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This post is a follow-up one after my earlier article about upskilling for the energy descent future. It?s been triggered by another question, this time from a healthcare student in the USA.

His email says that he is just completing his undergrad biological sciences degree, and he was wondering whether a qualification in medicine or naturopathy would be better preparation for the societal changes that are sure to come after peak oil. Please read my earlier post first if you have not already done so, as I will not revisit its content in any depth.

Hierarchy of needs
Maslow talks about a hierarchy of needs in his work Man?s Search for Meaning, starting with the most basic ones necessary for physical survival, progressing to the more social and interpersonal ones.

In order to put learning and knowledge in context, I would like to propose a hierarchy that one could ponder when considering post-peak upskilling in healthcare.

1. Daily wellness practice
By this I mean some sort of mind-body technique (eg meditation, yoga, tai chi, Qigong, or self-hypnosis) that needs no material or equipment, improves physical and mental health, and requires regular practice to master.

2. Family healthcare
This step recognises the importance of the health of your family (at all times, but especially after peak oil) for your own physical and mental well-being.

3. Community healthcare
This is the goal that many have in mind when they start a healthcare course: providing care to the local community. While this will take up most of your time and attention, I would urge you to look past it and have big dreams by moving on to the next levels.

4. Healthcare teacher
If there is a splintering and relocalisation of life in a post-carbon world, it is likely that complex and energy-intensive education systems will undergo simplification. While no-one can foresee how far that might go, I think one must always have in mind the next generation of healers after yours. There is a long tradition of clinical teaching whereby working health professionals provide clinical training to their younger peers ? I can see this continuing, and predict that it will assume even greater importance in the future, especially as you progress to the next level.

5. Healthcare mentor in an apprenticeship system
In the old days of medicine in England, an aspiring student would apprentice themselves to a local doctor or surgeon and learn on the job. I think this model will assume great importance in essentially all vocational pursuits, as education becomes localised and more informal. There is also a precedent in traditional societies, where one would be called to be an apprentice to a local shaman or medicine-man; knowledge would then by transmitted bit by bit as the student proved themselves worthy. The Eastern martial arts, and religions such as Buddhism, also worked on this model. It involves a commitment from both parties, and implies a long-term and trusting relationship.

6. Healthcare master
My conception of this final level, the pinnacle of achievement, is one that must be bestowed by others rather than self-awarded. It is the stage that is reached through years of diligent learning, practice, and self-reflection. It embodies the ideas of intuition, wisdom and modesty. It is awarded by a community to one who has demonstrated that they care about others, through selfless acts of compassion. It is the goal that we all should aspire to.

Qualification characteristics
My earlier post deals with course length, cost, dependence on external materials, and whether or not formal qualifications are needed or not. In this one I will discuss several other things that I think are important. These are listed below.

Personal interest
You need to really like something to spend the rest of your life doing it. Also, when you are passionate about something it is often easier to succeed, and you tend to attract patients and others into your life that you can enjoy working with.

Ease of learning
It may sound simplistic, but a course that you find easy is better than one that is difficult or even impossible for you to master. Why? Getting a course completed and obtaining clinical experience is of paramount importance, especially when the timing of peak-oil is uncertain. It also allows you to access post-graduate courses that are otherwise inaccessible (thereby allowing you to focus on what most interests you or to gain a secondary qualification).

Ease of remembering
Again it maybe over-simplifying, but it is probably better to choose a course that you will find easy to remember. Inherent in this is having an intuitive understanding of your subject matter. An example: I have noticed that I can grasp and retain some areas of medicine very quickly; in contrast there are those areas that I have always found tough going (and while I have the basic knowledge I do not have the inclination to study them further, or need to refresh them from time to time). Why might this be important? Because no-one knows exactly how tough life is going to become. I always think that one should prepare for the worst ? if you?re cold, confused and half-starved it is going to be the simple things that you remember, and it will be the intuitive things that you do to help yourself and others.

Emphasis on basic skills and knowledge
The course that teaches you the fundamentals that can be applied to almost any situation should be better than the one that deals with minutiae (compare the first-aid ABCs with learning how to drill burr-holes in a head-injured patient). Such training will allow you to apply your skills to many unforeseen scenarios (ie ones that weren?t rehearsed, practised, or even thought of before they happen), using improvised equipment in an imperfect, and perhaps physically-challenging, setting.

Flexibility
I think that an eclectic mix of skills will serve you better than becoming a specialist in one small area. The 80/20 rule applies here: you will use a small percentage of your knowledge and physical skills the majority of the time. The problem is that you won?t know beforehand which small percentage it will be. So there is no problem combining medicine and massage, or herbalism and nursing and so on ? it just gives you a greater repertoire for problem-solving. Or even one healthcare discipline (say physiotherapy) and a non-health one (say botany or carpentry): you might become a community resource for wildcrafting natural-growing plants; or perhaps help to plan and build a small community hospital.

Independence from technology
It?s obvious that, to be successful once oil becomes scarce and infrastructure starts to break down, any healing modality needs to be either (i) inherently independent of high-technology (like massage); (ii) adaptable to a low-technology future (like preparing one?s own herbal remedies rather than relying on commercial extracts); (iii) amenable to stockpiling of equipment before peak oil; or (iv) able to be performed successfully with scavenged oil-age detritus (eg acupuncture using needles fabricated from car parts or electrical wiring etc).

Location and portability
The main trust of this idea is the location where one might practice: can it be done outdoors as well as inside; at night or in the dark as well as in the light; while out walking (or hunting ?) with minimal equipment? Also, is it amenable to always being carried with you (like a herbal first aid kit or acupressure), or can your gear be moved quickly if you need to evacuate or hide?

Materials
In closing I?d like to focus on materials and extol the virtues of simplicity. Start thinking about how you might pursue your vocation with a few simple tools rather than many. How you might use recyclable or natural materials rather than petroleum-sourced ones. How you might use items found in nature rather than manufactured ones, or how you might salvage or adapt ?waste? items.

Consider how you might make your own equipment if you suddenly have to start from scratch. How you might store any necessities. Do they have a shelf life? Will they go off, rot, or be eaten by mice, rats or cockroaches? What type of containers will you need, and where will you get them? What happens if they break? Do you need to control the temperature or humidity level of your storage area? How might you purify your materials if they become contaminated?

Summary
How can you pursue your chosen field so that you make do with less? I would love to hear how you might adapt your vocation to energy descent, so that others may benefit from your insights and creativity. Please leave a comment below if you can.

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Good Morning,
I am writing today to let you know about an Australian Senate enquiry that may consider the future of healthcare in Australia. The enquiry is examining the likelihood that the era of cheap and plentiful crude oil is drawing to an end, and what that may mean for our society.

I am a GP in Newcastle NSW, and a member of the local Hunter Urban Division of General Practice. I am concerned that medicine in particular (as well as society in general) will be ill-prepared for peak oil, especially as it is predicted to occur as early as 2010.

In collaboration with a Victorian anaesthetist (Dr James Barson), I recently co-authored an in-depth submission on the healthcare aspects of peak oil to the Senate enquiry. We submitted it on behalf of the Australian chapter of the Association for the Study of Peak Oil and Gas (ASPO-Australia), and it is available on their website: http://www.aspo-australia.org.au/

In brief, our submission covered:

• Ways that modern medicine is oil-dependent
• How Australian general practice is susceptible to peak oil, and how that might be changed.
• Why hospital medicine is vulnerable to peak oil, and how it might be remodelled.
• Ethical challenges of healthcare and peak oil
• Introduction to the methodology of oil vulnerability analysis
• Demonstration of the vulnerability of the health care system to fuel supply disruption
• Techniques of relocalised healthcare

I refer you to the Senate website for more information on peak oil: http://www.aph.gov.au/senate/committee/rrat_ctte/oil_supply/int_report/index.htm. Note that our submission was made after the release of the interim Senate report, but we hope that it will be considered for the final report.

Additionally, I have started a website called Peak Oil Medicine (www.peakoilmedicine.com) where I discuss these issues at depth.

Peak Oil Theory Background
The peak oil theory was formulated in the 1950?s by American geologist M King Hubbert. His theory states that sooner or later, oil production from any given field will reach a maximum (or peak) before turning downwards and declining.

He based his theory on what he observed occurring in US oil fields at that time, and accurately predicted the peak in Lower-48 US oil production in the early 1970?s.

His method has been validated by production patterns in other countries, and by extension has been applied to global oil production.

His theory shows that a peak in oil PRODUCTION typically follows the peak in oil DISCOVERY by about 30 years.

It also predicts that we will find progressively fewer new oil fields, and that they will be smaller, more technically challenging, cost more, and be located in more environmentally sensitive, climatically hostile, or geopolitically unstable areas.

In this context, the new US oil discovery in the Gulf of Mexico (called ?Jack-2?) is completely congruous with his theory (deeper water than ever before, much more expensive, in a ?hurricane zone?, and only has enough reserves to supply world requirements for six months).

According to his theory, world oil production will eventually peak and then enter a permanent decline. Back in the 1950?s world oil discoveries were around 30 billion barrels per year, while annual consumption was 4 billion barrels. Currently, these figures are roughly reversed: we now burn 7 or 8 barrels of oil for each one that we discover.

When global peak oil occurs, there will not be enough crude oil to satisfy progressively increasing world demand (especially from countries like China and India). Prices must then increase (due to supply and demand), and may reach relatively astronomical levels (US$200 a barrel has been suggested).

Such price increases will have a profound impact on our society, and are thought likely to trigger global recession or depression (akin to the 1930?s). Unfortunately, there are no ready oil-substitutes on the scale required: one US study (called the Hirsch Report) suggests that it will take 20 years of urgent and massive mitigation action to avoid significant economic impacts.

Summary
From the perspective of peak oil, modern medicine is clearly unsustainable. While there are many reasons for this assertion, I would draw your attention to two:

1. Many modern pharmaceuticals are based on crude-oil feedstocks.
2. Plastics are derived from oil, and modern medicine is pervasively dependent on them.

The implications of peak oil are such that even if one remains unconvinced about if and when it might occur, the consequences may be so devastating that not to consider how our system might respond to such a crisis would be foolhardy.




Yours faithfully,

Paul Roth

Open Letter to Australian GPs
Image Credits: Taken from Robert Hirsch?s peak oil report and subsequent work.

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The focus of this article is to explore how the tools, materials and techniques that are used within the healthcare system can be made sustainable.

Relocalisation
By the very nature of relocalisation, a myriad of small niches and individual situations are created, each with a series of challenges to be successfully negotiated. Such an idea is the opposite of globalisation, where we have seen a homogenisation of global culture, the destruction of regional economies, and the degradation of local facilities and infrastructure. Inherent in this phenomenon is the ?one-size-fits-all? solution that is often poorly suited to the particulars of a certain problem. In contrast, voluntarily decreasing the size of human activity and relocalising it may give us the best chance of negotiating the challenges of the next decade or two.

The answer to most of the problems that will confront us will need to be found locally. This will be forced upon us by the realities of peak oil, but perhaps is worth doing anyway to allow the richness and compassion of true community living to infuse us all.

As it is impossible to predict with any certainty the exact techniques and materials that will be available in the future, I will explore in this article some of the general principles that might combine to form a sustainable and ethical health care system.

After reviewing and contemplating many sources, these principles have mainly been based on the permaculture concept as developed by its co-originator David Holmgren, and discussed in his book Permaculture: Principles and pathways beyond sustainability. He has been aware of the coming peak in global oil production for several years, and his book explicitly and extensively considers what he calls ?energy descent?.

I will also examine the work of E. F. Schumacher, originator of the ideas of ?intermediate size? and ?intermediate (or appropriate) technology?, and author of Small is Beautiful: A study of economics as if people mattered.

Permaculture principles
David Holmgren has formulated twelve principles of permaculture. The first six look at the system from the bottom-up (the small details), while the second six look at it from the top-down (the big picture). He has also incorporated system design and explicit ethical considerations into what is a holistic system ideal for our purposes. The twelve principles are:

1. Observe and interact
2. Catch and store energy
3. Obtain a yield
4. Apply self-regulation and accept feedback
5. Use and value renewable resources and services
6. Produce no waste
7. Design from patterns to details
8. Integrate rather than segregate
9. Use small and slow solutions
10. Use and value diversity
11. Use edges and value the marginal
12. Creatively use and respond to change

One of the many appeals of permaculture is that it overtly considers the ethical principles at work, and reflects them in the design process. Holmgren says that the embodied ethics are primarily based on land and nature stewardship.

Permaculture is about self-reliance and ?sustainable consumption?, as Holmgren puts it. This idea involves a contraction of production and consumption back to human-sized levels (those needed for the survival of the individual). To achieve this, permaculture is formulated around the principles observable in natural ecosystems and sustainable pre-industrial societies (as demonstrated by their long-term stability and spiritual connection with the land).

Holmgren says that ethics are central in the development of a solution to peak oil. They ensure ?long term cultural and even biological survival,? and are particularly important when the power within a society is large and focussed, because they act as a limiting or regulating mechanism. The three main permaculture ethics are:

1. Care for the earth
2. Care for people
3. Fair share

Permaculture-inspired ideas for healthcare after peak oil
We will need to look at the big picture first, and not get lost in the details of a solution. The strategies used at each location will be different, and will likely need to be adapted to changes that occur over time (for example if there is a sudden influenza epidemic, severe drought, or other catastrophe).

As permaculture uses ?self-maintaining systems?, the implication is that each individual will need to take more responsibility for their own body, and try to be as healthy as possible. There will need to be a change in focus from the treatment of disease to the promotion of wellness. This idea is derived from the principle of minimising waste, as it is wasteful to use scarce healthcare resources treating a preventable disease.

The system will also need to allow for changes in illness patterns. On the one hand, people are likely to be much more active, eat less processed food and lose weight. On the other hand, accidents, musculoskeletal injuries and infectious diseases may be more prevalent.

Additionally, it will be important to enlist the whole community in achieving good health, and the current boundaries that separate medical workers from the general public will become blurred.

Sustainable healthcare systems will probably include plant-based treatments (based on the ability of plants to catch and store solar energy). Holmgren says that ?herbal medicine might not provide a complete pharmacopoeia, but we can, to a very great extent, successfully treat many ailments with locally grown and processed botanical medicines.? While you may or may not agree with this assertion, it is the idea behind it that is important: that locally produced things can fix health problems.

The focus on diversity and small-scale and slow (or lower-tech) solutions is based on Schumacher?s work. It is a concept that supports relocalisation, and the judicious use of technology on an appropriate scale (perhaps using a microscope to check a urine specimen for infection in a doctor?s office, rather than sending the specimen off to the lab for culture).

A negative implication of diversity is that solutions will need to be designed to resolve a variety of problems unique to each location. An example: Distribution patterns of mosquito-borne illnesses like dengue fever and malaria are likely to alter as climate change accelerates, possibly making them a major problem in one location but not another. The diversity principle also suggests that medical systems will need to be designed with built-in flexibility to handle emergencies and other unforeseen events.

Appropriate technology
Schumacher discussed his ideas in his book Small is Beautiful: A study of economics as if people mattered. He believed that ?production from local resources for local needs is the most rational way of economic life.? Appropriate technology uses the minimum level of complexity required for the job at hand. It ideally can be made locally (or at the least maintained and repaired there), is of low cost and requires little maintenance.

For our discussion, appropriate technology should be made from locally available, sustainable materials, and contain little or no oil derivatives. There are many examples of this technology related to healthcare; the main ones are in public health areas like sanitation and clean water provision.

A final idea of Schumacher?s is that the reduced efficiency arising from using appropriate technology necessitates more human labour to produce a given amount of goods. This ensures full employment (thereby occupying otherwise idle workers) and is theorised to promote health, beauty and permanence.

Summary
Following oil peaking, we can choose to allow our society to slide into anarchy (as has Zimbabwe, and to a lesser extent Russia). Or we can choose an ethically-based and ecocentric pathway leading to a compassionate, humane and richer society typified by clusters of small-scale, self-sufficient communities. The choice is ours.

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An ethical conflict occurs whenever the rights of two or more people, or groups of people, come into conflict. Put another way, it occurs when everyone can?t get what they want, and tough decisions need to be made about the allocation of scarce resources.

It is particularly likely that ethical dilemmas will arise during the redesign of the healthcare system as a response to peak oil. This is because there will be a conflict between what is best for society as a whole, versus what is best for the individual.

It is also likely that the quality of life, safety and material abundance that we currently enjoy will decline once oil becomes scarce and expensive. It is probable that the next few decades will be characterized by the scarcity of many things, necessitating the need for rationing of healthcare and other important services.

Why ethics?
Ethics are important because:

• Reasoned and ethical action is a sign of a civilised society.
• Ethics includes the ideas of fairness, equality and compassion. I believe that we must strive to remain as ethical as possible, so that the best qualities of humans and their society may survive for the benefit of future generations.
• Ethical societies value and care for their young, old and infirm.
• A more ethical approach to the environment is needed for its survival, and our own.
• Medical practice has always been informed and guided by ethics.
• Doctors have an ethical duty to patients that should be absolute, regardless of the society in which they practice, or the conditions in which they find themselves.

A physician has three main ethical duties to patients:

• Beneficence ? ?do good?
• Non-maleficence ? ?do no harm”
• Respect for autonomy ? ?a patient?s rights and preferences are important?

These ethical duties are inviolate, and should form the foundation upon which all further activity (including considerations of rationing) is built. Ethics must be considered in our response to peak oil if we are to remain a just and compassionate society.

Healthcare rationing
Rationing presents peculiar ethical challenges, because the conflict between community and individual rights is brought into stark relief. And while health care systems already have some rationing (in the form of the Pharmaceutical Benefits Scheme and public hospital waiting lists in Australia, for example), it is likely that much tougher decisions will need to be made in the future. These decisions are likely to involve issues of life and death, such as who may have access to potentially life-saving treatment, and who may not.

The case of renal dialysis
Consider the example of renal dialysis (as it has been discussed extensively in the bioethical literature). It is a complex and expensive undertaking, and is already being rationed in New Zealand. They have introduced a strict and explicit system of rationing to determine who may have access to dialysis, and essentially who may die fairly quickly of end-stage renal failure. Their system relies on a set of clinical guidelines that were developed by a consensus process in the early 1990s, and considers age and the presence of significant co-morbidities. The intent was originally that no-one over the age of 75 years would be dialysed. The system has generated a large amount of controversy and public discussion, and has been tested in the courts at least twice.

Rationing inevitable regardless of peak oil
Even if oil peaking wasn?t imminent, it is likely that the ethical dilemma of rationing would become increasingly important anyway. There are two reasons for this statement:

1. Ageing populations in Western socities will need much more care as the get older, especially as the baby-boomers enter their seventies.
2. As medical technology continues to produce technological breakthroughs, the cost to access these treatments goes up. This is because ?designer drugs? and ?magic bullets? are becoming more common but have very high development costs. As these sorts of treatments (termed pharmacogenomics) tend to be targeted at uncommon or rare conditions, the cost per patient is high so that research and development costs can be recovered. They also tend to be targeted at age-related diseases like cancer, so demand will increase significantly in the coming years.

It is clear then that sooner or later, countries like Australia will need to make tough decisions about health care rationing, which will result in serious illness or death for those that miss out. There is no way to dodge the magic bullets! The rights of the individual will always collide with the good of society, thereby producing ethical dilemmas.

Developing ethical decision-making frameworks
Coming resource scarcity, whatever the cause, is adequate motivation to develop an ethically-based framework that can guide fair and just decisions about resource allocation. Such a framework ensures that the decision-making process is transparent, and that it satisfies the ethical duties of honesty and disclosure. It also ensures that the concept of justice (in this case distributive justice) is incorporated by including a process of public consultation. An honestly conducted public enquiry satisfies the ethical duty of fairness, and should reduce conflict down the track by seeking consensus up-front.

Having explicit guidelines for clinical decision making is one of the two ways that healthcare rationing can be achieved. Explicit guidelines are prescriptive and relatively inflexible. The New Zealand experience shows that they may be open to legal challenge, or trigger widespread debate and dissent in a population. Even though the idea of such guidelines is attractive, there are several potential problems in addition to legality and public opinion:

1. Fails to acknowledge that medicine is both art and science.
2. Difficult to incorporate new information or clinical developments once treatment has started.
3. Doesn?t acknowledge clinically-relevant differences between patients.
4. Relatively inflexible.
5. Susceptible to outside influence (such as political or media pressure).

The other way of rationing scarce healthcare resources is through an implicit process. Such a system relies on the making of discretionary decisions within a fixed healthcare budget. Strategies include:

1. Queuing (eg public hospital elective surgery waiting lists).
2. Decreased service intensity (eg monthly therapy sessions instead of weekly ones).
3. Substitution of less expensive services for more costly ones (eg generic medications).
4. Excluding some treatments from the public system completely (eg weight loss medications and the PBS).

So while at first explicit guidelines seem more attractive, implicit rationing (within a given budget) seems better able to respond to the complex, diverse and rapidly-changing environment likely to occur after peak oil. It will also be more likely to have the speed and flexibility required to cope with shortages, natural disasters, accidents and civil unrest, and allows physicians to make exceptions to rules that seem unfair or unwise in specific instances.

Distributive justice
It is a moral imperative that rationing be fair and just. It is also a practical one both politically and socially (to maximise the chances of re-election, and reduce the risk of revolt, respectively). Inequality in the distribution of goods is evident when favouritism or discrimination occurs: the process is then said to be unfair or unjust.

According to Kjellstrand (1996), there are three theories of justice that are frequently applied to medical decision-making:

1. Egalitarianism ? All people have intrinsic worth. Equal access to health care is a right. Need for services is the primary criterion to make decisions.
2. Utilitarianism ? Values the good of the community over the good of the individual. Equality subordinated to overall outcome.
3. Libertarianism ? Primacy of personal autonomy. No automatic right to healthcare. Healthcare is just another service for those who want and can afford it.

These three different views of the one ethical principle explain how conflict in resource allocation occurs. We need to recognise the difficulty, complexity and challenge of making decisions after oil peaking. We should favour processes that are as fair and honest as possible, but which retain their flexibility and are able to react to changing conditions quickly.

Values after peak oil
In the interests of stability and safety after peak oil (themselves utilitarian values), it is likely that the order of priority for the three theories listed above will be (1) utilitarianism; (2) egalitarianism; (3) libertarianism. This is because the good of the community will be of primary importance as our society adapts to changed and unstable conditions, and resource scarcity means that limited medical services must be allocated to maximise the greater good, and promote security and safety. For instance it is likely that workers and those with useful skills will receive treatment first, as the survival of the group will depend on the survival of the able-bodied and skilled. Although the order of the other two approaches will depend on local factors, one would hope that compassion and charity might remain important.

A new land ethic
Different ethical viewpoints make distinctions between those entities that count in a moral consideration, and those that don?t. At one extreme is the belief that only living humans with the capacity to think are worthy of moral consideration. This viewpoint excludes the foetus, unborn future generations, and the natural world from consideration.

At the other extreme is the viewpoint of deep ecology, whereby all things are seen as being equal, morally important, as having intrinsic net worth, and as deserving of being treated in an ethical manner. This includes nature. The current state of our environment serves as evidence that our globalised industrial society doesn?t extend basic moral protection to the natural world, thereby allowing phenomena such as the clear-felling of old-growth forests, strip-mining and global warming.

In contrast, many indigenous peoples held their environment in high regard, often to the point of sacredness. This reverence for the natural world is one of the factors that allowed some indigenous cultures to develop sustainable societies.

In a scarce oil future, it is envisaged that many of us will live in much closer approximation to nature, spend a significant part of our time working the land using low-tech methods, and depend on the health of local ecosystems for our own health and survival.

Although this article is about medical ethics and rationing, it is worthwhile considering the type of ethical approach to nature that will be required to achieve long-term sustainability in a relocalised future. The ?land ethic? of Aldo Leopold and the ethics of the permaculture system demand a respect for and partnership with nature that will be crucial to our survival. Both approaches acknowledge that natural things have intrinsic worth and moral standing. It logically follows then that they deserve to have the same ethics applied to them as we use for ourselves.

Once the place of nature in an ethical framework has been clarified, the preceding discussion on rationing can be used to determine the way that other goods (such as water, food, clothing, shelter and energy) are shared and distributed. Indigenous people used an oral tradition of stories, rules and taboos to disseminate and enforce their systems of land stewardship (for example a prohibition on hunting female animals during breeding season, or the way that water holes were to be managed during a drought). Hopefully we can formulate a similar system of ethics that includes all of nature as a moral being worthy of ethical consideration. Only in that way can we effectively deal with peak oil and energy descent.

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It is clear that the current model of general practice (aka primary care or family medicine) will be unsustainable in a scarce oil future. So the question remains: How can it be remodelled to be more sustainable within the limitations imposed by peak oil, yet still deliver effective and ethical health care to the population?

Structure versus technique
One needs to separate the structure of a future healthcare system from the knowledge or techniques used by practitioners within it, to begin to answer this question. For example, consider a book: the chapter structure provides a framework for the knowledge contained within it. And while most books share the concept of chapters as an organising system, the content of each book is different. And so it will be for the pattern of healthcare. The reduction in travel and material flows brought on by peak oil will necessitate a greater reliance on local materials, knowledge and infrastructure, with greater heterogeneity in the way healthcare is delivered. It will be guided more by local factors than it is now, and feature a range of customised solutions to the problems of healthcare delivery in each region.

Focus on principles
This section will focus on some principles that might be used for designing the structure of a possible future system. Due to the difficulties of foreseeing the exact nature of the challenge posed by peak oil, I have attempted to provide a ?big picture? consideration of the more theoretical and ethical factors that need to be considered, rather than a prescriptive list of specific solutions. After your reading of this article, I hope to have raised more questions than I have answered.

Redefining general practice
The terms general practice and primary health care sometimes seem to be used interchangeably, although conceptually they are different. I make this distinction because primary health care, while including general practice, encompasses a wider sphere of activity, as it involves health care workers other than doctors, and activities other than medicine (such as health promotion and community nursing, for instance).

Bringing people together
After peak oil, the fundamental question to be answered will be: ?How can we bring doctors and people together without using oil-based transport?? Two related questions are ?Where should general practitioners be located within the community?? and ?How will people move around without using oil?? There are at least four possible ways to structure an answer to these questions:

1. Localised ?centrality?
One possible model of local medical reorganisation is through the related processes of delegation of healthcare responsibility and triage. As currently used in some developing nations, this model involves a large number of semi-trained health workers, scattered throughout the community, who would provide basic first-aid and simple medical treatments. Training in triage would allow these workers to identify the more unwell patients, who are then passed upwards through a series of facilities of increasing medical complexity, with most doctors sitting closer to the top of the organisational structure. They would provide more specialised treatment to those who needed it, as well as be responsible for passing education and feedback back down the chain to their subordinates.

2. GP dispersal
In this model, general practitioners would be dispersed throughout the community, ensuring that essentially all people in urban areas could access a doctor by walking or riding a bike (or horse in country towns). This system would involve a reversal of the current trend towards practice amalgamation, and would see many small one or two doctor practices developed in the same pattern as population clusters. This perhaps is most like the way that general practice developed in Australia, with many combined residence/surgeries scattered throughout a community.

3. Nursing home multi-use
This response recognises the ageing of our population, and the progressively increasing need for aged care that will result. It also acknowledges that the aged use proportionately more medical care than younger people (up to eight times more than children has been quoted), and also that there are likely to be flows of people (staff, relatives and visitors) and materials (including food and supplies) into nursing homes, making them a focus of activity within the community. It doesn?t consider whether or not nursing homes will remain as they are, or whether caring for the aged will once again be done by their own families at home. This strategy would see general practices established at nursing homes (to make use of the flows of people and materials), and perhaps an even greater expansion of the nursing home role to include other essential healthcare services, community gardens, urban farms, and other relocalising efforts. In this scenario, the nursing home becomes a hub of community activity.

4. Medical ?flying squads?
This is an old idea made new again and is possibly a subset of the first strategy: Mobile teams of general practitioners, surgical teams, medical specialists, allied health professionals, or multidisciplinary teams would move around community facilities and private residences to provide care as needed. This option could exist within the triage and delegation structure, and would be particularly important in rural areas.

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