Sunday, June 24, 2012

Public health and austerity: A troublesome combination

This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.

              --T.S. Eliot, "The Hollow Men"

The modern end-of-the-world imagination often seeks out great Hollywood-style cataclysms: an asteroid collision, all-out nuclear war, a solar flare that wipes out the electrical grid, even a worldwide epidemic that leaves few alive. Less compelling is the possibility of relentlessly rising death rates that finally overwhelm birth rates and quietly set worldwide population on a downward path.

While such a development would (gruesomely) address population pressures over time, it would be both highly disruptive--the costs of coping would be very high compared to family planning--and also morally repugnant if allowed to occur through intentional neglect.

The idea that a decline could unfold in this manner, however, is so far from any policymaker's mind that it doesn't even seem to register. And, yet the seeds for it are being sown right now. As the world economy continues to sputter, government revenues fall. More and more nations are embracing fiscal austerity and public health budgets are being cut. The situation has become exceedingly dire for Greek citizens whose health care system is being slashed to meet austerity targets demanded by Eurozone lenders as the price for keeping the government financially afloat. Because many pharmacies have not received government payments for drugs they dispense in such a long time, these pharmacies are now demanding cash up front. And, impoverished Greeks are finding it difficult and often impossible to pay.

While money is one issue and an important one, complacency is another. The amazing triumphs over infectious diseases in the last century have led policymakers to ignore the realities: 1) The prevention of infectious diseases requires constant monitoring and preventive action and 2) the treatment of such diseases requires both the judicious use of existing drugs so as not to hasten resistance and the regular development of new drugs and therapies as infections agents evolve and gain resistance to existing drugs.

Earlier this year Dr. Margaret Chan, director-general of the World Health Organization, warned that overuse of antibiotics might mean that minor cuts and infections could once again become deadly since resistance to today's antibiotics is rapidly on the rise and few new drugs are being developed to replace them.

India is now the third country to report what is being called totally drug resistant tuberculosis. Part of the problem is poor disease management. Too often patients are given the wrong treatment regimen. But also more than 50 years have passed since new drugs designed to defeat TB were developed. Our success to date has been our undoing. It has not been all that profitable for drug companies to do the extensive research for a new drug to treat a disease that has been largely under control.

In the United States, whooping cough, thought to be a problem banished by a vaccine in the 1940s, has reappeared in what the state of Washington calls an epidemic. Budget cuts are preventing local health departments from even tracking the epidemic accurately. The state believes far more cases go unreported than have been catalogued. If we can't even keep track of an epidemic, how can we expect to fight one effectively?

Perhaps the poster child for the collapse of the public health system is Russia where the breakup of the former Soviet empire led to major disruptions of public institutions including public health. A country in which AIDS is rampant as well as tuberculosis, Russia has experienced persistent population declines since the breakup. (I covered this previously in this piece written in 2010.)

Part of what makes public health spending a hard sell is that it simply cannot supply the kind of compelling narratives that such routine medical miracles as heart valve replacements and cochlear implants (which restore hearing in some deaf patients) are able to supply. Public health successes are about what doesn't happen, about people who don't get sick, epidemics that don't get out of control, about the healthy and problem-free delivery of newborns, about the birth defects that are avoided. (I've written on this problem several times, but especially applicable is a piece entitled "Asymmetrical accolades: Why preventing a crisis almost never makes you a hero.")

The notion to date is that cutbacks in public health are part of a broader but temporary austerity. But persistent strains on the world's oil supply suggest that the engine of global growth will no longer be cheap or plentiful. (All the hand waving about new discoveries and new extraction techniques aside, world oil supplies remain flat. The industry's cheerleaders and dupes conveniently forget to mention depletion which is constantly eating into the production capacity of existing fields by at least 4 to 5 percent per year.) That means growth will have to be fueled by some other energy source though it's not clear what that is. And, the financial headwinds of too much debt could mean that no matter what happens on the energy front, the world is stuck in low or no growth mode for another decade and possibly beyond.

That means waiting for growth to return and replenish government coffers so that governments can in turn increase public health budgets will open a long window of vulnerability--just when all factors suggest we will need increased public health vigilance. The gradual degradation of public health services will never make good Hollywood material. The trend is more in line with T.S. Eliot's ending of "The Hollow Men." The world may indeed end with a whimper, the whimper of souls expiring one by one for lack of appropriate public health measures--but at a rate that throws global society into a constant turmoil from which it will be difficult to recover.

Kurt Cobb is the author of the peak-oil-themed thriller, Prelude, and a columnist for the Paris-based science news site Scitizen. His work has also been featured on Energy Bulletin, The Oil Drum, 321energy, Common Dreams, Le Monde Diplomatique, EV World, and many other sites. He maintains a blog called Resource Insights.


scarecities said...

We should perhaps hold up this research and its conclusions to the anti-science evolution-deniers that make the USA a laughing stock throughout the scientific world.
We live on this planet courtesy of bacteria. They are unaware of us, we are all too aware of them. They could get along perfectly well without us, without them we would die within days. They were here before us, and will still be here when we've departed.
However, we have spent a century or so trying to kill them off through our obsession with ultra cleanliness and ever more sophisticated drug manufacturing methods; we had no choice in this, everyone rightly demanded cures for just about everything, and our drug industry duly provided it, but our war on bacteria has provided the evolutionary boost to them. We cleared trillions of weaker bacteria leaving the field clear for stronger ones to thrive and multiply. Every new 'war' had the same effect, to make bacteria more powerful.
We are now at our limits for devising new killing methods against what we see as our enemies, but they have grown too strong for us and our weapons now longer work.
Our wars at the bacterial level have been driven by the same forces as at human level, every aspect of medical intervention is driven by primary energy input. when those inputs fail, as they are beginning to do right now, the newly powerful bacteria will return in overwhelming force.
Ultimately the only weapon we have in our arsenal is primary energy, and anything to do with modern healthcare needs lots of it. As our post industrial society declines back to a pre-industrial one, the expectation of healthcare will persist and governments will strive to supply it, but without cheap energy input, no 'modern' healthcare system can survive even at the smallest scale. We might retain medical knowledge, but be unable to support it much above the medieval level. Bugs are the primary life-form on this planet and outnumber us trillions to one; they ruled our world before we were stupid enough to try to outsmart them after we became their tenants. It could be they’ve had enough of our antics and are about to terminate our lease.

Mike said...

I agree with everything that scarecities said. I started my own blog on industrial civilization's demise, posting on various topics, but the one that really got my attention was on bacteria.

Here is the link to the post:

Especially interesting is that our sewer systems have become breeding grounds for super bugs. Read what Dr Edo McGowan PhD says about this.