Crafting Resilient Health Systems: An Introduction
During the 20th century an indispensible yet unrecognized factor allowed the health sciences to attain dizzying levels of organizational complexity and achieve countless life saving and prolonging breakthroughs. The health professions drew upon ever-increasing amounts of human and natural resources, particularly energy. For example, energy’s significance was overlooked because –save for a few periods of scarcity deemed anomalous or political contrivances- its main supplies –the fossil fuels natural gas, oil, coal- seemed infinite and its cost trivial. Therefore, the complexity of modern health systems and their accomplishments are an epiphenomenon of economic expansion made possible first and foremost by natural resources; only secondarily are they reflections of capital and labor expressed through human intelligence, drive and ingenuity. The era of cheap and plentiful energy is over and this has profound implications for the health sciences and modern world.
Industrial economies –despite spin and statistical massaging from governments- are contracting, not because they are in “recession”[i] but due to ecological overshoot[ii] and reaching the limits to growth.[iii] Ironically, the health care system in the United States continues to expand –however, public health financing has been in decline for about a decade- as if ecologically induced macroeconomic decline will soon reverse. Medicine is in essence betting it can go on claiming more resources as net energy inputs[iv] available to society dwindle and the economic pie shrinks.[v] To state the obvious: if we are in ecological overshoot and at the limits to growth something’s got to give.[vi]
This series of essays explores what to do about this through the following questions, “What kinds of health systems –dentistry, public health, medicine, nursing, pharmacy, and allied fields- are feasible in a world forced to adapt to ecological overshoot and reaching the limits to growth? And, equally important, what needs to be done to create these systems?”
To answer these questions we must begin by noting that the health professions are dependent upon larger social, political, cultural and economic institutions; and these larger institutions and systems are in turn made possible by the earth’s resources and located within –not outside of- its biosphere. In other words, all human economic activity traces back not to economic theory guiding private investment and public policy, but to nature.
As this is written, in summer 2012, these human systems –and institutions- continue to move heaven and earth attempting to restart growth without acknowledging let alone contemplating the natural resource and biophysical constraints to which they are subject. If this insight, that humanity is part of nature, were fully appreciated the economic contraction that is occurring and creating political, social and financial instability would make sense and point to a sustainable way forward for humanity.
Virtually all leadership in the health sciences and in the master systems and institutions they rely upon believes that market forces combined with technology and appropriate governmental policies eventually will provide Gordian Knot solutions to end the so-called recession. This confidence is in my view myth-based and virtually impervious to logic, data and argumentation.[vii] It is, however, being whittled away at by accumulating corporeal experience.
For those of us presumptuous enough to think we see through this mythology the experience of doing so is eerily voyeuristic and simultaneously distressing to witness the hubris, mounting ineptness, destructiveness and desperation of those exercising institutional power. They do not realize the danger inherent in prolonging and thereby widening the mismatch between the prevailing political/economy –call it end state capitalism, free market capitalism, crony capitalism, corporatism, globalization, neo-liberalism, kleptocracy, creeping fascism, and so forth- and thermodynamic and ecological forces.
In the health sciences the opportunity to play a visionary role in facing the wrenching revolution underway remains unrecognized and is slipping away.
Characteristically, at this point a writer should offer a hopeful scenario in which health sciences leaders would realize humanity’s dilemmas and pilot the transformation of consciousness and activity necessary to overhaul the health system. This could happen, but it is highly improbable. As a cohort health professionals –especially leadership- are imbedded in the perquisites, political intrigues, mythology, institutional ruts of thought and psychology of perpetual growth, and all the derivative beliefs and cognitive biases that this commitment spawns.
I keep lines of communication open because epiphanies can occur for individuals, if not for institutions.[viii]
For instance, I sent the dean of a school of medicine, who has commented on some of my work, the following reflections on his recent “State of the Medical School” address to his faculty and staff. I offer it here as, first, an open invitation to those in the health sciences who know something is profoundly out of sync and, second, as an insight into the status quo-bound worldview of the medical profession.
A recurring theme of his talk was how the “economic crisis” was affecting his medical school. For instance, he noted that before 2007 grant proposals stood a 32% chance of funding approval and now that has fallen to and astounding 13%.[ix] He thanked his faculty for working tirelessly to write grants under these grim circumstances and said he was looking for new sources of grants and other funding support. His basic message to them: Stay the course; this recession will end. Here is an excerpt of my email to him.
Dear Dean _______:
“The Great Recession” is in fact the front end of human economic activity reaching the climax phase of resource exploitation in an ecological niche. It signals the end of growth and the beginning of a perilous transition to a no-growth economy. In sum, the market and belief in endless growth are (erroneous) social constructions of reality, not reality itself. Properly understood, economic reality rests on a foundation of biology, ecology, and physics.
Once this realization occurs our human ingenuity can be properly channeled to live within the bounds of the biosphere.
Let me end with a few points on what those leading the health professions can do.
- Stop trying to grow; it’s now counterproductive since any “growth” is in fact another claim on declining energy and resource availability. This means that we no longer have the energy inputs to maintain, operate and expand the economy; that’s a central reason why we’ve got a real unemployment rate of 17%.
- Start thinking actively about how to contract and consolidate medicine, nursing and public health (but public health may have to be expanded as medicine contracts!). This is a massive topic, with profound ethical implications and hydra-headed health challenges posed by a shrinking world economy. It needs the attention of great minds.
- Develop a vision for medicine, public health and nursing in a contracting world. For instance, I ended the article I sent you two years ago like this: “The nation will be forced to downsize medicine, treat health care as a public good, and educate the citizenry about public health.” I suggest this is where we are inevitably headed, so why not –like some forms of martial arts- merge with this force?
My experiences over the past several years have led me to conclude that the health sciences lack resilience and are highly likely to be forced into chaotic contraction. I now see that the impetus and work to create a post-growth health system will come from below and outside the current system; in some scattered places this is already underway. Some on the inside will join in as the crisis sharpens their perception of social-ecological realities and weakens their ties to the faltering growth-based system.
Here is a truncated version of how I arrived at this position:
- At a peak oil conference held at a school of public health several years ago the professor leading the discussion said to our group, “We’ve got to have arguments designed to convince ‘The Man.’” At that time I was skeptical of this suggestion but said nothing in rebuttal. Suddenly I felt startled and said myself, “Like it or not, it is what I’ve been doing.”
- If we ask what The Man has done regarding the issues I’ve raised here, the answer is, to cite a few of endless examples, he’s sponsored Potemkin policy performances such as the Durbin and Copenhagen Climate Change Conferences and the Rio+20 Earth Summit. Rio+20 was convened with no major political leaders present while the G20 heads of state met at Los Cabos, Mexico to continue their (futile and counterproductive) efforts to “rescue the world economy.”
- The Man does not grasp the links between ecology, finance and economy; he will not discuss them because in his world these connections do not exist. He is unperturbed by the collapse of the Greek health system –as part of the collapse of the entire Greek economy- for at least three reasons. First, it is occurring in the name of a ritualistic chastising -“austerity”- to ignite long-term growth and, second, due to the (socially constructed) moral imperative, “you must repay your debts.”[x] Third, it is to preserve the prevailing hierarchy of wealth, status and power, where finance appears to sit atop the fulminating social pyramid.
- The Man represents what Occupy Wall Street has successfully labeled the 1%, and George Monbiot ruefully refers to as the purveyors/profiteers of “the consumption machine.”[xi]
- A New Yorker cartoon from earlier this year captures The Man’s public policy orientation with a speaker saying to an audience, “We have to address the dangerous gap that has emerged between the rich and the super-rich.”
- The Man’s power appears formidable, and at present it is, but only to destroy and suppress change; and his legitimacy is waning. He cannot lead us into the future.
Now that I’ve labeled The Man as a hazardous anachronism, to whom is this series addressed? The small –at present- yet critical portion of the population that understands the social-ecological predicament humanity faces is my general audience. Those within this audience who are or will become concerned with protecting the health of their communities are my specific audience.
Not everyone aware of our dilemma will choose to work directly on building a viable health system. Some will choose to devote their time to other equally critical activities: political reform, crafting local economies by building local agriculture, transportation, sanitation and energy systems, or to rethinking the role and place of education; and the arts will play a sublime role in reintegrating human consciousness with the natural world. I hope to learn from them and acknowledge their contributions as this work, which is a movement towards forming a coherent body of knowledge necessary to build viable, resilient health systems, takes form.
My audience holds or will entertain these beliefs.
- A post-growth health system will be vastly different (less social and technological complexity and reduced natural resources throughput is assured) from what currently exists –in all industrial nations, not just the USA.
- Laboring to build sustainable and resilient health systems will be guided by and in turn reinforce cultural values and a mythology organized “to achieve greater social equity and economic security in ways that reflect biophysical reality.”[xii] This new social reality will emerge through the interplay of action-in-the-world and contemplation; and it will supersede the crumbling mythology of growth.
- Although initial efforts may seem desultory and inchoate and meet many barriers, they are part of the process of having to act, learn and craft in the face of opposition, confusion, fear, risk and uncertainty.
By implication, I’m arguing that as public health and health care funding declines, along with society-wide economic contraction, sundry and profound instances of ecological devastation, and shortages of once taken-for-granted natural resources, those health systems leaders who continue to wait for a return to growth will become increasingly irrelevant and unable to understand the emerging social-empirical world.
Those who arise to protect the health of the population –not excluding those current health leaders capable of change and adaptation- will be able to explain and illustrate through their actions how and why “small is beautiful,” how to achieve a lot with little, and offer a vision of the post-growth world that overcomes the natural dread of the new and unknown. In short, they will have an unprecedented opportunity to shape the emerging social world. Importantly, creating a workable and lasting post-growth health system is a piece of larger efforts to create community sustenance, resilience, and solidarity; and to renew such forms of community as Gemeinschaft[xiii] and faith in the rule of law.
The opening up of opportunity for institutional change does not guarantee an egalitarian and communitarian outcome; nor does it automatically signify a descent into barbarism, feudalism or other hierarchical forms of tyranny. Further, a population dieback could simply overwhelm all egalitarian visions as well as the Mad Max scenarios science fiction has to offer. Let us above all else strive to give all people the chance to fashion this new world.[xiv]
Let me close this introductory essay by stating that “the specifics” of what to do about the set of crises, dilemmas and predicaments is gargantuan. We confront conundrum-like questions we must answer -if only provisionally so as to act- if we are to know where to spend our time and allocate precious resources. Here are a few examples.
- How will the decline of the current world unfold?
- In a steady slow unwind?
- In a stepwise punctuated decline?
- In a sudden collapse?
- Some chaos-drive interplay of the above scenarios?
- At what point will there be enough of a change in collective consciousness for a widespread (cultural) consideration of the idea that we’re at the end of growth?
- What if this shift in social awareness does not occur or occurs very late? (Of course, it’s already very late.)
- How much change, that is, how much loss of complexity in our institutions is required?
- What levels of government are sustainable?
- For instance, there are at least three political/economic scenarios for the possibilities of a resilient health system:
- Nation-state remains
This will be exhausting; it is possible those of us in middle age or beyond are no more than transitional figures. So I’m trying to play this as an invigorating latter-life game where I carve out my role as a complement to that of competent “youngsters.” Finally, I promise not to be dogmatic unless bedrock ethical issues are involved. This is too unprecedented a challenge for anyone to claim encyclopedic expertise; beware of those who do.
[i] On the one hand, one could say the recession we are in is caused by ecological overshoot/reaching limits to growth. That is, without growth it is no longer possible to support a predatory financial debt-based economic system. However, the connotation of “recession” is that the economy should once again “pick up,” that is, return to growth. Rather than a recession, therefore, this is an ecologically “normal” contraction of economic activity brought by the overexploitation of natural resources.
[ii] Catton, William R., Jr. Overshoot. Urbana: University of Illinois Press. 1982.
[iii] Meadows, Donella, et al. The Limits to Growth: The 30 Year Update. White River Junction, VT: Chelsea Green Publishing.
[iv] I am referring to the concept of how much energy is expended to extract energy from the earth, also know as, EROEI, EROI or net energy. There is a substantial literature on this topic, and it is typically dismissed or misunderstood by those with economic blinders on who think a new era of oil production is on the horizon.
[v] Many who label themselves members of the political left or progressive movement believe that the limits-to-growth is a red herring issue. For them all scarcity is contingent upon invidious social class relationships and economic growth is taken-for-granted in their vision of the future.
[vi] President Obama’s Affordable Care Act leaves health care in the control of profit-making corporations. I believe this to be an unsustainable arrangement. See: Marcia Angell, “Did John Roberts Give Mitt Romney A Gift?” Huffington Post, June 29, 2012. http://www.huffingtonpost.com/marcia-angell-md/roberts-romney-health-care_b_1637397.html?utm_hp_ref=politics. See: Physicians for a National Health Plan, “’Health law upheld, but health needs still unmet’: national doctors group.” PNHP, June 28, 2012. http://www.pnhp.org/news/2012/june/‘health-law-upheld-but-health-needs-still-unmet’-national-doctors-group. See: Dan Bednarz and Jessica Pierce, “The Ethics of Sustainable Healthcare Reform.” Health after Oil, August 28, 2009. http://healthafteroil.wordpress.com/2009/08/28/the-ethics-of-sustainable-healthcare-reform/.
[vii] This is why we have an endless stream of “experts” coming forward to claim that “the data” show that peak oil is not a problem. In fact, peak oil is a central driver of the collapse of modern economies and finance. See: the website Economic Undertow for an articulation of this premise. http://www.economic-undertow.com/.
[viii] Mary Douglas, How Institutions Think. Syracuse: Syracuse University Press. 1982.
[ix] For a lucid example of the faith in growth consider the increase in schools and colleges of public health since 2000. The number went from approximately 28 to 49. This is in the context of shrinking grant-funding opportunities, which are relied upon to support a high percentage (50% -80%) of faculty salaries. This epitomizes Field of Dreams magical thinking: “If you build it, (the money) will come.”
[x] Graeber, David. Debt: The First 5,000 Years. Brooklyn: Melville House. 2011.
[xii] Rees, William. “The Way Forward: Survival 2100.” Energy Bulletin, June 22, 2012. http://www.energybulletin.net/stories/2012-06-22/way-forward-survival-2100.
[xiii] Wikipedia. “Gemeinschaft and Gesellschaft.” Wikipedia. http://en.wikipedia.org/wiki/Gemeinschaft_and_Gesellschaft.
[xiv] De Young, Raymond and Thomas Printz. The Localization Reader: Adapting to the Coming Downshift. Boston: MIT Press. 2012.
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