Public Health: Slow Motion Disaster

Of the four aspects of our deindustrial predicament I outlined in a previous post – fossil fuel depletion, economic contraction, declining public health, and political dysfunction – public health has received far and away the least attention from the peak oil community. This is ironic, to use no stronger word. I’ve argued at length elsewhere that the energy shortages and economic breakdowns sometimes claimed as causes of imminent industrial collapse will play out instead over decades of unsteady decline, and taken a certain amount of heat from apocalyptically minded peak oil theorists for that. Here, though, the shoe is on the other foot. Though it’s all but unnoticed outside of a small cadre of worried professionals, the disintegration of public health in coming decades promises a disaster in slow motion.

It’s not surprising that this particular crisis has gotten so little air time. Public health is one of the least regarded, though among the most necessary, of the basic services industrial society provides its citizens. It’s not exciting stuff. Sanitation, pest control, water treatment, food safety regulations, and the like are exactly the sort of humdrum bureaucratic activities that today’s popular culture ignores most readily. Even infectious disease control rarely achieves the level of intensity chronicled, say, in Randy Shilts’ history of the AIDS epidemic, And The Band Played On; more often it’s a matter of collecting statistics, tracing contacts, and sending emails to local officials and hospitals in the certain knowledge that most of the recipients will just hit the delete button. On these pedestrian activities, though, rests the industrial world’s relative freedom from the plagues that visited previous societies so regularly and killed so many of our ancestors.

The impending collapse of public health, like most aspects of our current predicament, has an abundance of causes. One is the failure of government at all levels to maintain even the very modest support public health once received. Lacking an influential constituency in the political class, public health departments far more often than not came out the losers in the tax and budget struggles that dominated American state and local politics in the last quarter of the 20th century. Worse, food safety regulations were among the consumer protections gutted by business-friendly politicians, with results that make the headlines tolerably often these days.

A second factor in collapsing public health is the end of the antibiotic age. Starting in the early years of the 20th century, when penicillin revolutionized the treatment of bacterial infections, antibiotics transformed medical practice. Dozens of once-lethal diseases – diphtheria, tuberculosis, bubonic plague, and many others – became treatable conditions. A few prescient researchers cautioned that microbes could evolve resistance to the new “wonder drugs” if the latter were used too indiscriminately, but their warnings went unheard amid the cheerleading of a pharmaceutical industry concerned only with increasing sales and profits, and a medical system that became little more than the pharmaceutical industry’s marketing arm. The result has been an explosion of antibiotic-resistant microbes. The media not long ago announced the emergence of XDR (extreme drug resistant) tuberculosis in Africa and Asia, adding to the list of microbes even the best modern antibiotics won’t treat.

A third and even more worrisome factor is the impact of ecological disruption on patterns of disease. As the number of people on an already overcrowded globe spirals upwards, more and more of the earth’s wild lands come under pressure, and microbes that have filled stable ecological niches since long before our species arrived on the scene end up coming into contact with new hosts and vectors. HIV, the virus that apparently causes AIDS, seems to have gotten into the human population that way; Ebola and a dozen other lethal hemorrhagic fevers certainly did, along with many others. At the same time, global warming driven by our smokestacks and tailpipes has changed distribution patterns of mosquitoes and other disease vectors, with the result that malaria, dengue fever, and other tropical diseases are starting to show up on the edges of today’s temperate zones.

Add the impact of fossil fuel depletion on these three factors and the results are unwelcome in the extreme. In a future of soaring energy costs and crumbling economies, public health is pretty much guaranteed less access to local government budgets than it has now, meaning that even the most basic public health services are likely to go by the boards. The same factors make it unlikely at best that pharmaceutical companies will be able to afford the expensive and resource-intensive process of developing new antibiotics that has kept physicians one step ahead of most of the antibiotic-resistant microbes so far. Finally, ecological disruption will only increase as a world population dependent on petroleum-based agriculture scrambles to survive the end of cheap oil, and the likelihood that many countries will switch to coal means that global warming will likely go into overdrive in the next few decades.

The inevitable result is the return of the health conditions of the 18th and 19th century, when deadly epidemics were routine events, childhood mortality was common, and most people could expect to die from infectious diseases rather than the chronic conditions that fill the “cause of death” slot on most death certificates these days. Factor in soaring rates of alcohol and drug abuse, violence, and malnutrition – all of them inevitable consequences of hard economic contraction – and you have a situation where the number of people on the planet will take a sharp downward turn. Statistics from Russia, where a similar scenario played out in the aftermath of the Soviet Union’s collapse, suggest that population levels could be halved in less than a century. This doesn’t require massive epidemics or the like; all it takes is a death rate from all causes well in excess of the birth rate, and that’s something we will certainly have as the deindustrial age begins.

The role of modern medicine in these transformations is complex. Especially in America, but not only there, economic forces long ago turned the theoretical triumphs of scientific medicine into a real-world fiasco. For well over a decade now, medical care has been the leading cause of death in the United States – add together the annual death toll from iatrogenic (physician-caused) diseases, nosocomial (hospital-transmitted) infections, drug side effects and interactions, risky but heavily advertised elective surgeries such as stomach stapling, and simple malpractice, and the resulting figure soars well above the annual toll for heart disease, or cancer, or anything else. As economic decline puts mainstream medical care out of reach of most people, death rates from these causes will drop correspondingly, and at least in the industrial world this may cushion the impact of the factors just discussed for a while.

Many people are already voting with their feet by abandoning conventional medicine for various alternative and traditional forms of medicine. Even when these don’t work – and of course some of them don’t – placebos are at least less likely to cause harm than the toxic drugs and invasive surgeries that form the mainstay of today’s conventional medicine. Many alternative health care systems, on the other hand, treat common illnesses quite effectively. Another factor, though, makes alternative methods much better suited to the coming deindustrial age than scientific medicine. Today’s medical system is among industrial civilization’s most voracious users of energy and natural resources; almost without exception, alternative medical treatments use much less of both. Many of the most effective alternative systems – herbalism and acupuncture come to mind – evolved long before the industrial system came into being and use very modest amounts of sustainable resources to treat illnesses. In an age of energy scarcity and hard ecological limits, systems like these are the wave of the future.

The tangled roots of the public health crisis make it a particular challenge to prepare for on an individual basis. Some things can certainly be done. A solid knowledge of first aid, nutrition, sanitation, and basic nursing procedures will go a long way. Sensible eating and healthy exercise are essential, though today’s obsessive pursuit of fashionable thinness needs to be jettisoned; people before the petroleum age, when reserves of body fat played a vital role in survival, tended to be plumper than current fashions allow, and a return to 19th-century standards of normal weight is as necessary as it is inevitable. Those who learn and practice effective alternative health care methods will be at a distinct advantage, and may also find themselves with a marketable trade.

Still, in the absence of effective public health measures, even the best health care – alternative or otherwise – will have its limits. No medicine can take the place of adequate sanitation, pure water, clean and wholesome food, and the other foundations of public health so many of us take for granted nowadays. All these things will be in short supply in the deindustrial future, and so illness and death will be a constant and familiar presence. Learning to live with that reality will also be an essential skill in the twilight of the industrial age. We will no longer be able to afford the fantasy that death is something that only happens to other people – and in the process of coming to terms with our own mortality, we may just learn something essential about being human.