Online Course: Building Sustainable Health Systems: The Essential Role of Public Health

In spring semester 2011 the Institute for Sustainability and Post-carbon Education at Bristol Community College in Fall River, Massachusetts will offer an online course titled, “Building Sustainable Health Systems: The Essential Role of Public Health.” The premises of this course are that 1) the structure and content of public health, medicine and nursing will be deeply transformed as society reaches the limits to growth and 2) public health is critical to all socioeconomic localization and community building. The course is designed to allow public health professionals and members of the community to work synergistically and strategically as ecologically mandated social change emerges.

Crucially, acting on the reality of reaching the limits to growth runs antithetical to the received paradigm of health care and public health, whose guiding metaphor is that the macro-economy naturally and perpetually expands and will, therefore, facilitate the continual increase of funding for healthcare and public health. In other words, virtually all health research, theory, policy analysis, and practice (mistakenly) posits a growing tax base provided by an expanding economy.

In this course we begin with the counter-premise: that government resources for public health will continue to contract for the foreseeable future and are likely to never again increase unless other commitments, like military spending, various subsidies and tax breaks, and bank bailouts, are curtailed or scaled down.

Thomas Kuhn’s book, The Structure of Scientific Revolutions, elucidates how and why awareness of the need for paradigmatic/meta-theoretical change is resisted in scientific communities; it also covers how rival paradigms emerge as problems accumulate that the dominant paradigm cannot solve. This crisis phase of paradigmatic breakdown is now beginning throughout society and, it follows, in the health sciences. Consistent with Kuhn’s analysis, the consequences of crashing into the limits to growth are being ignored or misunderstood. The longer this goes on the worse will be the wrenching changes mainstream public health –as well as medicine and nursing- will undergo even as the society it serves and is dependent upon also writhes.

Nearly all of the professionals we know in the health sciences –and especially the frontlines of public health- are consumed by pressing endogenous problems like a lack of resources to meet mounting threats to health stemming from economic contraction. Many leaders we have spoken with recognize that if the economic crisis does not end soon their work will be disrupted; yet they fail to see that this is not a temporary recession but a crisis of sustainability rooted in ecological and thermodynamic realities that do not respond to political machinations or economic nostrums. In sum, the dominant strategic response is that of “weather the storm, the sun will come out tomorrow.” However, some frontliners are responding “cyberneticly” in that they are questioning the dominant solution-less growth paradigm. Nonetheless, our conversations indicate that for the vast majority the idea of society and their profession reorganizing around reducing the consumption of natural resources is either absurd or a Pandora’s Box better left untouched.

Complementing Kuhn’s logic, this set of reactions is similar to observations by Joseph Tainter and Jared Diamond that collapse is hastened by a cultural incapacity to grasp that the very beliefs –perpetual growth and increasing complexity are always good and inevitable- that led to the ascendance of the culture are now exacting costs that hasten its collapse.

An example of this inward fixation is illustrative. Recently one of us attended a talk by a senior medical school administrator on how to coordinate the array of health professions providing for the care of patients. During the Q & A session one of us asked, “Have you done scenario planning for how the current bundle of exogenous crises, economic, fiscal, the end of cheap energy, global warming, and so on, mesh with the endogenous concerns you raise today? In other words, we may be hitting the limits to growth –and that means socioeconomic and political change that will deeply affect medicine.” He tilted his head and cradled his face in his fingers, thought for a long moment and said, “You know, that never occurred to me; I’ve never thought about that.”

We have organized this course around what we believe is the central policy question this health administrator –serving as a personification of the health sciences lack of awareness- will be forced to contemplate: “How can the nation’s health be protected as socioeconomic contraction progresses?”

At the cultural level the pursuit of unending growth is no longer the magic elixir but now is the source of our illness. The Federal Reserve and government cannot restart growth unless they become modern day alchemists able to create energy –to do work and create tangible wealth- from money. This is the insight our society is presently some psychological distance from gaining.

A simple translation of this meta-reality of limits to growth into the context of public health is that we face two generic classes of risk:

To the social determinants of health: the conditions in which people are born, grow, live, work and age. One need not look far for examples: 42 million on Food Stamps; 7 million jobs lost in the past 3 years; people facing heat-versus-eat choices this winter; widespread and growing lack of health insurance; the so-called “entitlements” endangered.
To social and technological complexity and the overall operation of public health services, given that service delivery requires –like all systems- energy and other (processed, embedded, and manufactured) physical resources to function. Main example: declining public health budgets in a context of increasing need for services.

The course has these teaching objectives:

Illustrate how modern public health’s mission and domain activities have evolved over the past century.
Explain how this history lends itself to building sustainable public health systems.
Outline the threats to public health, divided into
1. Those that endanger population-level health and
2. The viability of modern public health systems.
Present scenarios for the future of public health
1. Becoming sustainable through
  1. i. Resource conservation and reductions in complexity
  2. ii. Building an organic professional-community relationship
    1. Think voluntary fire departments as one example
    2. Disseminating public health information through the community, much as was done 100 years ago when the role of “germs” in disease was discovered and led to modern public health. In this era it will be the “discovery” of humanity’s place in the biosphere.
    3. A focus on defining public health as lodged within healthy ecosystems.
  3. Attempting to continue business as usual
Illustrate (through interviews) with public health administrators and local community builders
1. The dimensions of the ongoing sustainability crisis
2. Actions now being undertaken to make public health sustainable
Present a tentative model of what a viable public health system looks like focused on a systems understanding of “supply-side sustainability.”[i]