Archive for May 20th, 2008

Public Health and Welfare (_Depletion and Abundance_ Book Excerpt)

Sharon May 20th, 2008

I’m short on essay constructing time right at the moment, and I thought it might be nice to include an actual excerpt from _Depletion and Abundance_. 

One of the central arguments I make in the book, an argument probably familiar to most of my readers, is that the things we most need to prioritize in adapting to difficult times are the things that most people say they care about most already – education, healthcare, basic security issues.  So my approach, when I wrote about health care was not to try and comprehensively answer what we should do about medical care, but to a. make the argument that this needs to be a much bigger priority in discussions of peak oil and climate change and b. say that it is possible to create a “shadow” health care system that would serve not just our needs in a future crisis, but the needs of millions of Americans who have no access to health care now.  I don’t claim to answer every question about how X condition can be dealt with, or what might or might not be available to many people, but I do try and get the ball rolling, and ask that we bring health care to the center of our discussions of the future.

It is a long chapter, so I’m going to break it up into several pieces.  Bear with me if something you think is important isn’t here yet – it may be coming up in a later post.  Enjoy!

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If you are going to deal with the issue of health in the modern world, you are going to have to deal with much absurdity. It is not clear, for example, why death should increasingly be looked upon as a curable disease, an abnormality by a society that increasingly looks upon life as insupportably painful and/or meaningless. — Wendell [ad1] Berry

“I’ve been in hospitals,” I said. “They take away your pants. Then they hurt you and starve you and expose you to disease. Then they bill you for it. A lot.” — Spider Robinson

As I mentioned in the first chapter, many Peak Oil and Climate Change activists have, as much as everyone else, tended to think that the biggest energy consumers in our lives are the places we most urgently need to focus our attention. This reasoning has led us to emphasize things like transportation and energy replacement. This is a reasonable assumption, of course. You look around and think “Where do the fossil fuels go at present?” and it seems reasonable to associate large usage with the most important sectors of our society. But if you rethink the problem, and truly get your mind around the fact that the future really is going to be very different from the present, we can begin to think about it in terms of optimization — the places where we get the most quality of life out of our fossil fuel inputs. That is, I believe we have, thus far, been asking the wrong questions about what matters.

If we were to ask “Where do we need energy the most?” we would get a very different answer. Perhaps the most bang for our fossil-fueled buck comes in health care. In fact, when anyone suggests moving to a much lower-energy society, the most disturbing and frightening thing for them to imagine losing is usually health care. When we talk about the changing economy, the question that most immediately jumps up is “What will we do about health insurance?” The shift here — from medical care to insurance — is a telling one, because right now medical care is so costly that almost no one can afford to pay for it outright. And yet, medical care in and of itself does not have to be as expensive as it is for us. The French, who arguably have the best medical system in the world, spend only half what we do.

In the coming changes, the most important things will be making sure that people can live simpler, lower-energy lives without unbearable costs. That means keeping infant mortality low and lifespans long. It means stabilizing population. As we’ve seen, to a large degree decisions about how many children to have are based on expectations of those children’s survival. In a society with a great deal of uncertainty about the future of children, we can expect rising, rather than falling birthrates.

Along with access to education and basic social welfare programs such as support for the elderly and disabled and food price stabilization, I would argue that one of the most urgent projects we can engage in is in finding a way to maintain the benefits of modern medicine in a low-energy society. And as I research this problem, I increasingly believe that this can be accomplished, that we have the resources to create a low-energy national health care — or, if our government will not lead on such a project, that states, regions or even communities can enable such a health care model.

I am not claiming that we can reproduce modern health care as we know it, or that the change will be without cost or difficulty, but I do believe it is possible to integrate a lower-energy health care system into our existing models, and that the project of doing so, besides preparing us for a crisis, might also improve the lives of the 40 million Americans currently without access to health care.

Now, just as I am not a demographer, an economist, a nutritionist or any of the other things I’ve presumed to do research on and offer analysis of, I am not a medical professional. My intent here is not to offer specific medical advice, but to jumpstart the conversation about what kind of low-impact, low-energy medical infrastructure we can have. My goal is not to end the conversation, but to begin it, and to pass on my thoughts to those who can take it further.

The Myths of Medicine

It is difficult to begin to triage the current medical system without first evaluating our assumptions about how the medical system works. I think many of us are carrying three false beliefs about medicine. They are:

1. More health care is better, and good health care must be expensive.

2. The benefits of modern medicine always outweigh the costs

3. Social good programs like health care are things you get to later rather than sooner.

The first assumption seems fairly obvious — in a world where billions of people, including millions of Americans don’t have access to health care, it would seem that if you could get all the health care you wanted, that would be better. But in fact, the data are more complex than that. For example, a recent article in The Atlantic by Shannon Brownlee, author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer[ad2] , includes the telling quote by a Dartmouth Medical School professor: “If we sent 30 percent of the doctors in this country to Africa, we might raise the level of health on both continents.”

That is, even something that seems to be as obvious a good as a large number of doctors isn’t necessarily so under the current system for a host of reasons, including the fact that multiple specialists attending to treatment often lead to confusion and errors, and that doctors tend to concentrate in wealthy areas, so that more doctors doesn’t mean better distribution of health care.

Americans spend about twice as much money on health care as Europeans do, but our lifespans are no longer and often shorter. We take more drugs than they do, endure more medical interventions at the end of our lives, report lower levels of satisfaction and happiness with our health and suffer more from anxiety and depression than people with lower levels of health care. It is also true that our present medical system is not about “health” so much as treating disease, and that a system that actually focused on preventive care, health and wellness — all much lower-input practices than our present one — might work better with less energy.

In his book Aging Well Dr. George Valliant describes tracking several groups of men over more than 50 years, including Harvard graduates and inner-city, lower-class Boston men, and notes that among all these groups access to health care was not the defining factor in quality of life or health in the senior years — basic self care and staying away from doctors was. That is,

…being able to afford better doctors, hospitals, and healthcare is unrelated to their health or longevity. “It’s not economic at all,” he asserts. “People [ad3] who go to hospitals are sicker than people who don’t. Having better doctors and hospitals is a bit like locking the barn after the horse is out. The trick is not going to hospitals in the first place.” (Valliant )

[ad4] 

Though it is obviously important that sick people have access to health care, at present only three out of every 100 dollars spent on health care in the US go to any kind of help maintaining good health, rather than to the treatment of medical problems. For example, midwife Kathy Breault observes that an increase in Caesarean sections is tightly linked to an explosion of gestational diabetes in women, which often causes very large babies that cannot be delivered vaginally. The increase in gestational diabetes is almost entirely a product of our industrial diet and sedentary lifestyle, and yet while health insurance will pay for a C-section, it will only rarely fund nutritional education or cooking classes and never pay for a babysitter to allow an expectant mother to cook a meal, shop at a farmer’s market or get some exercise.

It is important to realize that Americans have similar lifespans to average Cubans, and higher infant mortality rates, despite the fact that Cuba is a vastly poorer nation and spends about $186 per person annually on health care — compared to $4500 per person in the US. In Kerala, a state in India, lifespans are not quite the same as in the US, but they similar to those of inner-city African Americans. Kerala infant mortality rates are lower than mortality rates for infants in Cleveland or Baltimore’s inner city. That is remarkable because Keralans use one seventeenth the resources we do to maintain health.

There are other examples of “low income, high well being” nations that spend very little on health care, demonstrating that neither energy use nor expenditure is the determining factor in long lifespans and low infant mortality. What does matter is making health care and its corollary, education (the ability to obtain and make use of health information is tied to literacy levels to a large degree), a major social priority, even to the exclusion of other projects if resources are limited.

The Amish are another important example. Amish people in the US have a number of factors that would seem to place them at risk of higher infant mortality rates and lower lifespans — they receive little preventive care, eat a high-fat diet, have no health insurance, use herbal and home remedies first, and give birth to most of their children at home, using lay midwives. And yet the average Amish lifespan is virtually the same as that of the average non-Amish American, despite their spending one fifth or less on health care.

All of these examples demonstrate the simple truth that, although hospitals and medical care are energy intensive, it is not impossible to dramatically reduce our need for expensive, energy intensive medical care by prioritizing health and general welfare.

Whenever I talk about going to lower-energy usage, a percentage of people shout out something like “But that would mean going back to the stone age, to lepers walking the streets and people throwing their feces out the window on our heads!” (Okay, I exaggerate a little for effect.) But I think it is fair to say that variations on “Without power, life would be intolerable” is a common assumption, and that it is tied to myth #2 above, that modern medicine is an unmitigated good.

Now, do not mistake me — I believe that much of medicine is good. But everything comes with a price, and sometimes we simply choose not to see the price of things clearly. That is, often when we worry about the dangers of losing modern medicine and society, we see clearly the costs of not having easy access to high-technology, high-energy medical care, but don’t see, because we have assimilated into them the high costs of the medicine and the society that makes it possible.

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 Next time…more on evaluating the costs and benefits of energy intensive societies.

 Sharon