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1. The wellness and health management in the ideological framework of Jeremy Rifkin

Bruno Corda Angelo Barbato

Jeremy Rifkin is one of the world’s most recognized economists who in his recent work^{1 2} has stressed the progressive rise of a new economic system, gradually alternating and replacing capitalism. The engine of this transformation is the digital revolution, allowing the internet of things. Telecommunications’ Internet of things (or, more properly, the Internet of Things or IoT), is a neologism referring to the extension of Internet to the world of objects and concrete places³ . The internet of things is made up of a network between the energy internet, the communication internet and the logistics internet⁴ . Rifkin summarizes his economic thinking in three basic paradigms (energy, communications and logistics), stating that in the evolutionary change of these archetypes, man becomes the star of a new industrial revolution.

The first industrial revolution (about 1760-1870) was an economic transformation process or industrialization of society in which the agricultural and craft-trade systems became modernized and industrialized. Characterized by the generalized use of power-driven machines and of new, inanimate energy sources (such as fossil fuels - steam engines), the scheme was favored by a strong component of technological innovation. This was additionally accompanied by the phenomena of growth, economic development and profound socio-cultural and even political changes. This first industrial revolution began in the textile (cotton), metallurgical (iron) and mining (hard coal) industries.

The insurgence of the second industrial revolution (about 1870-1970) is conventionally set to 1870 with the introduction of electricity, chemicals and oil.

The third industrial revolution (1970) refers to the effects of mass introduction into industry of electronics, telecommunications and informatics⁵ .

In recent years a new generation of scholars and specialists have began to realize that the management and centralized control of commerce is giving way to peer production and horizontal distribution. The scale of property exchange on the market is becoming less important than access to goods and services on the network. Additionally, conscience is rising around the social capital as true economic value rather than the market capital.

The main result will be a more equitable society based on sharing and cooperation between citizens and a sustainable economic model, particularly from an environmental point of view.

The new paradigm will lead to a progressive market decline as we know it today, parallel to the development of a sharing economy based on the cooperation of the consumer who meanwhile also becomes producer (prosumer). This is the first new economic system to make its appearance since the birth of capitalism and socialism at the beginning of the 1800. A free economy is emerging, a mix between capitalism and collaboration. In 2050 Jeremy Rifkin predicts that capitalism will still exist, but it won’t be the sole economic system. Young people today collaborate with all sorts of things, produce and share their videos, their music, their news.

Online training courses are open and free, all this with marginal costs equal to zero. In fact, when producing a video, the marginal cost to distribute it to a billion people is virtually zero.

We're starting to see a new economic system in which there aren’t only producers and consumers, owners and workers but also prosumers; millions of people who access the Internet platforms of things and are able to produce, consume and share any virtual service: news, knowledge, music, video. We are bypassing the great twentieth-century organizations at almost zero marginal cost: free of charge, in abundance and outside the market. This is a revolution.

What will happen to Multinationals?

Many of the big and vertical ones of the twentieth-century have already been destroyed, as has happened, is occurring and will continue to take place in the music and video industry, in editorials and in television.

At the same time, thousands of other new companies have emerged in the economy of sharing. Not just Google, Facebook and Twitter, but thousands of profit and nonprofit companies that are building the sharing economy, thereby enabling young people to share what they create.

It 'a very destructive process to the market economy as we know it today, but it is only the beginning of a revolution towards the democratization of economic life.

Germany is leading this revolution, and even small countries like Denmark and Costa Rica are doing well. Germany is ahead in the internet of energy with 27% of the energy produced by sun and wind. It will be over 35% by 2020 and 100% by 2040. The costs of technologies for energy production are significantly reducing as has happened in the computer industry. A solar watt costed $ 150 in 1970, now it’s charged 64 cents and it will drop to 35 within 18 months. Once Germany has paid off the investment expenses, the marginal cost of energy produced will be close to zero. The sun and the wind do not send any bill to be paid to the Germans. It's free. Germany is heading towards an energy system at zero marginal cost that will make the economy more productive and efficient in the world, hugely benefitting its businesses and families.

China, too, has begun to change its energy policy with investments starting at 82 billion dollars in 2015 to digitize the electric grid smart. Millions of Chinese will be able to produce solar and wind energy in their home and share it in the national electricity grid.

In electrical engineering and telecommunications, a smart grid (intelligent network) is the combination of an information network and an electrical distribution network in a manner allowing to manage the power grid “smartly”.

Precisely the "intelligent" characteristic must be highlighted under various aspects or features as the efficient distribution of electrical energy for its more rational use, minimizing any overloads and variations in voltage around its nominal value⁶ .

Digital smart grid is a concept which, carried from the power supply, will be increasingly developed in the computer network connections. This has implications not only for Wi-Fi, broadband and big data. It is needed to move towards the trend of digitizing the three major paradigms of the economy: energy, communications and logistics (including transport systems).

There are no longer virtual or natural boundaries facing the great global problems such as population growth, food resources, over-exploitation of land resources, pollution of the planet and consequently uncontrolled problems at the limit of survival , of space and of the biosphere’s balance. These represent problems towards which consciousness is growing, issues we can no longer postpone, or worse, ignore.

A new global and social consciousness is inevitably making its way, demanding a complete change of paradigms. Vertical and power relations will gradually give way to relations of cooperation and sharing of forces.

Empathy and assertiveness, keywords of sharing and collaboration, will integrate the necessarily narcissistic, closed and conservative communities of all sizes and places.

As masterfully described by Jeremy Rifkin, history shows that a shift in energy, communication and logistics represents the dawn of a substantial economic revolution in all societies of the world. Consequently, as always happens during great changes, it is crucial for the future of society to seize the opportunities of such shifts, renewing and adapting their inner world to a new global vision. At present, the history of man and of civilization has reached a global dimension.

The paradigmatic events of the third industrial revolution described by Jeremy Rifkin have produced the greatest evolutionary acceleration in human history. As always, it is up to man to know how to seize new opportunities. The faster man makes this happen, the deeper and more aware the willingness to change themselves will be.

The first big change is radical, the gradual transition from a self-centered individual awareness to an open and multifocal collective. In summary, the ability to combine oneself with others and with the surrounding world is needed. This three-dimensional view, which effectively defines the so-called biosphere consciousness is the new interior condition absolutely necessary to be able to rapidly take advantage of the great benefits that this revolutionary global process can generate.

Not knowing how to seize this great opportunity, or worse, not wanting to participate in the change can result in unfavorable social events, which are already perceivable, if not visible.

History is continually proposing this.

Individuals and companies are therefore becoming increasingly collaborative, more involved, more empathetic, more attentive to the world in which they live in. The change will impact our lives more rapidly the more we are active participants.

This will happen in the production of goods, but above all in the collective sphere of relations, so-called services. First and foremost, is health, where the value of empathy is one of the anchors of the modern conception of the doctor-patient relationship.

The doctor-patient relationship has always been the cornerstone and the centerpiece of the "cure" process in all its stages, from prevention to diagnosis to therapy.

In some national contexts, such liaison has gradually shifted towards the establishment of mathematical sterile space protocols of production chain in the Health "Companies", sometimes operated by speculative organizations. These companies are both public and private. Speculative, in this context, because the “enterprises”, rather than focusing on the "production of health", end up feeding themselves and their survival.

Why are the delivery systems for health care services continually reviewed? What is constantly changing? Why do public health systems tend towards privatization and not vice- versa? Why is an important profession such as health care more than any other at the centre of debates and controversies? Why is one of the most important services that every state should give priority to so different from country to country?

The evolution of society has gradually shifted its focus to the level of the hierarchy of needs, as has inevitably been the case also for one of the basic services organized for citizens in modern societies, "health protection".

Today, the close individual-environment connection is undeniable, seeing the correlations between environmental degradation and health risks. This awareness has been gradually triggering growing consciousness and the culture of prevention.

The environmental crisis, the crisis of health and the crisis of values are closely linked and interdependent. The system responds to the request for health with an increasing number of expensive and technologically sophisticated performances; trying to modify the natural history of "disease", which in itself already implies "lost health”. Neglecting, instead, primary prevention which is to be made both on the polluted and unhealthy environment around us, as well as on individuals, accompanied by an appropriate policy of information and health education in search of a more simple and sustainable lifestyle.

Ethical and social values are sometimes contrasted by economic value, hence the need to make the health system sustainable while ensuring conditions of equality and universality.

All countries in the world are committed to finding answers for the enhancement of its citizens’ health.

Various countries, principally the developed ones, have established health care management models essentially of two types: a predominantly public model named Beveridge after the Englishman who at the end of World War II brought public insurance coverage to the United Kingdom, the "National Health Service"; and the Bismarck model, which takes its name from the Prussian/German statesman who introduced the private health insurance system.

Different countries have tried, even with customizations, to adjust such organizational models to the ever-changing demand for health, in the variable environmental and economic contexts, in order to maximize their population's health.

In the 90’s, the World Health Organization altered the attention level of health protection systems, shifting attention from the treatment of diseases, to seeking the psychological well-being of individuals and the environmental determinants of health.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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