Catch Me If You Can: Mafia’s Infiltration into Italy’s Healthcare System

Catch Me If You Can: Mafia’s Infiltration into Italy’s Healthcare System

Mariarita Piraino
8 Feb, 2024

This blog joint second place winner of the 2023 winner of the Bill Tupman Prize, submitted in partnership with the ECPR-SGOG Summer School.

Essential to millions of Italians, healthcare has not gone untouched by the Mafia’s ever-diversifying business models and influential reach. Rather, inadequate controls may leave an opening for the corruption of the Mafia to extract criminal proceeds from the vital system. As seen in the case of Matteo Messina Denaro, the system has also been used to mask the identities of Italy’s most-wanted.

The Long Run of Stragismo bosses in Italy.

During the years 1992-1993, known as the years of Stragismo’ the Cosa Nostra in Sicily orchestrated the infamous assassinations against anti-mafia judges Giovanni Falcone and Paolo Borsellino.

The attack on Judge Falcone involved the use of 500 kilograms of explosives, which detonated on a section of the highway connecting Palermo airport to the city. This horrific act resulted in the death of the judge, his wife, and four members of his security. The bombing on Via D’Amelio targeted Judge Borsellino while he was visiting his mother when a car, loaded with explosives, exploded, claiming the lives of pedestrians and security agents.

The Cosa Nostra attack targeted prominent state figures who dedicated their lives to fighting the Mafia, each making significant contributions to Italian jurisprudence and establishing a stronger anti-mafia legal framework. In fact, the legal structure that has been established over time has implemented and strengthened sentences for the crime of Mafia association, as outlined in Article 416 bis. Thirteen years after the massacres, many of the perpetrators and instigators of the attacks were handed sentences of life imprisonment.

Among the few remaining to be captured was Matteo Messina Denaro, also known as ‘U Sicco’ or ‘Diabolik’, who headed a local Mafia clan and held relatively high-ranking positions within the Cosa Nostra. Whilst other mafia figures were arrested, Denaro went underground.

In 1993, he was included in the list of the ten most wanted fugitives in the world, remaining on that list for almost 30 years until the day of his arrest on January 16, 2023, which took place inside a private clinic in Palermo. During his extensive time in hiding, he succeeded in building a network of personal protection and contacts that allowed him to maintain a low profile until his capture.

The work of the investigators was thorough, and for years they tried to create a hostile environment around the boss by arresting his accomplices – just as they had done to capture the notorious Cosa Nostra boss Bernardo Provenzano. Furthermore, the interception of the boss’s family members allowed investigators to discover that Messina Denaro was ill. Through checks on the healthcare system databases, they were able to identify a list of suspicious patients, including a certain Andrea Bonafede, a relative of a friend who had helped the boss and had undergone liver surgery at the Maddalena Clinic in Palermo in 2022. However, on the day of the visit, Bonafede was at home, and the booking of a chemotherapy session in Bonafede’s name initiated the raid (for greater detail, ‘La Cattura. I misteri di Matteo Messina Denaro e la mafia che cambia, by Lucia M Palazzola).

Not Longer Just Cement, Olives and Lemons

After the arrest of Matteo Messina Denaro, the Carabinieri of the ROS (Special Operations Group) are dismantling the network of supporters who helped the fugitive in his daily life: his sister Rosalia who managed communications and finances, the doctor Alfonso Tumbarello who provided prescriptions and concealed the patient’s identity and Andrea Bonafede who acted as a frontman, and others as well.

Critically, particular scrutiny was aimed at the role played by the doctor, Alfonso Tumburello, and the fact that he was arrested in a medical clinic. His arrest, opened up a vital and relatively recent debate about the relationship between the mafia and the healthcare system in Italy.

Criminal organisations, far from the abstract concept that the term “mafia” tends to evoke, have the ability to adapt to the various markets they infiltrate, while always pursuing the same economic objectives. Therefore, although the field of healthcare is more sophisticated and different from traditional infiltration markets, Cosa Nostra has also adapted to this different context.


In Italy, healthcare has always been of particular interest to organized crime due to the significant economic resources that need to be managed both at the public and private levels. However, the presence of organised crime in the national healthcare system is not only of an economic nature but also has deeper historical roots.

A reference can be made to the case of Dr. Michele Navarra, who exploited his position in the 1950s for economic and political reasons. The healthcare sector was, and still is, capable of providing numerous benefits that are difficult to condemn but have a strong impact on the local population, the electoral system and economic revenues.

Furthermore, since the 1990s decentralisation of powers in Italy, the appointment of healthcare personnel has been influenced by the interplay between the healthcare sector and politics.

A Vulnerable System

When referring to personnel within the healthcare system, mafia infiltrations involve a much broader range of actors. These include appointments conferred by political bodies (such as the appointment of the general director), as well as administrative and healthcare directors or even managers of facilities and operational units. In the Italian public healthcare system, regional political appointments of general directors of Local Health Authorities can sometimes result from improper negotiations involving internal or external interests to the system.

This practice can compromise objectivity and transparency in the selection of general directors as candidates who satisfy political or other interests may be favoured, rather than appointments made on the basis of competence and professional merit. It is important to note, however, that not all political appointments are improper or inappropriate.

However, when they are made without an adequate selection process based on competence, the integrity of the healthcare system can be compromised.

Another risk factor is the outsourcing of public contracts, including the collection and disposal of hospital waste, meal preparation and distribution, cleaning, security, and laundry services, as well as centralized booking centres, payroll processing, accounting, and funeral services. In fact, another significant weakness in the healthcare system is the tendency to rely on complementary services provided by external suppliers. Indeed, the healthcare system is exposed to episodes of corruption, further increasing its vulnerability to forms of external criminality, especially of a mafia nature, due to a regional regulation that nevertheless leaves the possibility of infiltration into the national health system.

Indeed, these administrative inefficiencies are often attributed to certain regional healthcare systems, which can indirectly facilitate both internal and external criminal conduct within the sector. This can be partly attributed to the excessive bureaucracy that characterises public healthcare. These inefficiencies allow criminal organisation to gain social consensus in various ways: from employment to subsidies, from the failure to collect fees to securing political candidacies or support, contracts and even public services.

Of course, the relationship between healthcare and politics is necessary as the National Health System is based on the possibility for all citizens to access necessary care. However, the boundary between the two spheres is very delicate, and therefore, stronger controls and a more guaranteed meritocratic system could help prevent possible mafia infiltrations. Therefore, it is imperative the Italian healthcare attain a better equilibrium, protecting the country’s critical services from excesses of political power and the threat of Mafia involvement.

Mariarita Piraino is a PhD candidate in organised crime studies at the University of Milan. Her current research interests focus on illicit drug and firearms trafficking, dynamics of transnational organised criminal groups and their relations with terrorist organisations.

Main image Credit: Carabinieri Handout courtesy of the Caribinieri. 

The views expressed in this article are those of the author and do not necessarily reflect the views of RUSI, ECPR, Focused Conservation or any other institution.