Friday, December 29, 2006

Of leeches & midwives?

What will be the implications for medicine and health care following peak oil as we slide down the oil and energy downslope into a low-tech/no-tech world?

The leap forward in health care and medicine in Europe and North America as we moved into the then high-tech world of the industrial revolution and the Victorian era was earth-shaking. Medicine came of age, became a science and a profession and an industry driven by methodical research and development aided by amazing new advances
in chemistry, diagnostic procedures and instrument technology. It was still, by our modern standards, crude and seemingly barbaric in many ways. But those new developments opened the door to the modern high-tech medicine that has become such a vital driver to the improvements in general health we enjoy today.

The impact in the last fifty years that modern medicine has had on saving and extending lives has been little short of miraculous. The incidence of infant deaths in this country has dropped from twenty-six per thousand live births as recently as 1960 to under five today. The average life expectancy has climbed from sixty-eight to over eighty-one years in the same time. Procedures such as bypass surgery and organ transplants have saved countless thousands of lives over the past few decades. New medicines and gene therapies have given us life-extension control of many formerly terminal conditions. In these past fifty years decreased infant deaths, improved medical survival rates and increased life expectancy rates have helped the human population triple to over six and a half billion people. And all of this has been achieved in the developed nations with a piddling 278,000% increase in the cost of providing health care since the end of WWII. That is two-hundred-seventy-eight-thousand percent.

Data released by the Canadian province of British Columbia show that in 1947 the province expended 1.2% of its annual budget on providing health care at a cost of $4.6-million. Fifty- eight years later in 2005 providing health care services was consuming 35% of the province's annual budget for a total outlay of over $12-billion. ( Even with a tripling of the province's population that is nearly a 1000-fold increase in the cost of health care services per person. Health care budgets have mushroomed by 400-1000% every ten years over this interval.

And yet there seems to be no end in sight, no suggestion of cutting back or slowing down. There are always new diseases to conquer, new disabilities to overcome, new medical conditions to bring under control, new surgical procedures developed around emerging technology, new surgical justifications based on newer and better diagnostic capabilities. A recent medical technology article suggested that if we totally eradicated arthritis, which the article suggested was possible, we could add another 35 years to the average life expectancy. That's a little over four months. But at what cost? And to what benefit?

The dozen or so most developed countries in North America and Western Europe expend more directly and indirectly each year on health care and medicine than the combined GDP of the fifty poorest nations on the planet. Clearly these expenditures do not benefit all peoples equally, and seemingly never will. While the average life expectancy in these wealthy nations is increasing by about 1 year every five years the life expectancy in the poorest third world nations is steadily declining. The medical technology of which we are so proud and on which we are so dependent has not yet become the medicine of the people. It remains the medicine of the wealthy.

But how much of our general improvements in health are due to these miracles of medicine? It is widely acknowledged and proclaimed that the greatest impact to human health and longevity since the Victorian era has been in the areas of hygiene and nutrition. This would seem to be born out by the wide disparity between rich and poor nations in life expectancy and infant mortality rates. This pattern is also borne out in the wealthy developed nations with the disparities in infant mortality and life expectancy between the poorest and richest in our own society. This, of course, begs the question that if our improved longevity has been so critically dependent on hygiene and nutrition why have health care budgets exploded by over 250,000 percent in the past fifty-eight years with only very marginal improvements (and in many cases declines) in general health?

One of the clear though debatable answers is that our affluent lifestyle is killing us, offsetting some of the gains that would have been made by those grotesque budget increases. Obesity, and especially childhood obesity, and the health risks associated with it has reached epidemic proportions. Health problems associated with chemical toxicity, such as the alarming increase in childhood asthma, childhood diabetes, childhood arthritis, and more, are increasingly a major contributor to our skyrocketing rises in health care costs. The costs continue to rise for treating diseases and medical conditions due to smoking, drugs and alcohol and other substance abuse. And the preponderance of our health care efforts and costs continue to be directed toward cures rather than focusing on or even encouraging prevention and mitigation.

What has all of this to do with peak oil? Simply this. As we pass peak oil and peak energy all of that medical technology will at first get increasingly more expensive and then start to go away, become increasingly unavailable. The health care disparity between rich and poor nations and rich and poor people will begin to narrow until, eventually, there will be no gap at all. Our modern medicine is critically dependent on high technology and that technology is critically and still increasingly dependent on the high consumption of energy from research to application. The energy on which it depends is becoming increasingly expensive and soon will become increasingly unreliable and increasingly unavailable. We saw in New Orleans after Hurricane Katrina hit how useless that technology becomes when the energy supply goes away. We saw how poorly trained and hard pressed the medical practitioners were to adapt to the reality of having to practice medicine without the support of that energy hungry technology. If we look at the state of health care in poor third world nations today, and if we remember the realities of New Orleans in the wake of Katrina, we get a glimpse of the level of health care we will over time be sliding toward on the energy downslope. When the grid goes away emergency generators kick in. When the emergency generators go away reality kicks in.

The impact on medicine of the approaching decline in oil, other fossil fuels and other sources of energy goes far beyond the visible and obvious things like MRI machines, CAT scans, X-ray equipment and laser surgery equipment. It will affect the cost and availability of energy to separate air into its component parts like medical grade oxygen, the availability and production of the plastics and the high purity metals from which medical implements are manufactured, the equipment for screening blood supplies, the ubiquitous electronic equipment that monitors patients' vital signs, the air ambulances that shorten that critical time to get seriously injured and ill patients to treatment facilities, the high tech ambulances that are never more than a few minutes away, the home treatment and support equipment that allows patients to get the treatment they need in the home environment, the anaesthetics, the antibiotics and sterilization products that are so critical to disease management in hospitals, the EKGs and other equipment in your family doctor's office. All of these things and so much more are critically dependent on that steady, reliable flow of energy that we have come to take so much for granted in our modern world.

The impact on all of these things won't have the immediacy of flipping off a switch. We won't suddenly wake up one day and find ourselves in the hands of witch-doctors treating our medical problems with leeches, potions and incantations. We won't suddenly have to call on a midwife when the baby is due, though an increasing number of women are choosing that approach today. Society will, for some time, continue to try to absorb the escalating costs of health and medical care. In peak oil discussions, however, it has long been suggested that among the first casualties
on the other side of peak oil will be those who are medically dependent, those dependent on medical technology and on high-tech medications. When escalating cost is replaced with increasing scarcity, however, when dependability gives way to an increasing decline in reliability and availability, the impact will begin to be felt across the totality of our society. At some point even the rich will no longer be able to get the best health care because money will not be able to get what is no longer available at any price.

We are beginning to see the leading edge of these problems even today. It is getting beyond just the horrendous escalation in cost. Wait times are increasing for surgery, much of it critical, and even for getting an appointment to see the family doctor. An increasing number of smaller communities no longer have resident
doctors, patients having to travel ever-increasing distances to doctors in other communities, many relying on the services of circuit doctors who visit their community at ever-widening intervals as these doctors must serve an ever-growing number of communities. Medical and surgical electives are no longer as readily offered or approved as they were even ten years ago. Doctors and nurses are increasingly having to work longer hours, see and deal with more patients, and more and more mistakes are happening as a result. The cost of medical malpractice insurance is skyrocketing beyond the reach of many doctors. The shortage of doctors continues to grow as older doctors retire and fewer and fewer young people choose to pursue medical careers in the face of the workloads and the cost of malpractice insurance and lawsuits. This is all indicative of a situation that will deteriorate ever more rapidly over the coming decades.

Consistently in election after election when polls are taken health care is at or near the top of people's lists of concerns. We no longer view good health as an aberration but rather as a right. If we are to continue to enjoy good health into and beyond the energy decline we are going to have to refocus on those areas of prevention that were so key to health improvements in the Victorian era, hygiene and nutrition. An ounce of prevention, says the old saying, is worth a pound of cure. When that pound of cure is no longer available that ounce of prevention may be the only road to good health still open to us.


Anonymous said...

I agree that we need to prepare for post-peak medicine. I've bought a couple of basic health care reference books, such as "Where There Is No Doctor", which is currently used in third-world countries, but I figure it will be useful everywhere after oil depletion really kicks in.

Dr James Barson, ASPO Australia said...

You raise some interesting points in your discussion.

The issue of how to sustain health care in the age of energy descent is huge problem and it is very poorly appreciated by the medical profession, administrators, politicians and the public.

The Health Sector Working Group (HSWG) of ASPO Australia has addressed the issue in a submission to the Australian Senate who are having an inquiry into Peak Oil.

(Submission 135b (HSWG)

It is a cruel twist of fate that the crippling impact of oil depletion on the health care system will coincide with the period of peak health care demand by the baby boom generation.

The Canadian and Australian health care systems have more in common with each other than either does with the system in the US.

I would really like to hear from any from Canadians who are thinking about these issues.

My colleague Dr Paul Roth is also very active in this area and can be contacted at his blog "Peak Oil Medicine".

Dr James Barson
Convenor HSWG ASPO Australia

Liz said...

Actually, it has been demonstrated that one-on-one midwifery care is the best-practice model for most normal pregnancies, both in terms of costs and results. The obsession with reducing risk seems to have taken hold to the extent that normal, healthy pregnancies and births are subjected to a host of unnecessary interventions which don't really achieve all that much benefit for the average woman, and in many cases actually increase the risks of a negative outcome.

The difficulties in childbirth and resulting higher maternal/infant mortality before the medical model was institutionalised can most often be traced to nutritional deficiencies, in particular rickets which affects pelvic development, and were eliminated by improved nutrition rather than a shift from "medieval" midwives to "modern" doctors and hospitals. There were certainly many good things which resulted from the increasing involvement of the medical profession (eg. forceps-assisted delivery, caesarean sections) but these are unnecessary in the vast majority of births and they are now worryingly overused.

By far the most intelligent solution would be to decentralise birth care for normal pregnancies out of hospitals completely, and to reserve obstetricians for the (comparatively few) high risk cases. Free standing birth centres and teams of homebirth midwives are infinitely more sensible from an economic perspective even today, and have the benefit of ensuring that skills in assisting normal childbirth are not lost for the post-peak future.