Archive for May 29th, 2008

Public Health and Welfare Part II – Depletion and Abundance Book Excerpt

Sharon May 29th, 2008

This is the second part of what will be a four part series, the excerpt on health care from _Depletion and Abundance._  You don’t have to read part one, but it will make more sense if you do:

 The section focuses on the third and fourth myths of high energy medicine.  The next two suggestions will be ways we can triage the health care system – so if you think I forgot something, it might be there.  Or it might not – this is hardly all there is to say about post peak medicine, but because so far there is so little on the absolutely essential topic, my goal is to give a broad overview and a set of broad strategies. 

 One thing I don’t talk about in the book, because I’m trying to present an overview, is strategies for relocalizing drug availability.  Obviously, there are natural alternatives, but for those for whom they are not adequate, we need a better alternative than “sorry.”  I certainly on’t tend towards an apocalyptic vision in which all medicine production disappears – instead, I tend to think that ordinary human poverty will price most of us out of the drug market, the way it already does for billions of the world’s poor.  Obviously, for those who are dependent on medicine, that’s a huge problem.  But one of the fascinating things I found in my research was that some medicines – not all, but some, could probably be made in college or high school chemistry labs, if the raw ingredients were stockpiled.  Later on, I do talk about making a couple of simple antibiotics that way (and both of them have huge downsides, so this is not a way to go unless you have to).  But several research chemists I discussed this with did say that a variety of older, simple drugs could probably be made if power were available to college or even good high school labs.  This suggests that prioritizing health care and education might be even more important, and that building relations with your local chem prof or high school chem teacher might be worthwhile for some people.  It won’t fix everything, of course, there are risks involved, and many medicines are simply not reproducable on those scales.   Which again, argues for collective action and strategies to make sure that basic medications are available.


The Costs and Benefits of Modern Medicine

In considering the second myth, the first thing we need to do is establish what gains from modern medicine we have received. Our intuitive response to modern medicine is to exaggerate our need for its input in many cases, or exaggerate its benefits compared to the alternatives. By this I mean that modern medicine and modern industrial life do enable us to treat some illnesses better than others but also cause or enable other illnesses to occur more frequently. Were we suddenly to experience a catastrophic energy shortage (something I do not view as especially likely, but will use as a model here), like that which struck Cuba during the special period of the 1990s, we would likely see some illnesses increase and others almost wholly disappear.

Among the medical concerns we would not see, or would see infrequently in a low-energy, relocalized, sustainable society, would be death and injury from car accidents. Right now, 1 million people die annually worldwide from car accidents, and another 7 million are injured or disabled. Car accidents are the leading cause of death for people under 25

Illnesses we would probably see less of in a low-energy society include all communicable illnesses, including things like flu, colds, SARS, and other airborne diseases, particularly those originating in other nations (fewer people traveling means less disease transmission). We would also experience fewer “lifestyle diseases” such as high blood pressure, heart disease, strokes and type two diabetes. All of the illnesses brought on by poor diet and sedentary lifestyle would certainly be reduced. In fact, in the aftermath of the special period in Cuba, a significant rise in lifespan was seen because of increased exercise and better diets.

We would also probably see fewer medically induced deaths. A study released by Health Grades, a private medical quality control group, suggested that in 2000, 2001, and 2002, an average of 195,000 people died from in-hospital medical errors. The study suggested that this number is double previous estimates. In addition, the hospital environment, including inappropriate use of antibiotics is responsible for the spread of “superbugs” such as MRSA, which has now escaped the hospital environment and is showing up in schools. A recent study in the Journal of the American Medical Association suggests that the US has 95,000 MRSA cases per year, of which approximately one out of five is fatal. More people die in the US from MRSA than die from HIV. Though it is probably too late to eradicate some of the superbugs already created, a lower input health care system, used less often, would create fewer opportunities for superbugs to evolve and escape into the general populace.

Over the longer term, much lower emissions of pollutants, industrial toxins and carbon would make a huge difference [ad1] in reduced levels of cancer, autism, birth defects, neurological disease, asthma and lung disease, among others. As far as I know, no one has yet run the numbers to calculate the total net gains and losses here, but I mention this mostly to observe that we pay an enormous price for our lifestyle, and yet we tend not to think of it in those terms. We tend not to think of the sudden death of a family member from a heart attack or a child’s cancer as part of the cost of our society — we tend to think of it in isolation. But when we envision change, we tend to see the full costs of that difference[ad2] .

There would be costs, in terms of lives, in a lower-energy medical system. If we anticipate that we could manage many essential treatments, but that high-input items such as elective surgery, helicopter evacuations, defibrillators in every public building and other high-energy medical investments might be less available, some people would suffer and die. There is no question of that, and it is not something that should be minimized or elided. But it is important to remember that some people who would have died in a high-energy society would not suffer and die in a lower-energy one, and that too should not be minimized or elided.

Why Health Care Should Be At the Center of Things

The third myth is the one that says that we must focus on the economy, on rail systems, on everything but health care. Underlying this assumption is the belief that if we’re headed for disaster, it is self-evident that we can’t provide universal health care. After all, we don’t have that now. But we cannot allow that to be a barrier.

Instead, I wish to make the case that we absolutely must focus our energies on health care — to the exclusion of other projects, if necessary. The national discussion on universal health care has focused so far only on creating “perfect” modern models — that is, systems where everyone can have as much unconstrained access to treatment of illness as they want. In fact, when universal health care is proposed, the notion that any kind of constraint of access might occur is the single most effective negative argument. How many times has each of us heard the claim that if we had universal national health insurance, we might have to wait for surgery?

But if we imagine a national health care service [ad3] that focuses on maintaining health (as opposed to treating sickness), on delivering basic preventive care as widely as possible, and on investing in the health care measures with the greatest possible benefits for longevity and public health at low cost, we might be able to create a model that could co-exist with any national health insurance plan and, until/unless one is created, could serve the existing needs of the 40 million Americans currently without health care. Such a system would reduce the death rate from lack of health care access (18 million people die each year because of insufficient access to health care). Right now, many insurance programs simply will not pay for preventive measures. For example, my midwife friend Kathy Breault notes that she has difficulty getting insurance reimbursement when she vaccinates for the HPV virus, which causes cervical cancers, but no difficulty getting payment for expensive tests once a patient has an abnormal pap smear.

And if we were to look more carefully at the Amish, the Cubans, the Keralans, we might find a model of health care sufficiency that is an optimization of the best of the modern and the low tech, and we might begin to make decisions more wisely about how to expend our energy and financial resources to keep people healthy.

By “sufficiency” I mean the notion, advanced by Professor Thomas Princen, that instead of seeking out market-based efficiency solutions, we might find a principle of “enough” that can be widely applied. Some Americans have far too little access to medical care, and some have far too much. The notion of restraint and optimization in health care, up to now advanced only in the service of HMO bottom lines, might be used, instead, to create an adequate health care system that might serve people’s needs, rather than market needs. What Princen calls “enoughness” seems to be a real phenomenon in health care, available to us in the light of other societies that use less health care, use it differently, and still obtain the same positive results.

The examples of Cuba and Kerala, both poor places that have elected to preserve health care and social welfare above all else, even in times of crisis, should point out what is possible for us. Going into this crisis, our society as a whole is probably going to do some things to adapt while leaving others undone. I write this book in the hope that we will have a model to work on if we are left with the burden of doing the work that governments left undone, of making do from where we are, but also in the hope that we will begin to prioritize our remaining resources as Cuba and Kerala did, even if times get very difficult. Historically, that has not been the American way — when times get hard, we ration basic needs like food, shelter and health care by price, leaving a large segment of the population’s needs unmet. But we could alter that.

Now, both Cuba and Kerala have roughly socialist economies, and it would be easy to leap to the conclusion that I am calling for socialism here or that socialism is a necessary prerequisite to providing health care in an increasingly impoverished society. Neither is true — I believe all useful economic models are hybrids of multiple philosophies, and I hold no particular allegiance to a single economic model. Moreover, I don’t believe that using government resources to tend to the well-being of one’s populace is a socialist project — any more than using government resources to support a war machine is.

If we pay taxes for any reason at all (and sometimes most of us wonder), it is that government should meet the needs of ordinary people. Right now, I think most Americans of all political stripes would agree that it is not doing so. And any analysis of health care must begin, for example, with the fact that the American military budget is twice the military budget of all other nations together, and that what we have spent on the war in Iraq would provide lavish health care many times over. Yet I’ve never met an American who thinks that the war in Iraq is a better investment than health. It seems self-evident to me that this is not a question of Marx versus Adam Smith, but a question whether government should serve the people or the government — something I think we can get an easy consensus on.