Wednesday, October 18, 2006

Public Health: Slow Motion Disaster

Of the four aspects of our deindustrial predicament I outlined in a previous post – fossil fuel depletion, economic contraction, declining public health, and political dysfunction – public health has received far and away the least attention from the peak oil community. This is ironic, to use no stronger word. I’ve argued at length elsewhere that the energy shortages and economic breakdowns sometimes claimed as causes of imminent industrial collapse will play out instead over decades of unsteady decline, and taken a certain amount of heat from apocalyptically minded peak oil theorists for that. Here, though, the shoe is on the other foot. Though it’s all but unnoticed outside of a small cadre of worried professionals, the disintegration of public health in coming decades promises a disaster in slow motion.

It’s not surprising that this particular crisis has gotten so little air time. Public health is one of the least regarded, though among the most necessary, of the basic services industrial society provides its citizens. It’s not exciting stuff. Sanitation, pest control, water treatment, food safety regulations, and the like are exactly the sort of humdrum bureaucratic activities that today’s popular culture ignores most readily. Even infectious disease control rarely achieves the level of intensity chronicled, say, in Randy Shilts’ history of the AIDS epidemic, And The Band Played On; more often it’s a matter of collecting statistics, tracing contacts, and sending emails to local officials and hospitals in the certain knowledge that most of the recipients will just hit the delete button. On these pedestrian activities, though, rests the industrial world’s relative freedom from the plagues that visited previous societies so regularly and killed so many of our ancestors.

The impending collapse of public health, like most aspects of our current predicament, has an abundance of causes. One is the failure of government at all levels to maintain even the very modest support public health once received. Lacking an influential constituency in the political class, public health departments far more often than not came out the losers in the tax and budget struggles that dominated American state and local politics in the last quarter of the 20th century. Worse, food safety regulations were among the consumer protections gutted by business-friendly politicians, with results that make the headlines tolerably often these days.

A second factor in collapsing public health is the end of the antibiotic age. Starting in the early years of the 20th century, when penicillin revolutionized the treatment of bacterial infections, antibiotics transformed medical practice. Dozens of once-lethal diseases – diphtheria, tuberculosis, bubonic plague, and many others – became treatable conditions. A few prescient researchers cautioned that microbes could evolve resistance to the new “wonder drugs” if the latter were used too indiscriminately, but their warnings went unheard amid the cheerleading of a pharmaceutical industry concerned only with increasing sales and profits, and a medical system that became little more than the pharmaceutical industry’s marketing arm. The result has been an explosion of antibiotic-resistant microbes. The media not long ago announced the emergence of XDR (extreme drug resistant) tuberculosis in Africa and Asia, adding to the list of microbes even the best modern antibiotics won’t treat.

A third and even more worrisome factor is the impact of ecological disruption on patterns of disease. As the number of people on an already overcrowded globe spirals upwards, more and more of the earth’s wild lands come under pressure, and microbes that have filled stable ecological niches since long before our species arrived on the scene end up coming into contact with new hosts and vectors. HIV, the virus that apparently causes AIDS, seems to have gotten into the human population that way; Ebola and a dozen other lethal hemorrhagic fevers certainly did, along with many others. At the same time, global warming driven by our smokestacks and tailpipes has changed distribution patterns of mosquitoes and other disease vectors, with the result that malaria, dengue fever, and other tropical diseases are starting to show up on the edges of today’s temperate zones.

Add the impact of fossil fuel depletion on these three factors and the results are unwelcome in the extreme. In a future of soaring energy costs and crumbling economies, public health is pretty much guaranteed less access to local government budgets than it has now, meaning that even the most basic public health services are likely to go by the boards. The same factors make it unlikely at best that pharmaceutical companies will be able to afford the expensive and resource-intensive process of developing new antibiotics that has kept physicians one step ahead of most of the antibiotic-resistant microbes so far. Finally, ecological disruption will only increase as a world population dependent on petroleum-based agriculture scrambles to survive the end of cheap oil, and the likelihood that many countries will switch to coal means that global warming will likely go into overdrive in the next few decades.

The inevitable result is the return of the health conditions of the 18th and 19th century, when deadly epidemics were routine events, childhood mortality was common, and most people could expect to die from infectious diseases rather than the chronic conditions that fill the “cause of death” slot on most death certificates these days. Factor in soaring rates of alcohol and drug abuse, violence, and malnutrition – all of them inevitable consequences of hard economic contraction – and you have a situation where the number of people on the planet will take a sharp downward turn. Statistics from Russia, where a similar scenario played out in the aftermath of the Soviet Union’s collapse, suggest that population levels could be halved in less than a century. This doesn’t require massive epidemics or the like; all it takes is a death rate from all causes well in excess of the birth rate, and that’s something we will certainly have as the deindustrial age begins.

The role of modern medicine in these transformations is complex. Especially in America, but not only there, economic forces long ago turned the theoretical triumphs of scientific medicine into a real-world fiasco. For well over a decade now, medical care has been the leading cause of death in the United States – add together the annual death toll from iatrogenic (physician-caused) diseases, nosocomial (hospital-transmitted) infections, drug side effects and interactions, risky but heavily advertised elective surgeries such as stomach stapling, and simple malpractice, and the resulting figure soars well above the annual toll for heart disease, or cancer, or anything else. As economic decline puts mainstream medical care out of reach of most people, death rates from these causes will drop correspondingly, and at least in the industrial world this may cushion the impact of the factors just discussed for a while.

Many people are already voting with their feet by abandoning conventional medicine for various alternative and traditional forms of medicine. Even when these don’t work – and of course some of them don’t – placebos are at least less likely to cause harm than the toxic drugs and invasive surgeries that form the mainstay of today’s conventional medicine. Many alternative health care systems, on the other hand, treat common illnesses quite effectively. Another factor, though, makes alternative methods much better suited to the coming deindustrial age than scientific medicine. Today’s medical system is among industrial civilization’s most voracious users of energy and natural resources; almost without exception, alternative medical treatments use much less of both. Many of the most effective alternative systems – herbalism and acupuncture come to mind – evolved long before the industrial system came into being and use very modest amounts of sustainable resources to treat illnesses. In an age of energy scarcity and hard ecological limits, systems like these are the wave of the future.

The tangled roots of the public health crisis make it a particular challenge to prepare for on an individual basis. Some things can certainly be done. A solid knowledge of first aid, nutrition, sanitation, and basic nursing procedures will go a long way. Sensible eating and healthy exercise are essential, though today’s obsessive pursuit of fashionable thinness needs to be jettisoned; people before the petroleum age, when reserves of body fat played a vital role in survival, tended to be plumper than current fashions allow, and a return to 19th-century standards of normal weight is as necessary as it is inevitable. Those who learn and practice effective alternative health care methods will be at a distinct advantage, and may also find themselves with a marketable trade.

Still, in the absence of effective public health measures, even the best health care – alternative or otherwise – will have its limits. No medicine can take the place of adequate sanitation, pure water, clean and wholesome food, and the other foundations of public health so many of us take for granted nowadays. All these things will be in short supply in the deindustrial future, and so illness and death will be a constant and familiar presence. Learning to live with that reality will also be an essential skill in the twilight of the industrial age. We will no longer be able to afford the fantasy that death is something that only happens to other people – and in the process of coming to terms with our own mortality, we may just learn something essential about being human.


Jan Steinman said...

How dysfunctional is the US health care system? In some ways, the schmuck with a job and insurance gets worse health care than those further down the economic ladder! How weird is that?

I'd been without routine health insurance for nearly twenty years before moving to Canada this past spring. I was healthy, and I knew that I had four magic words that were good for a discount of 50% or more on health care: "I don't have insurance!"

My regular doctor routinely charged me $50 cash for a visit that normally cost an insurance company $120 or more, and she filled bags with drug samples for me, making my effective prescription "co-pay" $0. I'm pretty healthy, and made use of this every other year or so, if I got a bad sinus infection, or a nasty cut got infected and wouldn't heal well.

But more amazing is what happens with something more serious. Due to a ruptured disk (L1-S5) and near-paralytic pain, I could not be seated or standing for more than a few minutes for eight whole weeks in 2001. Why eight weeks? That's how long it took me to get an appointment with a back "specialist." And they say Canadian medicine is slow!

When I finally saw her (after waiting a half hour, lying on the cold tile floor, my butt hanging out of the ridiculous examination garment), she gave me a quick neuro exam, left me hanging out for another 15 minutes, then came back.

"We think you're an excellent candidate for surgery!" she announced with obvious delight upon gracing me once again with her brief presence, as if this were good news.

So this was the time to put my four magic words to the test. Could I get a hefty discount on surgery? Would she throw me out on the street? Would I ever walk again? I swallowed, and nervously said, "I don't have health insurance!"

"Well, we can try something more conservative before we try surgery," she said, and put me on a week's course of oral steroids.

After three days, I was noticeably better. At the end of the week, I was perhaps 85% better. I still have some permanent numbness on the back of my thigh and the outside bottom of my foot, but today I'm perhaps 98% as good as ever. This past summer, I built stone foundations and cob walls, so I'm no cripple.

I never saw that doctor again, but she did call to see how I was doing. "If I had gotten in to see you sooner, might I have avoided permanent nerve damage?" I asked. She mumbled and hedged, but I think so -- when she said I needed surgery, she said it needed to happen fast, to avoid further nerve damage. How much "further nerve damage" occurred in the eight weeks it took to see her? She wouldn't say.

So my four magic words cost me about $50 in pills, and saved me perhaps $10,000 in surgery -- not to mention a dozen weeks of recuperation. Is this a great country, or what!

With that experience, the election disaster of 2004 (I'm talking about Oregon's Measure 37, not the idiot in the White House), and a sober assessment that the US is not a very good place to practice voluntary simplicity, I emigrated to Canada this spring. I have yet to test the health care system here, but for the first time in twenty years, I have full-coverage health insurance -- for under $50 a month per person for my spouse and I.

Jan Steinman said...

(Oops! My link to a story about Oregon's Measure 37 was fubar in the above story. This link should work better -- I've tested it!

I consider the take-over of local politics by moneyed interests much more insidious than anything that happens in Washington, DC.)

RAS said...

Once again you have written an excellant post. I too expect the death rate to soar due to the return of many old foes and the collapse of industrial health care. I also think that after a period of time things will get better again -after all, plumbing and sanitation were in use in certain places as far back as Rome, and even Crete! They certainly had no electricity or industrial medicine, but did a good job with both issues.

Adrynian said...

Excellent post, as usual!

A solid knowledge of first aid, nutrition, sanitation, and basic nursing procedures will go a long way. Sensible eating and healthy exercise are essential...

Absolutely! They are *key* preventative and basic curative measures for any good health care system. The developed world seems to have forgotten this in favour of fancy & expensive procedures and equipment, with the corresponding result that we are facing, for the first time in centuries, a *drop* in the life-expectancy of the next generation (even without considering PO, CC, etc.) due to poor nutrition and sedentary lifestyles that result in obesity, diabetes, and their many consequent diseases.

While many of my American friends out there might not like to hear it, Cuba is actually a great source of "how-to" information for developing a system that provides low-cost, (relatively) low-energy health care (i.e. life expectancy on par w/ the US for, I believe, ~1/100th the cost per capita). They had to learn to make due when the USSR collapsed and took their oil imports with it.

Their response was to fund largely preventative medicine, to hugely increase the supply of doctors per capita (which consequently reduces their cost as per supply & demand), and to support decentralized agriculture and urban gardens (so people would have a source of fresh, nutritious vegetables to make up for the loss of factory-farmed food). (The exercise they got just by not being able to drive their cars around anymore.)

That's not to say it was easy. Far from it: for almost a decade after the collapse of the USSR, calories consumed per capita by Cubans were *far* below where they were before its collapse and only recently did they recover to 'healthy' levels (although they're still below pre-collapse levels). (As a side note, limited caloric restriction can be beneficial insofar as it can extend your lifespan by somehow inciting a survival reflex in the body's biochemistry.)

There is a really good artical about it (minus the bit about the benefits of limited caloric restriction) in a previous issue of "The Ecologist" magazine from the UK. It may be available online; either way, when I get home I'll post the issue#.

taran said...

While your critique of modern medicine is certainly warranted, I think it is important not to dismiss the many achievements made by "scientific medicine" in favor of alternative medicine. To be sure, alternative medicine has its value, but when it comes to repairing broken bodies and saving lives in critical condition, nothing in alternative medicine can remotely compare to modern medical practice. In fact, so many of today's problems in modern medicine have little or nothing to do with the practice of medicine. As long as profit margins dictate the relationship between doctor and patient we will have a dysfunctional heath care system.

For the future, I see no reason why "scientific medicine" will not continue in the age of peak oil. The difference might be that we pay our doctors with chickens!

Minnesotan-with-a-view said...

This reminds me of the statements by population control advocates - Humanity must either decrease our birthrates or nature will increase our deathrate to compensate.

I remember getting a tour of our local water works years ago and seeing a poster on the wall, showing the rates of some illness around 1900 before and after the new water treatment plants were built - details lost but looked like an inpressive score for "technology"!

On one hand, it would be nice to follow the "young male" approach to healthcare - do WTF you want, and what doesn't kill you makes you stronger, and no thanks to doctors.

On the other hand, we know A LOT more about diseases now than 200 years ago and knowledge is power, so maybe at least in basic hygene, we'll survive long enough to make a few wise choices.

Back to the first hand, if bugs evolve, maybe humans must also, and that means returning to reality some of us just don't have the "right" genes to survive the coming diseases, however capable we are in other measures of success...

Adrynian said...

The immune system doesn't really fight most diseases by having "good genes", so that argument is rather fallacious. Its actually more like a learning system where, by exposure over a person's lifetime to various viruses and bacteria it builds up a "database" of "known" infectious "forms" (e.g. the protein coatings on many viruses, etc. that let them fool our T-cells and whatnot into not killing them off right away). A mother's body and early childhood exposure to dirt are important sources of information to the learning immune system at first - which is why you shouldn't keep too clean a house: your kids will just wind up with allergies to everything if they don't get a chance to eat some dirt.

Unfortunately, bacteria and viruses have evolutionary time-scales measured in as little as weeks or months, or at most years. Since humans don't breed until they at least hit puberty (at ~12, and for the past several generations we've been breeding later so now the average reproductive age is more like 25-30) this means the evolutionary time-scale for humans is measured in, at minimum, decades, if not centuries. In a situation like that, no matter how "good" our genes are, viruses and bacteria will *always* find chinks in our genetic armour. There are so many more of them and they have so many more chances to adapt to every adaptation we make that it simply boils down to a matter of probabilities, and the probabilities favour the microbes, not us.

Having said that, I would like to address this "social Darwinism" that you're espousing. Basically, it's toxic. I'm not saying that some people can't have "better" genes than others - for example, some people have a much lower predisposition to cancer or depression. But even in these cases, the environment plays a *huge* role in helping to determine how those genes get expressed and whether or not those predispositions will manifest (look up GxE, i.e. Gene-by-Environment, interactions in biology). For example, even the best genes in the world won't protect you from the radiation damage and consequent cancer you will suffer if you handle refined plutonium, and even a predisposition for depression can be overcome given a healthy environoment.

Saying some people have "bad genes" is no excuse to attempt to justify what are frequently political decisions to consign often ethnic minorities or the lower classes to suffer Mother Nature's justice - which is just an atheistic version of the idea that the successful are really God's believers, aka the righteous, while those who suffer really just deserve it for being heathens, unbelievers, or sinners (only in this case, people deserve their fate for having "bad genes"). This is nonsensical crap that masks the real economic and power inequalities that frequently motivate such diatribe in an attempt to justify those very real and deadly inequalities, while undermining any attempts to raise peoples' awareness of them, to promote compasion and consideration of others, or to actually address these inequalities in a proactive manner.

No matter how good or bad your genes are, it will be primarily the poor and ethnic minorities who suffer from a constrained healthcare system, and most of this could be avoided with universal access to proper sanitation measures, basic first aid, healthy food, and plenty of exercise. You can't excuse or justify sickness on the basis of "bad" genes; you can't justify it at all, because even in a "Third World" country like Cuba, people can have high life expectancy and a healthy lifestyle if the political will to make it happen is present.

Adrynian said...

The issue of "The Ecologist" that I was referring to in a previous post is June 2005 (older than I thought) and the article is titled, "Cuba: Health without Wealth".

Interesting statistics from the article:

USA (doesn't have Canada)

Population: ~293mil
Area: ~9.6mil (sq. km)
GDP per capita: ~$36k
Infant mortality (/1000): 6.5
Life expectancy: 77.43

Docs/Patients Ratio: 1/352
Aids cases (/1mil): 241.2
Immunization of 1yr-olds: 95%

Vehicles (/1000): 815


Population: ~11mil
Area: ~110k (sq. km)
GDP per capita: ~$3k
Infant mortality (/1000): 6.3
Life expectancy: 77.04

Docs/Patients Ratio: 1/170
Aids cases (/1mil): 7.3
Immunization of 1yr-olds: 100%

Vehicles (/1000): 23

I'm not calling Castro a saint by any stretch of the imagination, but these are some pretty impressive stats for a developing country. It just goes to show what political motivation can do when it's directed towards helping people rather than making war or helping the rich get richer - and I'm not claiming Canada has been any better about this lately, either; we've been resting on our laurels for years.

Adrynian said...

A brief note: perhaps a better example than handling refined plutonium where good genes wouldn't stop someone getting cancer might have been sun-tanning every day or eating foods contaminated with PCBs. Good genes may hold it off for a while, but unless you're one in a million, a high-risk environment will still eventually result in you getting cancer. (Actually, I'm not sure of the real probability, but I'm fairly certain that it's small enough that those peoples' genetic contribution to the next generation won't have a very significant impact on the genetic quality of the general population - especially with all the man-made, bioaccumulative, and/or non-degrading toxins that have been released or spilled throughout industrialism - and especially in the past century - that are now just waiting around for the opportunity to give practically *everyone* cancer, eventually.)

Mark said...

Another lucid post. You're building up to a book at this rate.

I posted a comment a few weeks back when you mentioned healthcare. Conventional medicine certainly is completely dependent on fossil fuels and specialised knowledge.

Herbalism and Acupuncture are very well placed to step (or re-step) into the role of primary healthcare. Once again the local wise woman or herbalist will be much in demand. I believe this, along with fresh organic, locally grown food and wholesome labour in strong communities will increase health levels for those lucky enough to live in that situation.

I would like to make the case for an unmentioned health care system which similarly does not require unsustainable inputs of energy and is extremely effective in the right hands: Homeopathy.

In 1800 Homeopathic practitioners and colleges outnumbered those of the conventional school in the US. In the 1830's, Austria lifted their ban on Homeopathy due to its effectiveness in a Cholera epidemic. It is in the epidemics of the past 200 years that Homeopathy has shown itself most visibly as remarkably curative, including the Spanish 'flu of 1918.

Here's an article which recounts the history of Homeopathy in epidemics.

There has been a very effective suppression of Homeopathy in the west, especially in the US. It's medicines are controversial. But instead of inspiring scientific curiosity after 200 years, it has instead been the object of derision and predjudice -- and with good reason, since the principles it works upon, if affirmed, would upset many powerful vested theories and interests.

My ongoing experience and those of many I know is that it works and does so more curatively than conventional drugs and any population would be very well served by the "big 5" of Herbalism, Acupuncture, Homeopathy, Chiropractic & Osteopathy.

Thanks John. Looking forward to your next post.


Adrynian said...

I'm wondering what will happen to contraception once oil-derived products and services become scarce. I've only seen this mentioned occasionally at Energybulletin and elsewhere, but it seems crucial to stabilizing world population levels, yet we may be facing a future without conventional contraceptives (e.g. primarily the pill & condoms). I've only sort of heard about herbs that might be able to perform an abortive function, but even then, my understanding is that it's a dangerous risk for the woman, not even mentioning the moral outrage among some people if one even suggests the possibility.

Contraception is a key component to any future without continual population booms, overshoots, & busts, along with female education (i.e. empowerment), and a basic social safety net (so people don't think they need to have 6 kids so some will be around to support them when they're older). The only other option is abstinence, and let's face it, evidence shows that's failed everywhere it's been tried.

Eligere said...

Mark, I started trying a few homeopathic remedies (over the counter items)and have found at least one -- a sinus formula -- quite effective, and with none of the side effects of conventional otc medications.

John Michael Greer said...

As usual, a flurry of thoughtful comments. I'll respond to just a few of them.

Adrynian, the example of Cuba is indeed relevant, and for more reasons than you mention. There, as in many other parts of the world, being a physician is a middle-class job with modest income prospects; prices are low because there's an ample supply of physicians, and medical costs aren't propped up by insurance and government regulation.

Taran, you're quite correct that many of the core problems with today's mainstream medicine have to do with its social and economic context, not the practice itself. At least two aspects of scientific medicine -- sanitation and wound surgery -- are likely to be kept by the medicine of the future, simply because they work better than the alternatives.

As far as modern medicine continuing into the deindustrial age, though, I suspect it won't, for two reasons. First, it takes exorbitant amounts of energy to maintain the infrastructure that makes modern medicine possible, and that won't be available -- especially when there are other, low-energy healing modalities competing with it. Second, modern medicine is developing such a negative reputation that I suspect, once the AMA can no longer call on the legal system to suppress alternatives, a very large number of people will think of today's conventional medicine roughly the way people today think of being treated with bloodsucking leeches.

Mark, I could have mentioned quite a few other health care modalities as well; by not mentioning homeopathy I certainly didn't mean to exclude it! I use biochemic cell salts, an offshoot of classical homeopathy, as one of the mainstays of my own health care, and have had excellent results with it. The one challenge homeopathy faces is that nearly all homeopaths these days get their medicines from a handful of international producers, and that won't be viable when transport costs start rising out of control. There used to be homeopathic pharmacies that compounded their own remedies in most large cities. That will have to come back if homeopathy is to survive.

Mark said...

Hi John,

The tissue salts are a wonderfully simple and effective sequence of remedies - I use them myself (I'm using Kali Mur right now for a cold).

Modern homeopathic remedies tend to be concentrated in the hands of a few large companies because it is only at that scale that the production of remedies becomes profitable enough to pay for the regulatory processes that Homeopathic medicines often have to undergo in order to become officially available.

However, due to the exponential nature of the ascending potency scales, only a tiny amount of the original substance is required to ensure a supply of that medicine for the lifetime of the practice.

Hence by purchasing medicating potencies of the "Polychrest" (major) remedies from a conscientious company such as Helios in the UK, the only issues remaining are skill, glassware and clean water. Alcohol and sucrose pills would be good but optional.

There are 200 or so Polychrest remedies, many are northern hemisphere plants, like Arnica, Calendula and Bellis Perennis (daisy). Others such as cuttlefish ink (Sepia) or more obscure minerals might be tricker.

Anyway, thanks for addressing a completely overlooked part of the Energy Descent story. Homeopathy and other holistic therapies do brighten up the picture of rampant disease & ill health that some, on the more survivalist end of the spectrum, tend to paint.

In fact, communities with this knowlege are more likely to thrive and will have something essential to trade. Perhaps the re-emergence of Druidic style apprenticeships in health and other lore will be the appropriate outcome for a more sustainable (and healthy) post-peak culture.

Jason Godesky said...

Brilliant! All I can do is add a note for "anarcho-herbalism and herbo-primitivism."

John Michael Greer said...

Mark, thanks for the homeopathy info. I just hope those with an interest in preserving the art are listening. As for Druid apprenticeships, we're already on it -- healing with natural methods is one of the elements of AODA's training program.

Jason, thanks for the kudos. I'm not sure what to say about the, er, "anarcho-herbalist" essay, though. The basic notion that it's crucial to return to a mode of health care dependent on local resources and personal skills is crucial, but I wonder about the historical knowledge of somebody who claims that people are hard to rule if they do their own health care -- neither Roman emperors nor medieval barons seem to have had the least trouble maintaining their power, despite the fact that their subjects did usually take care of their own health. It's almost always a mistake to generalize from the present case to history in general, since cheap abundant petroleum has had impacts no previous resource base has ever managed.

Marcy said...

Regarding genes: I don't think it's Social Darwinism to talk about genetics, b/c everybody is different, and they are susceptible to different things, and it's genetic.

Things like dandruff, acne, and athelete's foot. Those bacteria and fungi are EVERYWHERE. But not everyone has those conditions.

And there are people who are immune to malaria due to certain factors which are inherited, like sickle cell trait or being Duffy antigen null (for any blood bankers here), etc.

So, genetics DOES play a role. And even when there were epidemics, not everyone died. And not everyone who is exposed to something actually gets sick from it. Some of that is environmental, sure (good diet, adequate rest, etc.), but not all of it is.

I think a basic understanding of how our bodies work, a basic understanding of microbiology, and good hygiene will keep us in good stead.

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