engagement with the ecology of care, and made my life sweet and warm in Trieste.
 Published in 2006, this text refers to an episode at the Laboratorio P, during an exhibition to describe the workshop of Marco Cavallo, a papier mache horse built for the first public demonstration of the users and workers of the asylum in the streets of Trieste, in 1973.