Similar texts define and recognize the universal right to health.

With similar determination, both Italy and Cuba decided in 1978, along with 132 other states and 67 international agencies, to adopt the landmark Alma-Ata Declaration on Primary Health Care as a framework for achieving “health for all” by the year 2000. This commitment combined health with human rights and social justice to make essential health services universally accessible. This commitment was political, social, and professional, individual and institutional, in the areas of health and healthcare, social and healthcare, and well-being and improved well-being (welfare) in living and working environments. This commitment was demanding and ambitious, like all those aimed at guaranteeing human rights, the rights of a community and not just those of individuals. Both Italy and Cuba had undertaken a similar path long before, because health is also a project, a goal, an objective to be achieved and maintained, especially if it is to be for everyone. Health and healthcare are distinct concepts, but clearly interconnected: you cannot guarantee complete well-being unless you organize an adequate and appropriate system (a Service) to protect it.

Cuba

The development of a profound social revolution and political will led, starting in 1959 with the overthrow of the Fulgencio Batista regime and the proclamation of the Republic, to healthcare being based primarily on a primary care approach oriented towards equity. However, demographic changes and shifts in the population’s morbidity and mortality patterns, the rise of its cultural level, the emergence of medical thought oriented towards a clinical, epidemiological, and social approach, and the need to achieve qualitative improvements in the population’s health, required, for Cuba too, changes to the healthcare system to achieve and guarantee the right to universal healthcare. Thus, the family medicine model was launched, aimed at meeting the needs of the population’s epidemiological profile and level of satisfaction.

120 Family Doctor Plan

On January 4, 1984, this model, also known as the 120 Family Doctor Plan (Plan del Médico de las 120 Familias), Family Doctor, or Community Doctor, was launched at the Lawton Polyclinic in the municipality of 10 de Octubre in Havana, the country’s capital. The program began with ten pairs of doctors and nurses, who formed the first ten primary health teams (ESCs) working in family doctor clinics (MFCs). Each of these teams provided comprehensive medical care to an average of 600–700 people, approximately 120 families, hence the initial name. The program’s primary objective was to improve the population’s health through comprehensive interventions targeting the individual, family, community, and environment, in close collaboration with the community. Today there are 15,000 ESCs, which care for 140-180 families, without exceeding 1,500 patients. They are distributed throughout the country and constitute the backbone of the Cuban healthcare system.

Within these facilities, healthcare workers are responsible for the population’s primary medical care, particularly those most vulnerable, such as children, the elderly, and pregnant women. Special emphasis is placed on preventive medicine, hygiene, nutrition, sports, and the management of risk factors. Prevention is the cornerstone of the Cuban healthcare system. Home care is provided by the ESC in the patient’s home when the patient requires daily assessment, rest, bed rest, or isolation, but does not require hospitalization. The ESC manages its patients’ medical records according to an organized, continuous, and dynamic process that allows for planned and scheduled assessments and interventions with minimum frequency based on the patient’s group (presumably healthy, at-risk, sick, and disabled).

The second level of care is represented by the 436 community outpatient clinics. Each outpatient clinic serves a population of 30,000–60,000 people and collaborates closely with 20–40 ESCs. An average outpatient clinic offers around twenty different services: rehabilitation, radiology, ultrasound, endoscopy, emergency room, traumatology, clinical analysis laboratory, family planning, thrombolysis, medical and dental emergency room, maternal and child care, vaccinations and diabetes care, geriatrics, dermatology, psychiatry, cardiology, general medicine and internal medicine, pediatrics, obstetrics and gynecology.

To ensure continuity of care for the population, the Integrated Family Care Program, as its name suggests, involves the evaluation and development of actions between the members of the ESCs and the core working group of the outpatient clinic and the referral hospitals.

To achieve this goal, it was essential to have professionals trained to carry out the new missions of the service delivery system. This led to improved human resources training through the implementation of a new medical school curriculum, based on the identification of population health problems and with a graduate program focused on primary healthcare, and the development of a new specialty, integrated general medicine. The first specialists in this discipline graduated in 1987.

Italy

After 50 years, Law No. 833, which governs the entire and complex National Health Service, requires extensive updating. Once again, interventions are expected that are late, unsupported, partial, and sectoral. The last two are Ministerial Decrees 70/2015 and 77/2022. The former defines the qualitative, structural, technological, and quantitative standards of hospital care. The latter defines the models and standards for the development of community care within the National Health Service and is closely linked to the National Recovery and Resilience Plan (NRRP).

The implementation of both decrees is delayed due to staff shortages, the previous history of regional governance, uncertainties and critical issues in general practice, and the overgrowth and fragmentation of the hospital network. The application of Ministerial Decree 77 must necessarily include the application of Ministerial Decree 70, and therefore either the delays already accumulated are resolved or they will only increase, as is happening.

Community Homes

One of the essential elements of the 2022 reform implementation plan is the Community Home, defined as “the physical and easily identifiable place where citizens can access healthcare, social and health care needs, and the organizational model of local care for the target population.” But exactly what type of Home is needed, for what needs, for which community, with what functions… this is unclear.

The decree has identified organizational standards for a Community Home hub for every 40,000-50,000 inhabitants, with 7-11 nurses, 1 social worker, and 5-8 support staff (social and health, administrative). The services provided in the Community Home are divided into mandatory, optional, and recommended. The main and essential services are primary care services provided by multi-professional teams (general practitioners, pediatricians, outpatient specialists, community nurses, etc).

The number of Community Homes has been set at 1,038, rising from 1,715 following an agreement with the EU. By June 30, 2026, funds from the National Recovery and Resilience Plan (NRRP) have been used for new facilities or the conversion of existing ones (such as hospitals, outpatient clinics, and local health authorities). Since the end of the NRRP, there has been a frenzy of activity to place plaques and signs at the entrances of existing outpatient clinics, including those in hospital areas, labeled “Community Home.” The prevailing belief is that Community Homes are actually Community Homes, meaning that the standard prevails (the “of” instead of the “of”), and that the primary common good to be pursued is healthcare, not health. Therefore, Community Homes are simply outpatient clinics, Health Homes, and not always efficiently.

Italy and Cuba

The health services of the two countries have much in common. The principles and objectives are identical. Governance is, of course, different, given the resources available and the policies implemented and also endured, particularly the blockade imposed on Cuba by then-US President John Fitzgerald Kennedy on February 7, 1962, with “Proclamation 3447.“The tightening of the economic embargo during the first Trump administration, Covid-19, and, since January 2026, the near-total blockade of energy supplies resulting from the Venezuelan crisis have deprived the island of fuel, electricity, and access to international markets for drugs and medical devices. The collapse of a health system is not just a local tragedy: it is a violation of fundamental human rights that requires a response from the global community, regardless of any political considerations regarding the Cuban regime.

The commonality of Article 32 of the Italian Constitution and Article 72 of the Cuban Constitution, the focus and priority on primary care, the identification and designation of the community as the basic space and collective for social and health interventions, the Plan del Médico de las 120 Families and the Community Houses as models of intervention, the Cuban primary health care teams and the Italian multi-professional teams indicate that greater collaboration, sharing, and solidarity between the two countries would be beneficial to both peoples.

Italy also owes Cuba its support during the COVID-19 pandemic and the ongoing work of Cuban doctors in the Calabria Region to ensure the functioning of the local health service.
The organization of health services to ensure the right to healthcare is a powerful indicator of a country’s progress or decline, and the level achieved by Italy and Cuba is similar. The fact that a quality health service like Cuba’s is forced to fail to fulfill its functions should be of concern to anyone who cares about the universal right to healthcare.

At the beginning of the pandemic, for about the first eight months, the presence of identified variants was still very limited, and the forecast of low viral variability turned out to be completely wrong due to limited circulation and the number of observations. The health relevance of each variant depends on its transmissibility, virulence, and ability to evade our immune response. It is estimated that, until the end of 2021, the spread of Alpha and Delta was mainly due to their high transmissibility associated with a modest ability for immune evasion, while the success of the Omicron variant, which replaced the Delta variant, seems to be associated with a greater ability to escape our immune response. 

Most Sars-CoV-2 infections cause an acute illness that our immune system resolves within 10-15 days. After infection, viral particles reproduce exponentially in the respiratory tract, reaching a maximum concentration 2-5 days after exposure to the contagion, a time that corresponds to the onset of symptoms. This is more or less similar for all variants, but for Omicron, the peak of maximum viral concentration is about three days, a time during which the infection can be effectively transmitted.

In recent weeks, the number of reported Covid-19 cases in Italy is on the rise. The daily average of infections, which was less than 500 in mid-July, surpassed 3,000 at the beginning of September, with a peak of 5,547 on September 5th. Hospitalizations have more than doubled in a month (at the beginning of August only 812 Covid-positive patients were hospitalized, while on September 6th, the hospitalized were 1,872). The reported cases are more frequent among the elderly, and the figures are certainly underestimated due to frequent self-administered swabs and the lack of reporting for younger individuals.

Predicting the short-term epidemiology of Covid-19 is challenging, but it is conceivable that the waning of our immune defenses, already evidenced by the occurrence of further infections in people who have already been ill once (the latest ISS bulletin reports that 38% of the new reported cases had already been infected previously), and the emergence of viral strains with new antigenic characteristics will lead to periodic epidemic waves. To limit the impact of infections, one can act on reducing the share of people who have become partially susceptible and on the other hand on limiting the likelihood of the emergence of new variants. However, it is necessary to bear in mind that the two approaches are not alternatives, as the evidence of vaccination efficacy is solid for severe clinical cases but not as much for infections.

To reduce the share of cases that require healthcare due to decreased immunity, further vaccination is proposed. Last June, the EMA and ECDC signed a joint document advising vaccine manufacturers to formulate new monovalent vaccines targeting the Omicron XBB.1.5 variant, as the descendants of the XBB1 strain are predominant globally.

The demonstration of the efficacy of these products is complicated by the pre-existing widespread partial immunity, and what is expected is an incremental benefit, impossible to prove for simple infections but assessable, with adequate epidemiological studies, for more severe clinical cases. The evidence required at the time of marketing authorization is essentially laboratory-based, based on the titration of antibodies induced by vaccination, even in animal models, capable of neutralizing various Sars-CoV-2 variants. As for the seasonal flu vaccination, the choice of formulation of the new vaccines is the one considered most “reasonable” before the winter season. Compared to the flu, however, we have the disadvantage of the lack of clear seasonality, making it impossible to benefit from knowing which viruses circulate alternately in the two hemispheres of the world and are therefore predictive of individual seasons in each hemisphere. Monitoring the effectiveness of the vaccine in the field will be vital, also to understand if the path taken will also be valid for the coming seasons.

The new vaccines should be available soon, and a circular from the Ministry of Health has already given indications about the official recommendations, very similar to those for the flu vaccination. The protection provided by vaccinations is individual, highly recommended for subjects at risk of severe clinical cases, and the idea of achieving herd immunity has now been completely abandoned. But it is not desirable to think of letting infections run their course, due to the risk of the emergence of new variants.

The more people get infected, the higher the number of viral replications and the higher the probability that even more efficient viruses will emerge in spreading and causing disease. In short, it’s a vicious circle, which requires maintaining a certain level of attention and precautions to limit the spread and also reduce the circulation of “imported” variants to be promptly identified.

Dismantling or reducing epidemiological and viral surveillance and zeroing the general population’s attention to viral spread does not seem like an adequate strategy. It is instead necessary to strengthen the ability to early identify epidemic outbreaks and high-risk variants (“variants of concern” as defined by WHO). During the early stages of the pandemic, in the absence of much data, extensive use was made of mathematical models to estimate diffusion parameters and build scenarios and make public health decisions based on these. Now those same models could be even more precise and useful if fed with real data generated by good epidemiological surveillance, from studying epidemic outbreaks, intra-family transmissions to estimate secondary attack rates, from studying the transmissibility, virulence, and ability for immune evasion of the various circulating variants, also using wastewater surveillance to identify and characterize variants whose circulation is not identified by investigated clinical cases.

During the early stages of the pandemic, we had to accept the uncertainty of incomplete data for ongoing studies and the rapid times for which we were unprepared. Now, we have an opportunity to learn and be more prepared. It will be necessary to coordinate the health surveillance structures, organize prospective studies with suitable methodologies, with the involvement of competent bodies and trained personnel. We must also disseminate clear and correct information so that everyone is kept updated on the epidemic’s development and the actions and measures to be adopted, avoiding the creation of fears, false alarms, and especially the widespread misinformation that has sometimes fueled the resistance and skepticism towards the precautions and vaccinations adopted.

Just one month after the publication of the new guidelines (SOC8), the chapter on adolescence has left behind (especially in the English-language media) a dust-up of alarmist invective, conspiracy theory and biased reporting. In some cases, even in professional and field publications such as the British Medical Journal. The most critical aspect is certainly the removal of precise minimum age recommendations in case it is indicated to provide medical and surgical gender affirmation treatments required by adolescents. It follows the recommendation to involve close relatives, “unless their involvement is determined to be harmful to the adolescent,” thus contemplating the possibility of their exclusion from the evaluation and treatment framework. However, in hindsight, little or nothing has been reported about the rationale underlying these new recommendations. Still, SOC8 mark a significant step change in the approach to adolescent tgd health. Yet, to gain a better understanding of this shift, it is useful to set aside (for a moment) the context of public and political debate, and try to get a sense of Wpath’s approach and thus its work in light of the state of research.

Who are tgd people and how many are there?

Gender identity is a concept that has relatively recently entered common usage. It comes from psychology and denotes “a person’s deeply felt, internal, intrinsic sense of their own gender,” where ‘deeply’, ‘internal’ and ‘intrinsic’ are not poeticizing adjectives, but rather define a constitutive element of any person’s psyche. Gender incongruence or gender diversity occurs when a person develops a gender identity that differs from the gender assigned to that person, typically at birth based on observation of the external genitalia (to approximate, the ‘biological sex’).

It is still very difficult to estimate how often this phenomenon occurs worldwide. However, the data available are growing. While Western health providers report an average of 0.02 to 0.1 percent of the population, larger surveys range from 0.3 to 4.5 percent among adults to 2.5 to 8.4 percent among younger people. The growth in the data, as well as the leap between the percentages of adults and young people, should come as no surprise. In fact, it is only recently that large-scale systematic surveys have begun to be done, while at the same time both information as well as media visibility of tgd people and protective policies toward them have increased, fostering a phenomenon of emergence.    

What are we talking about when we talk about their health?

Nowadays, gender incongruence is defined as a condition in the International Classification of Diseases and Related Health Problems (WHO, ICD-11). It is, therefore, not considered an inherently pathological phenomenon, which means that in itself it does not cause any harm to individuals. Yet, at the same time, gender incongruence is still stigmatized in many societies around the world-and sometimes denied in its scientific underpinnings, branded as “ideology” or “gender theory.” This stigma can contribute to cases of abuse and violence. More than that, it often leads to the development of minority stress, in essence elevated levels of stress and psychological distress or even gender dysphoria - the latter is defined as a peculiar mental health condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and in this sense it is functional to the activation logics of most national health services. This set of socially induced symptoms typically have chronic valence and are statistically associated with significantly higher rates of depression, suicidal tendency, and self-harm than the average cisgender population (i.e., anyone who is not tgd). In all accounts, unable to ‘treat’ the phenomenon of stigma in human societies, health care for tgd people focuses on curative and preventive treatment of induced and related symptomatology through so-called “gender affirming” therapies. These mainly intervene on body aspects that heavily affect the psychosocial perception typically associated with stigma (consider genitalia, but also other socioculturally impactful aspects such as voice). Therefore, they may include hormone therapies and surgery. However, in some cases other much less invasive types of interventions are also sufficient.

Gender affirming therapies are called as such, as they support the gender identity developed by the tgd person. In this sense, they are diametrically opposed to “aversion” therapies, also known as “conversion therapies.” Historically, the latter have long been tried-and in some contexts are still practiced-following the (unfounded) assumption of correcting or healing gender identity. In fact, from the earliest scientific studies in the second half of the 1800s until recent times, gender incongruence has been regarded as a mental illness or disorder in itself (often confusing it, by the way, with homosexual orientation, which was considered equally pathological). As a result, various therapeutic approaches have been developed for decades in the attempt to align gender identity incongruence with biological sex (sometimes even resorting to practices such as electroshock). Conversion approaches, however, have not only been found to be inconsistent in their scientific and diagnostic assumptions, but, when applied, have caused a significant increase in psychological problems in tgd people, correlated in turn by an increase in suicide cases. Therefore, both Wpath and leading international health agencies now condemn their use.

Wpath’s new approach

The SOC8 come out ten years after the last update (SOC7), following an extensively documented elaboration and synthesis work to ensure transparency. The new guidelines are basically the result of a cross-comparison between analysis of new data and review of available scientific literature, as well as clinical experiences and circumstances. The author of this work was an international, multidisciplinary committee of about 120 members who are experts in various relevant fields, from health care to research, including a number of stakeholders. Finally, the Delphi methodwas used to draft the guidelines so that the committee’s professional consensus was reached on each and every wording in the text.

The presence of stakeholders (about 13% of the committee) with experience in health advocacy in the so-called transgender community from different parts of the world is one of the methodological innovations. This was introduced to broaden the perspective on nonclinical factors influencing health decisions, both in appeal to the health principle of including patients’ views on their own health issues and to ensure greater adaptability of the guidelines to different contexts globally. The latter aspect is particularly relevant. Indeed, the medical and scientific community has now recognized that the " expression of gender characteristics, including identities, that are not stereotypically associated with one’s sex assigned at birth is a common and a culturally diverse human phenomenon." However, most of the expertise, studies and scientific evidence regarding tgd people actually comes from the Western world. This has forced the committee to calibrate, as much as possible, the data and results of the studies. Also, to formulate the new guidelines in such a way as to reduce their possible friction with the variety of health policy realities worldwide. Consistent with this approach, one of the cardinal principles stated by SOC8 is the “flexibility” of the guidelines themselves. Hence, the explicit invitation to healthcare professionals and programs to modify them as necessary (by virtue of particular individual situations, lack of resources, need for specific harm reduction strategies, etc.) and in open communication, in order to promote healthcare best practice of informed decision-making.

So, what about the chapter on adolescence?

The creation of a chapter dedicated exclusively to adolescence responds mainly to three reasons 1) the exponential increase in the reference rates 2) the increase in studies on the subject of this population group 3) the peculiar issues regarding individual development in this age group. Scanning the specifics regarding these three aspects, one realizes both their actual relevance and the margins of uncertainty that still surround them, not the least of which is the fact that it is still unclear how gender identity develops psycho-physiologically. With good reason, Wpath itself strongly encourages further promotion of research on the subject.

Turning to the most controversial news, the previous guidelines diversified some minimum criteria according to the types of treatment: reversible, partially reversible, and irreversible. Grossly simplifying, for affirmative hormone treatments (estrogen or testosterone) parental consent was not required, but it was assumed that the adolescent had reached the legal age for health decisions, with reference to the 16 years of age valid in many countries (especially Western ones). For (almost) all surgical treatments, however, it was necessary to have reached the age of majority in one’s own country. In the preliminary draft of the SOCs8 released in December 2021, another predefined time grid had initially been proposed, which already reduced the minimum age for different surgeries: at least 14 years for affirmative hormone treatment, 15 years for chest masculinization, 16 for facial surgery, etc. Exceptions were allowed in case of significant reasons in the treatment setting. The final text of SOC8, instead, eliminated the chronological grid altogether. The only two explicit time indications in the new “Statements of Recommendations” are that “the experience of gender diversity/incongruence is marked and sustained over time.” And in the case of surgery, that “the adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result.”

Though, the new text is much more prodigal in its exposition of specifics. The peculiarities of the adolescent period play a considerable role here. Indeed, it is not just the common perception that it is an age of great identity exploration, forward spurts and abrupt backward turns. Accordingly, the first specification states, “it is important to establish the young person has experienced several years of persistent gender diversity/incongruence prior to initiating less reversible treatments such as gender-affirming hormones or surgeries.” On the other hand, scientific studies attest that body development often proceeds in a manner that is staggered compared to cognitive, emotional and psycho-social development. In addition, individual paths differ widely: some people mature earlier and some mature later in the skills needed to confront such health decisions, regardless of their age at registry. Consistent with this, it is recommended that a case-specific, ongoing and gradual “comprehensive biopsychosocial assessment” be carried out, calibrating the progression in the provision of more or less reversible interventions from time to time, depending on the available evidence. The approach to adolescent tgd health changes, therefore, center of mass. The tool of a predefined time frame, poorly tailored to the reality of individuals, is greatly reduced, leaving more room (as well as responsibility) for case-by-case assessment by the relevant health professionals.

Regarding the, albeit legitimate, question of whether it would still not have been appropriate for the guidelines to at least set arbitrary age limits as a matter of prudence-as is done with, for example, driver’s licensing or sexual consent-three considerations, namely of a bioethical, medical-clinical, and health-political nature, should be noted. The first is that “allowing irreversible puberty to progress in adolescents who experience gender incongruence is not a neutral act given that it may have immediate and lifelong harmful effects.” In this regard, recall what has already been said about the chronic valence of gender dysphoria associated with depression, suicidality and self-harm. The second consideration concerns finding the best approach to adapt the clinical framework. “For youth who have experienced a shorter duration of gender incongruence, social transition-related and other medical supports […] may also provide some relief as well as furnishing additional information to the clinical team regarding a young person’s broad gender care needs.” Although still few in statistical terms, the best available studies report extremely low rates of “detransition” (1.9-3.5 percent), i.e., disruption and reversal gender treatment. In addition, recent studies indicate that there are adolescents who choose the detransition, but still do not regret starting the treatment, as they experienced it as part of their understanding process. Finally, the last consideration concerns the global role of Wpath and the cardinal principle of flexibility mentioned earlier. The definition of age of majority, age of consent, or the age conditions regulating access to different health services can vary greatly from country to country. For example, within the United Kingdom the age of majority is 18 in England, Wales and Northern Ireland, however, it is 16 in Scotland; in other nations it is 21, as in Madagascar, and in others it even varies according to gender as in Iran: 9 years for women, 15 for men. Therefore, in the supranational perspective adopted by Wpath, establishing a predefined time grid a priori is not fruitful.

By the same token, it may also be easy to see the sense of contemplating parental exclusion from the treatment framework in case it may be detrimental to the adolescent. Based on studies, SOC8 recognize that “parent and family support of TGD youth is a primary predictor of youth well-being and is protective of the mental health of TGD youth.” Accordingly, their involvement in the assessment and treatment framework setting process is strongly encouraged, maintaining open and informed communication throughout the process. At the same time, by virtue of the social origin of health problems in tgd persons, in the case that the parental context is overly “rejecting,” the possibility is contemplated that “youth may require the engagement of larger systems of advocacy and support to move forward with the necessary support and care.” So, it is not recommended that health care professionals have the legal power to extinguish parental custody, so much as the possibility that, by the adolescent’s request, the pertinent institutions can take charge of the adolescent’s well-being.

In conclusion, in light of the new approach to health care centered on comprehensive biopsychosocial assessment on a case-by-case basis, it is worth noting that SOC8 provides 7 minimum requirements of different kinds (diagnostic, psycho-emotional assessment, informed consent, etc.) for the beginning of any treatment, even minimal, of gender affirmation to be recommended. In addition, there are 15 recommendations referring to the health care professionals themselves, especially regarding the kind of training and specialization needed, as well as procedures and health care best practices for proper evaluative and therapeutic approaches. Above all, this is what the Gold Standard of care for adolescent and tgd health consists of.

What’s next?

All in all, no national health service is obliged to accept the new Wpath guidelines (several did not even do so with the previous ones, or only partially). Certainly, best practice in the medical-scientific field would suggest that a process of comparison, evaluation and updating be initiated at the international level by the WHO, at the level of national institutions, as well as competent health professionals-as indeed explicitly suggested by SOC8. The risk is that the chaotic and instrumental rehashing of the current public and political debate on tgd persons will end up radically contaminating this pathway. In the end, it would be (once again) the health of tgd people to pay the price. Right from adolescence.