Dmitry Orlov writes from the unique perspective of an eyewitness to the collapse of the USSR - a must read.

No Tags

I got an e-mail from a health professional yesterday (another Aussie) who was a newcomer to peak oil, asking me what I thought might work in the future. I have listed some thoughts below. Please recognise that it is difficult to walk the tight-rope of controversy that exists between conventional medicine and complementary medicine at the moment. I choose to walk it, however, because:

• Modern medicine as we know it must fail sooner or later (for the reasons discussed on this site). Parts will remain but it is impossible to foresee which bits, or how they will be organised and delivered to people.

• CAM is very popular with people, and evidence is accumulating about its effectiveness from randomised trials, etc. One must remember that there can be no absolutes in medicine, and that future health care will probably be an eclectic mix of what works, both “conventional” and CAM (look at Cuba).

• The people who have survived major challenges and subsequently documented their experiences (see The Survivor Personality at the bottom of the booklist in the sidebar) are those who have remained flexible and creatively used whatever resources that were available. I think that the future may be so desperate that we cannot afford to neglect any possibly useful modality, and must be willing to put our biases and prejudices aside (ie both pro- and anti- CAM), at least for the purposes of this thought experiment.

• I feel that I have an ethical duty to the readers of this blog to present as full a range of information as possible, even if some of it is challenging, or flies in the face of currently-accepted practice. I am also very interested in the principles and philosophies behind the things that we see in our worlds, and feel that these sorts of articles are widely applicable and generalisable.

I have been thinking about evidence-based medicine, how it might be relevant to the future, but also how it depends on oil (at the moment); also how we might do research in the future (and why it is important that we do), and will discuss those issues in a future posting.

You need to differentiate between modalities that you’ll use for yourself and your family, and those that you will offer to your post-carbon community professionally. The latter group need more skills / training and at least at the moment a formal qualification. The former group you can do just with a book or two and a little practice on willing crash-test dummies (ie your family and close friends).

You also need to differentiate between those that need external supplies (like herbs) and those that don’t (like reiki). Because the future is unpredictable, it’s impossible to tell what will happen, and how stable it might be (for example consider Cuba versus Zimbabwe).

We just quickly need to consider where I’m coming from - my two big things are acupuncture and reiki, but I also have some (admittedly fairly basic) knowledge of herbal medicine and mind-body techniques / hypnosis. My apologies because I don’t know anything really about chiropractic or osteopathy training or equipment, and how difficult it would be to learn and practice.

Another thought: the timing of peak oil is unpredictable and possibly soon. The subsequent disruptions are also unknowable. Given those two factors, there will be an opportunity cost in both time and money to learn something (ie once you chose you can’t learn something else at the same time). So my advice on selecting:

• Pick what most appeals to you - you need to like it to remember it if you don’t have books etc in the future.
• Any knowledge will be helpful if you know more than anyone else in your local community.
• Decide whether you need a formal qualification or not. Reasons for: In-depth information; Regulatory requirements; Peer recognition; Clinical experience. Main reasons against are the opportunity costs (time, expense, learning other things).
• Consider the points discussed below.

Supplies needed and steep learning curve - herbalism
I have noted below some of the ideas that come to me about herbalism in a post-oil future. Note that this is not a full consideration, rather some jottings about the strengths and weakness. I have made a distinction between whether supplies are needed or not, and whether it can be quickly learned or not (shallow versus steep learning curve):

1. Sooner or later you’ll have to rely on what you can grow and process locally, because commercial liquid extracts etc will disappear.
2. You will be limited to what grows in your location, and the ones that you can successfully save seed from and regrow (if annuals) and those that are frost, drought or salt tolerant, or whatever, depending where you live.
3. If you’re looking at ones that you can produce yourself, remember the native ones that grow wild by themselves and that have been used for millenia by indigenous peoples. Perhaps you might buy yourself a “native medicinal plants” type of book and a plant identification guide and do some bushwalking in your local area.
4. Conversely, you won’t be limited to local native plants - you can plant whatever will grow (eg useful plants like ginseng become accessible), but remember that for some plants it takes a few years before they “bear fruit”.
5. For the ones that you grow yourself, consider how you might harvest, process (drying, liquid extraction or essential oil distillation, etc), and store them (without refrigeration or plastic). You would need to look at how herbal remedies were traditionally prepared.
6. Also consider what might happen if you were forced to move quickly (by human or natural disasters etc) and how you might transport your supplies.

Supplies needed and shallow learning curve - flower essences
Please suspend disbelief for this section, if you are inclined to dismiss it out of hand. Or perhaps skip down two sections to “Mind-Body Techniques”.

The healing systems that rely on the use of essences are more bioenergy ones than herbal ones. They therefore straddle this category and the next one. They depend on outside supplies of the various essences (such as Bach Flowers or Australian Bush Flower Essences), but because they are based on the idea of captured energy (ie they “represent” and “transmit” the bioenergy of each plant, rather than containing detectable active substances), they can be used to prepare new essences on-site (ie they act as the “mother essence”, and can be used to prepare an awful lot of derivative essences.

The so-prepared daughter or child essences can then be used for healing. Note that these techniques are generally very gentle and mostly used for emotional, rather than physical, healing. So while you might eventually run out, if husbanded properly, you might not for a very long time, or never. They are also very portable.

So get some supplies in if you want to go this way. You can also learn it quickly from books if you’re not interested in a formal qualification, or do weekend workshop etc that are pretty time effective. By the way, I’ve never done any training in these, just have a couple of books and a bit of Rescue Remedy that I find works well for my children. Note that there is not, to my knowledge, a significant acceptable evidence base.

No supplies needed and shallow learning curve (sort of) - bioenergetic therapies
Let’s return to the difference between a complementary therapy that you learn as a profession, and one that you learn primarily to treat yourself and your family. In a previous blog entry I have discussed the importance of taking self-responsibility for one’s own health generally, end especially after peak oil when you will need to rely on your own resources a lot more than you do now.

The bioenergetic therapies (primarily qi gong, reiki, healing touch, shamanism, pranic therapy, and others) admirably fulfil the need for a personal and equipment-free self-therapy. Why do I say this?

Firstly, the fundamentals are usually quickly grasped. It’s just the practice that takes time. Generally what you put into the esoteric therapies pays off, often in multiples (if one has the right intention). It is the same idea as learning tennis - once you know how to hold a racquet, hit a ball, and the fundamental rules, the more you practice the better you get. Same with reiki.

Next, unlike tennis, you don’t really need any equipment other than yourself - including your hands, body, breath and intention.

Thirdly, these therapies make a wonderful daily wellness practice. Unfortunately you do need to do it daily (or almost) to get the most benefit.

Fourthly, it is entirely portable, you never need to remember to take it with you, you have it even in emergencies, and if you need to evacuate an area quickly.

Next, it’s also great for children and pets, and can be very calming for all when stress is high.

Lastly, it can be extended to more of a profession if you so desire (with extra training and practice), thereby giving you something to do after peak oil.

And one last thought. It has been an interesting anthropological journey of discovery to find that many (unrelated) cultures around the world have developed their own version of shamanism, with remarkable similarities given the isolation of some societies. Why is this?

No supplies needed and steeper learning curve - mind-body medicine.
Included in this group is hypnosis and meditation, but also prayer, NLP, creative visualisation, positive affirmations, guided imagery, and a host of other techniques. Many of the things that I discussed in the bioenergetics section is relevant to mind-body techniques as well. Again the distinction between self and others arises. The learning curve is probably shallow for self-use of these practices, but much steeper if one wants to use them professionally with clients. They are also harder (but not impossible) to use with children. Again note that practices of this type have been around in traditional societies for a very long time: consider prayer and ritual, for instance.

Equipment needed and steep learning curve - traditional chinese medicine
To a large degree the same arguments apply here as listed for herbal medicine. There is a steep learning curve for professional acupuncture, but I feel that it is well worth it if you want to be a professional practitioner (based on its effectiveness in musculoskeletal pain in particular but many other diseases in general. Good quality evidence of its benefits is also mounting, and note that Cuba has embraced it whole-heartedly). Three thoughts about needles:

1. Currently they are almost exclusively single-use, so much so that it is extremely difficult to find reusable ones (and one must then consider infection-control issues, etc). Access to supplies is therefore an issue unless you can stockpile, but even then you must consider cost, portability and security.
2. Many materials other than surgical-grade stainless steel were used by the ancient Chinese to make acupuncture needles, so there is a precedent to make them locally.
3. Battery-powered laser could be used (with solar recharging) until the batteries fizzed: It is effectively and fairly commonly used in Western-style acupuncture.

At the personal level, I would commend acupressure as a very worthwhile practice. Just buy a book or two and there’ll be hours of fun to be had in the comfort and privacy of your own home. Seriously though, it can be very useful especially for pain relief, including in children and can be learned in a few hours by applying it as needed.

Links and Resources

Complementary and alternative medicine at the US National Institutes of Health:

Acupuncture

Herbalism

Mind-body

Bioenergy

TCM

Prayer

No Tags

While I am still having my sabbatical I thought that I should draw your attention to a TV show screened in Australia last night. It’s quite good, and covers everything from the prehistoric origins of oil and Drake’s oil well in Pennsylvania, through M King Hubbert to peak oil, climate change, and beyond. You can watch it online at the ABC-TV’s website by clicking here.

No Tags

As you no doubt know, I haven’t posted for a while. The reason: I have found my thinking increasingly dominated by gloomy thoughts of the future, especially since the birth of my third child three months ago. So in an effort to recapture some positivity, I’ve begun a mental vacation, and will start posting again in a few weeks. The easiest way to find out when is to subscribe to the rss feed. If anyone would like to contribute something for publication in the interim, I will gladly look at it. Best Wishes, Paul Roth.

No Tags

In short: It is astounding to see what could be achieved with limited scientific knowledge but with an abundance of common sense. I hope that we can rediscover and apply this type of approach while we still have abundant oil and a (relatively) stable climate.

Some random thoughts about the paper
It is obvious from the paper that practitioners of public health in the early twentieth century:

• Recognised that influenza was caused by a micro-organism that could be transmitted by droplets (note that we now know that it is a virus rather than a “bacillus” due to electron microscopy).
• Understood the need for isolation to prevent cross-infection.
• Acknowledged that health care workers (HCW) had to be protected from infection, but also that HCW could be the vector that transferred illness from one patient to another.
• Realised the effects of the environment (especially wet and cold conditions) and psychological factors (especially worry or stress) on immunity and vulnerability to infection.
• Understood that overcrowding alone was enough to initiate an infectious outbreak; conversely, there was also recognition that such overcrowding had to be remedied before an outbreak could be controlled.
• Recognised the role of secondary bacterial pneumonia as a cause of death in those with influenza; the converse situation was also acknowledged.

Conclusion
As there were no antibiotics or antivirals available in 1918, the crux of infection control was breaking the train of transmission through quarantine, isolation and reducing overcrowding. A secondary strategy was to give patients the best known supportive care (including rest, optimal nutrition, fresh air and sunlight).

Not only is such an approach demonstrably effective, it is also low-tech, cheap, and able to be used everywhere an outbreak occurs. It may also be the last best option for managing multi-resistant TB, HIV, MRSA and other “superbugs”.

Finally, be optimistic. If they could do it then (during World War I), we should certainly be able to do it now. It is just a matter of remembering what we knew then, and forgetting some of what we know now.

No Tags

This is a transcript of a US Army document published in 1918. I have marked what I think are the most important points in bold. It provides many lessons about managing infection without antibiotics. I will publish a commentary next week (which will bump the HIV article back another week - sorry :-)).

EXCERPTED FROM APPENDIX: THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR.

VOLUME II: ADMINISTRATION, AMERICAN EXPEDITIONARY FORCES.WASHINGTON, D.C.: GOVERNMENT PRINTING OFFICE, 1927.

The present epidemic of respiratory infection in the American Expeditionary Forces is largely influenzal in character, with a rather high incidence of secondary pneumonia due usually to pneumococci or streptococci and occasionally to influenza bacilli and possibly to meningococci. The mortality has been in the neighbourhood of 30 per cent. As primary pneumonia is likely to increase with the advent of colder weather, medical officers are reminded that the prevalence of pneumonia, as well as of other respiratory infections, in armies in the field depends particularly upon:(1) Overcrowding.

(2) Exposure to wet and cold.

(3) Fatigue, whether induced by overwork, a long journey, loss of sleep, or nervous exhaustion from worry.

Crowding forces the occupants in barracks or billets into close personal contact, and the greatest danger from it in relation to the occurrence and spread of respiratory infections is obviously in the increased opportunity furnished for droplet infection of the healthy inmates from those who already harbor pathogenic micro-organisms in their noses or throats.

In epidemics of pneumonia or of influenza, the disease is undoubtedly usually spread from man to man through the secretions or discharges from the mouth, nose, or other parts of the respiratory tract, and an individual who harbors virulent pneumoccoci or streptococci or influenza bacilli is obviously very likely to infect his cosleepers by coughing or sneezing, or even speaking loudly in close proximity to them.

In the present epidemic, the great majority of the cases of pneumonia are secondary to influenza—the natural resistance of the individual having been first broken down by this disease, secondary infection of the respiratory tract with pneumococci or streptococci has occurred.

In Panama, where climatic conditions were not severe, pneumonia was prevalent, particularly on account of overcrowding, and the same was found to be true among the workers in the South African mines. Prevention consisted particularly iii scattering the individuals and giving them separate dwellings in place of barracks.

Overcrowding
In relation to overcrowding, Medical War Manual No. 1, for 1917, authorized by the Secretary of War under the supervision of the Surgeon General and Council of National Defense, states that whenever possible the floor space per enlisted man should be 80 square feet, affording 960 cubic feet, and should never be less than 10 by 6 feet, or 60 square feet, which with a ceiling 12 feet high would afford 720 cubic feet. This manual further states that should an epidemic occur and should the soldiers be overcrowded, it may be assumed axiomatically that the epidemic can not be checked by other sanitary measures alone, but must be combined with measures to relieve the overcrowding. Owing to the shortage of lumber and materials, it was thought necessary in the American Expeditionary Forces to reduce the space per man to 1 linear foot, or 20 square feet—one-third of the minimum amount recommended. The order directs that bunks shall be 2 feet 8 inches wide by 6 feet 6 inches, double tier, in sets of four, 2 feet 8 inches apart, giving 1 linear foot of Adrian barracks per man. It is hoped that conditions will soon be such that this allowance may be increased. In the meantime, an effort must be made to prevent droplet infection by other means between the men sleeping side by side in barracks. A board partition 2 feet high may be built between the two adjoining bunks, Until this is done, wires may be run 2 feet above the bunks and the shelter tents suspended upon them between the adjoining bunks, Similar precautions should be taken in billets and tents. This is a more practical arrangement than placing the head to the feet of the adjacent sleeper. In cases where the overcrowding is excessive and the weather fine, the advisability of bivouacing the men in the open air under shelter tents, or other canvas, should be considered, If this is done, additional blankets obviously should be supplied. Relief from the dangers of overcrowding should be the first important consideration in connection with the checking of the present epidemic. Distance between beds is the important factor, not cubic space, in the prevention of the spreading of pneumonia infections, Crowding in recreation rooms at cinematograph entertainments, etc., should at present time be prevented as much as possible.

Wet and cold
Wet and cold are also important predisposing factors in pneumonia epidemics. A lowered condition of vitality from cold favors particularly the development of such infectious diseases as pneumonia and influenza, by lowering the resistance of the bronchial and pulmonary tissues to infection. Experiments suggest that infections with these diseases are favored by cold and chilling through the stimulation of the mucous glands with resulting closure of the small bronchioles with plugs of mucus. It is well known that the functions of the leucocytes are disturbed by cold, and it seems likely that phagocytosis may play an important role in connection with the mechanism of immunity in pneumonia, and that immunity is in this disease particularly related to the functions of the leucocytes. The movements and phagocytic action of the leucocytes occur ~most favourably at about the temperature of the normal body. Exposure of the skin to cold and wet leads to chilling of the leucocytes during their repeated passage through the skin capillaries, which may diminish their functional activity, and thus lower resistance to a point at which infection may occur. It should be borne in mind that cold wet feet produce a general reaction of the body and not only a local one, and that this condition also predisposes to infection. Cold and wet have less unfavorable action when accompanied by energetic muscular exercises, if a condition of fatigue is not reached. Additional efforts should be made to provide for the prompt removal and drying of the wet clothing of the soldier, and additional blankets at night must be insisted upon.

Fatigue
It should be borne in mind that fatigue induced by overwork and also by lack of sleep and worry in connection with wet and cold has been one reason for the excessive mortality from pneumonia in armies in the field. It is well known that normal resistance to infection may be broken down by fatigue.

Early detection
Greater attention should be paid by medical officers to the early discovery of cases of colds, cases of influenza, and other respiratory infections, and to prompt isolation and treatment of such cases. Carriers undoubtedly play an important role in disseminating pneumocoeci, streptococci, and influenza bacilli as well as meningococci.

Warning against spitting
Men should be specifically instructed at this time against expectorating in quarters, and the danger of sneezing and coughing and of speaking in close proximity to the face explained.

THE MANAGEMENT OF PNEUMONIA

1. Pneumonia, especially as it occurs among troops, and as it is now present in the American Expeditionary Forces, must be regarded as a highly contagious disease, and it must be managed with the same precautions as are taken in the care of other contagious diseases.

2. The epidemics of influenza now prevalent in many widely separated parts of France have at least one point in common; i. e., the occurrence of pneumonia as an incidence of the disease, a complication, or a sequel. The pneumonia is usually of a patchy type, different slightly in its characteristics in different regions, but characterized by rapid progress, great respiratory distress, frequency of early collapse, and high mortality. The causative organism may not always be the same; pneumococcus, streptococcus, and the influenza bacilli and occasionally the meningococcus all seem to contribute their share.

3. Early isolation and hospitalization of pneumonia as well as of influenza and similar respiratory infections will do much to prevent the spread of the disease and lower the mortality. Cases should be hospitalized, when possible in medical formations where they may remain until recovery, even though the initial trip by ambulance may be somewhat lengthened. Cases of pneumonia in the earliest stages withstand transportation fairly well, but later in the disease after they are hospitalized, they are greatly injured by moving. Numerous cases of respiratory infections have been evacuated by train or by motor, to arrive at their destination some hours later in profound collapse, to die within a very short time. Moving a case of pneumonia to make room for a battle casualty may kill the pneumonia patient and not aid the wounded, and the practice should not be tolerated.

4. Isolation or segregation should be practised in all cases of respiratory infection and such isolation should start in the field. Upon arrival at the hospital the cases of respiratory infection should be received in wards devoted to the observation of cases with respiratory infection; or if it is possible to make an absolute diagnosis on admission to the hospital, the case may be sent directly to the ward designated to receive cases suffering from that particular type of infection. The observation ward for respiratory diseases should be cubicled, a sheet or other partition being placed between adjacent beds. It is desirable that an accurate diagnosis be made as soon as possible of cases in this ward so that they may be transferred immediately to those wards designated to receive cases suffering from the different types of respiratory infection. All cases of uncomplicated influenza should be isolated in separate wards as rigidly as if they were cases of measles, and all beds should be cubicled. No cases of pneumonia should be sent to these wards, and should a patient with influenza develop pneumonia he should be immediately removed to a pneumonia ward. Cases of pneumonia should be segregated in wards set aside for this purpose. These wards should be cubicled. The reason why such rigid isolation and employment of the cubicled system is imperative is due to the fact that, first, cases of influenza are highly susceptible to pneumonia and may be infected with great readiness by a pneumonia patient in the near proximity, and, secondly, that the lobular type of pneumonia may be caused by several varieties of organisms, and should a patient with a pneumococcal pneumonia be placed next to one with a streptococcus pneumonia either one or both patients might readily contract a double infection. The course of the disease in such double infections is much more serious and the mortality much higher than in single infections. Cross infections will, therefore, be less common and the mortality reduced by cubicle isolation for all respiratory infections. The practice of receiving respiratory infections of unknown origin in wards with other medical or surgical cases is reprehensible and is responsible for many fatal cases of pneumonia in individuals who might otherwise have been returned to duty within a short time. Cubicle isolation may most readily be carried out by screening with sheets. This can be done by posts and the use of wire and can be adapted for tents as well as for wards. It is only necessary that the screen should reach midway between the foot and head of the bed, halfway between the bed and the floor, and 2 1/2 to 3 feet above the level of the patient. It is, however, highly important that the screen should extend several inches beyond the head of the bed.

5. Protection of medical officers, nurses, and personnel with gowns and fresh and clean gauze masks is important, both to prevent spread of infection among them and to prevent their transmitting infection to others. Attendants should be examined with the view to finding carriers: When found, these should be disinfected. Masking of all individuals who come in contact with cases of respiratory infection and fever, except in case of extreme urgency, and then only with precautions to prevent the transmission of the disease to others. Patients should be masked while being moved.

6. Special attention must be paid to all cases of respiratory infection, with fever with relation to the development of signs of pneumonia. It is often impossible at the outset to distinguish between cases of influenza, without consolidation, and actual pneumonia, All cases, with fever and with symptoms referable to the respiratory tract, must be viewed with suspicion and hospitalized, and the physical signs must be carefully watched.

7. Bacteriological examination in order to determine the infecting organism is important, not only from the standpoint of specific therapy, hut also to facilitate the management of cases of different aetiology. It must be remembered that pneumonia is really a group of diseases, with certain common signs and symptoms. The promiscuous mingling of cases of pneumonia, without determination of the infecting organism, is as harmful as the mingling of measles, scarlet fever, and smallpox.

8. Specific therapy, when possible, is advisable. This will at present be limited to cases of pneumonia due to pneumococcus, type 1. The indiscriminate use of serum, without proper type determination, is ill-advised, not only on account of the fact that it subjects the patient to unnecessary inconvenience, discomfort, and possibly danger, but on account of the fact that serum is scarce, and must be saved for the cases in which it is actually indicated. The polyvalent serum may be used in type 1 cases, as its titer for the type 1 organism is as high as that of the monovalent type I serum. The use of polyvalent serum in cases other than those due to pneumococcus, type 1, is not advised.

9. General treatment should be directed toward sustaining the patient and guarding against collapse. Under no circumstances should a patient with pneumonia, or suspected of having pneumonia, be allowed to walk, and after he is put to bed he should not be permitted to sit up for any reason whatsoever, He must be kept warm, but must be assured a continuous supply of fresh air. Fluids should be given freely from the start, and the patient should be induced to take them frequently and in considerable amounts. Sponge baths should be used to combat high temperatures.

10. Early cyanosis and collapse are characteristic of the present form of pneumonia. Treatment aimed to prevent and to combat circulatory failure should be instituted promptly on making the diagnosis of pneumonia. The early use of digitalis has been shown to reduce mortality, and is advised. It may be given in the form of a standard tincture, of which a total amount of 30 c. c. (1 fluid ounce) should usually be given. The following schedule may be followed.

If seen on the first or second day:

[table]

If seen on the third day, or later:

[table]

The hospitals should supply themselves with a standard tincture of digitalis. Do not use pills which are insoluble. Other stimulants, notably citrated caffeine and camphorated oil, may be used by hypodermic injection when collapse occurs or is imminent. The use of strychine has not been shown to be of value.

11. Morphine is of great value to control severe coughing, to relieve the pain of pleuntis, and to secure rest for the patient. It should be used without hesitation. For the troublesome tympanites that frequently occur, turpentine stupes, given while a small catheter is inserted in the rectum, are of value.

12. Most careful attention must be paid to the physical signs, particularly with relation to spread of the consolidation and to fluid in the chest. When the physical signs suggest fluid exploratory puncture, the microscopic and bacteriological examination of the fluid obtained should be performed promptly. Exploratory respiration is a simple procedure, with little, danger or discomfort to the patient. Local anesthesia may be induced by freezing or by intracutaneous and subcutaneous injection of cocaine or novocaine. When clear or even slight turbid fluid is obtained, even when the infecting organisms are demonstrated in the fluid, treatment by repeated aspiration with the Potain aspirator is followed by the best results, When purulent fluid is found, or in cases where fluid previously clear becomes purulent, operation is advised, with postoperative measures. necessary to insure free drainage.

13. Convalescence must be managed with care, both as to the condition of the patient and as to his transmitting the disease to others. Development of pleural exudate late in the disease, or during convalescence, is not uncommon, and frequent physical examination must not be neglected. Relapse or spread may also occur after the temperature has been normal for several days, and the patient should not be permitted to sit up or move about until 7 to 10 days have elapsed. During this period isolation should be practiced as during the acute stage of the disease. The use of mildly antiseptic solutions in the mouth and nasal passages is of value in reducing the number of carriers. Patients should not be allowed to mingle with other patients, and should not be evacuated until all signs of infection of the respiratory tract have disappeared.

14. Recovery and return to duty will be slow. The final stages of recovery will best be provided for in convalescent camps. No patient who has had pneumonia should be evacuated to a convalescent camp until his temperature has been normal for at least two weeks, and in cases where the infection has been severe or prolonged this period will be materially increased, The patient should be free from cough and other physical signs should be normal.

WALTER D. McCAW,

Colonel, Medical Corps, Chief Surgeon.

No Tags

Imagine for a few minutes that you are a young man living in New York City as the nineteenth century draws to a close. You work in a blue-collar occupation, working hard in sometimes harsh conditions to make ends meet. Suddenly you develop a cough that you can’t control. You cough up lots of phlegm. You start to sweat at night. Eventually, you start to lose weight. You keep losing weight. It is as though you are being consumed by whatever it is that is making you cough. Months pass. One day you don’t turn up for work. Your family is surprised at how many of your workmates attend your funeral. Some of them are coughing, too…

You, along with 10,000 others each year are victims of the same illness - tuberculosis. With a mortality rate of 280 / 100,000 head of population, TB is the commonest cause of death in the city. Young men from the poorer blue-collar groups bear the brunt of the illness, and in a time before antibiotics, there is no way to stop the spread of what is called “the captain of death”. Or is there?

Enter a remarkable man called Hermann Biggs, of the NYC Department of Health. He introduces a five-step program that is incredibly effective at containing TB, eventually reducing its death toll significantly. His program, and what we can learn from it today as we go forward into a scarce oil future, is the focus of today’s article.

Biggs’ TB Containment Strategy
There were five crucial components that lead to the control of tuberculosis in turn-of-the-century New York. They are:

• Mandatory notification
• Free sputum examination
• Individual nursing follow-up
• Public education about the nature of TB and it airborne mode of spread
• Strengthening of political will to gain financial and administrative support

Let’s examine each one in turn.

Mandatory Notification
The introduction of this legislated tool caused a flurry of controversy, not least amongst the medical profession of the day (who were worried about the threat to their autonomy). Eventually their opposition decreased, partly as a result of an undertaking to keep all notifications confidential. Notification served several functions. While it ensured that identified cases received the then gold-standard treatment (rest, fresh air, sunlight and good nutrition), it also allowed adequate follow-up of cases, the tracing of contacts, and verification of a patient’s compliance with public health measures.

Free Sputum Examination
If there’s one body fluid that I really don’t like its phlegm. Even more than vomit. The rest I don’t mind. But phlegm is special. There’s something about hearing someone hawk up a steaming gob of the stuff that just doesn’t compute. And it’s full of the TB bacillus, of course, if you have TB. Which is bad if you’re a close personal friend of the afflicted, but good if you’re a public health official tasked with tackling TB. Why is identification so important? It allows one to confirm the clinical diagnosis, ensure adequate treatment, and monitor progress. And as laboratory testing in nineteenth century New York was inaccessible for many (just as it is now), Biggs ensured its widespread use by removing the barrier of cost.

Individual Nursing Follow-Up
So if you worked for the NYC Department of Health 100 years ago, the only real way to control TB was to stop the disease from spreading (because you couldn’t treat individual cases with antibiotics). And the way you stopped it from spreading was to stop people with TB coughing it up in public places. The only two ways that you could do that was to either wait for the person’s body to heal the TB lesions (by providing optimal nutrition and rest), or to prevent them from attending such places (by hospital admission). Nurses played a crucial role by supervising treatment (mainly at home – thereby avoiding the infection of others), educating the patient and their family about hygiene practices (such as covering their mouth when coughing), and reported when people weren’t compliant with these measures (which prompted admission to one of the many sanitoria in the city).

Public Education
Biggs used many of the methods of communication available in his time. One of the most successful was the establishment of an antituberculosis movement (a bit like ASPO really) to promote the benefits of controlling TB. The messages that were propagated talked about how serious TB was, the benefits of what was called “hygienic behaviour” (which was mainly not spitting in public, and covering your mouth when coughing), and the advances in scientific understanding of TB. Like all good public health practitioners, Biggs kept TB firmly in the mind of the public and the politicians alike, which helped him with the final piece of the TB control puzzle.

Political Will
The historical record shows that Biggs was able to continually expand his diagnostic and clinical services (even during periods of financial hardship for NYC). Why? Three things – tenacity, political influence (due to a mastery of the public relations process), and respect from other doctors (as Biggs was a renowned clinician who never stopped practising clinical medicine).

Modern Day Parallels
Where are we now? Tuberculosis has almost become untreatable with modern antibiotics (see my earlier post and this video). This is especially so in the developing world, although a sizeable pool of drug-resistant TB is also circulating amongst those with HIV/AIDS in the West. So for various reasons, modern medicine has already lost the fight against TB. Even the current best practice treatment (the WHO’s DOTS program – which by the way has many parallels with Biggs’ approach) has approved inadequate due to a combination of budgetary and political reasons. So where to now?

Relationship to Peak Oil
Some experts (including Matt Simmons) say that peak oil occurred in 2006. While the evidence is not yet definitive, the gap between demand and consumption has widened (which is just as good, even if we haven’t reached peak yet). So we face the failure of TB treatment at the same time as an exploding HIV epidemic, peak oil, and climate change. Therefore TB will, sooner or later, resume its pre-eminence as the infectious killer par excellence. Our only hope is to design low-tech, local systems that encompass the same steps as Biggs’ plan from a century ago (but adapted to local conditions).

References
In writing this article I have drawn heavily from the following reference (because it is just so good): Lessons from the 18002: tuberculosis control in the new millennium. Frieden TR, Lerner BH, Rutherford BR. The Lancet 2000; 355: 1088-1092. I based last week’s post about the emergence of drug-resistant TB on these two articles from the CDC:

Shah NS, Wright A, Bai G-H, Barrera L, Boulahbal F, Martín-Casabona N, et al. Worldwide emergence of extensively drug-resistant tuberculosis. Emerging Infectious Diseases 2007. Volume 13 No 3.

Samper S, Martín C. Spread of extensively drug-resistant tuberculosis [letter]. Emerging Infectious Diseases 2007. Volume 13 No 4.

Next Week
When the Spanish flu pandemic hit in 1918, the US Army in France was severely hit. How they managed to contain the damage is the focus of my next article. And coming in two weeks: One country has managed to contain the spread of HIV in a way reminiscent of Hermann Biggs. Where is the country? What did they do? Stay tuned.

No Tags

An emergency has been declared in KwaZulu Natal, South Africa, where an outbreak of 53 cases of a highly lethal form of tuberculosis (TB) has occurred…

Is this report an historical one, or is it part of a drama unfolding right now?

Read on to find out more - the answer is lower down in this article.

I feel that infectious diseases are going to be one of the most challenging health problems to be dealt with after peak oil. Old killers - like tuberculosis - have already started to re-emerge in many parts of the world, causing the same diseases that they did in historical times. Unfortunately for us, though, they are new and improved versions (like a video ipod) that are resistant to many (and soon all) conventional antibiotics. Consider this recent report about extensive drug resistant tuberculosis (XDR-TB) - by the way an upgraded version of the “old” multi-drug resistant TB:

Outbreaks of multidrug-resistant TB (MDR TB) occurred in Spain at the height of the HIV epidemic, when 49 TB cases were reported in an HIV ward in Madrid from 1991 through 1995. In total, 22 hospitals from 6 different regions of Spain were affected by this outbreak. The strain responsible for the 1991–1995 outbreak in Spain fits the XDR TB case definition - it was resistant to the 5 first-line drugs, as well as to ofloxacin, aminosalicylic acid, cycloserine, ethionamide, capreomycin, amikacin, and clarithromycin. No effective medical treatment was available for these patients. In 2 of the hospitals affected, all patients died, with a short survival time (median of 44 and 49.5 days for the 2 hospitals) between diagnosis and death

Multidrug-resistant tuberculosis (MDR TB) has now been documented in nearly 90 countries and regions worldwide, with 424,203 cases estimated to have occurred in 2004 (4.3% of current TB cases). Treatment for MDR TB patients requires use of second-line drugs for at least 24 months. These drugs are more costly, toxic, and less effective than first-line drugs used for routine treatment of TB. Once a strain has developed resistance to second-line drugs, these new TB strains are even more difficult to treat with existing drugs. Untreated or inadequately treated patients are at increased risk of spreading their disease in the community, which could lead to outbreaks in vulnerable populations and widespread emergence of a lethal, costly epidemic of drug-resistant TB.

Such extensive drug resistance (makes these strains of TB) nearly untreatable with currently available drugs according to international guidelines

How resistance emerges
Improper treatment of TB (such as using too few drugs, relying on poor quality second-line drugs, or failing to ensure adherence to treatment) often leads to the emergence of antibiotic-resistance. Treat enough people improperly enough times and voila: XDR-TB. But why does this happen? Let’s briefly review the biology.

Antibiotics work because they impair some part of the bacterial life-cycle. There are many ways to do this, from weakening the bacteria’s outer covering or damaging its internal structure to stopping it from dividing or otherwise reproducing. Because antibiotics interfere with the processes of living, bugs that go through periods of inactivity (such as anthrax spores) or that are extremely slow-growing (such as TB) are much harder to treat than your average bug causing a sore throat. Additionally, within a given population of bugs (such as those in the lungs of somebody suffering pneumonia) there is always some natural, genetically-determined variability in antibiotic susceptibility (think bell-curve distribution).

So when one exposes those bugs to an antibiotic, the very susceptible ones are killed quickly, while the less susceptible ones survive longer. If treatment is adequate (ie the right drug at the right dose given for long enough), then the entire population is eradicated and the illness cured. But if you expose the bugs to the antibiotic intermittently or at a non-lethal dose, there is a selective evolutionary pressure that favours the less-susceptible (or more resistant) ones. So eventually the original antibiotic sensitivity profile changes, to be replaced by a more resistant one. Do that often enough and you amplify the resistance genes, resulting in high-level resistance to the antibiotic. Use enough (different) antibiotics inappropriately, and you have multi-resistant organisms. This is more or less the way that multi-resistant Staph aureus evolved, as well as XDR-TB (the same thing is happening with HIV, but that’s a story for another day). And while using a combination of drugs may overcome resistance for a while, eventually that strategy usually fails, too.

TB has always been tough
Tuberculosis has always been difficult to treat. I remember when I was at Uni 20 years ago that it needed four or five drugs for a year to eradicate it successfully. And while the details have changed, the basic principles remain the same: multiple drugs every day, multiple side effects from those drugs, and multiple months of treatment. No wonder people don’t finish their treatment. It is so difficult to ensure adequate treatment compliance that supervised treatment (where a health care worker observes the dosing every day, for example) has been used for years. Even then people pull out early. And in the third world it’s much worse: Medications are expensive, people are uneducated about the risks of inadequate treatment, inadequate doses and durations are used, and HIV makes it all worse because there is no immunity to help fight it off.

A commentary published in 2000 predicted that “failure to institute [current WHO treatment recommendations] is likely to destroy the last tools available to combat TB, and may ultimately result in the victory of the tubercle bacillus over mankind…

So back to the quote at the beginning of this article. Unfortunately it is not an historical anecdote. Rather it comes from a paper published in The Lancet in 2006. It is happening now. And if it has happened in the cheap oil era, what is going to happen as oil prices go on their one way upwards climb?

Factors leading to extensively-resistant TB, and why things might get even worse after peak oil
One of the papers that I’m basing this article on describes four factors that promote the development of resistance. They are listed below, where I hypothesise how peak oil might make them worse. Each of them leads to the exertion of the evolutionary selection pressure discussed above, because each exposes the organisms to the drugs without killing them. And if you think that the threat maybe isn’t real, remember that the tuberculosis organism is intimately acquainted with humanity, and has been around longer than our “modern” civilisation - tuberculous vertebral lesions have been found in Egyptian mummies.

1. Non-adherance to treatment regimens by patients
(i) Less public health education and awareness of the need to be compliant.
(ii) Fewer health care workers available (especially in rural areas) to directly observe treatment.
(iii) There may be (perhaps counter-intuitively) more movement around a given region as people travel for water, game, seasons or trade. This will disrupt treatment regimens, especially if frequent attendance at a health care facility is involved.
(iv) Fewer diagnostic facilities - this would have the effect of allowing infected people to remain untreated, and perhaps partly-treated people to cease medications early because they think that they are “cured”.

2. Incorrect drug prescribing by providers
(i) Less educational opportunities for health care workers - unaware of optimal treatment.
(ii) More drug resistance + fewer diagnostic facilities = inappropriate drug choice if XDR-TB is unsuspected.
(iii) Shorter (but inadequate) treatment courses to ration scarce medications.

3. Poor quality drugs
(i) Relocalised manufacturing may have less quality control.
(ii) Petrochemical feedstocks may be unavailable or in short supply - this could result in short-cuts or substitutions (which could effect drug potency).

4. Erratic supply of drugs
(i) Antibiotics may not be available at all.
(ii) The right ones may not be available.
(iii) Assuming that they are available - road, rail and sea-based transport may be haphazard and unpredictable or more regular but not very often (unless alternative fuels and infrastructure is developed, etc).

I’d like to add some other factors that I think will be prevalent after peak oil:

• More HIV (more TB and more lethal)
• More over-crowding (easier to spread through droplets)
• More refugees and mass migration (easier to spread)
• Less food and more malnutrition (less host immunity)
• More infectious diseases (that decrease host immunity)
• Peak oil related recession or deglobalisation may make some drugs (perhaps one or more vital ones) permanently unavailable.

So has there ever been a successful strategy for dealing with TB? Actually there has been, and it was implemented over a century ago, before antibiotics. It is the focus of my next article.

No Tags

One of the things that I am going to focus more on this year is the nexus between peak oil and climate change.

I feel the need to do this for several reasons:

1. Climate change is here, even if some scientists and most politicians don’t admit or believe it. (To my way of thinking, this is the same sort of disinformation that has been used by Big Tobacco; in both cases driven by profits).
2. It is likely that the inequalities in both health and healthcare access that already exist will be worse in the future.
3. Peak oil will is going to have major impacts on healthcare provision, perhaps starting as early as 2010 (when some estimate that PO will occur). This is a given even if our climate remains stable.
4. Climate change will massively alter what we have taken as normality for the last 100 years or more. I think that we will come to regard the 20th century as the last of the Holocene, and that we are about to move into a very different climate regime.
5. Global warming will cause many changes in global health; most of them are likely to be adverse.
6. It is the synergy between peak oil and climate change that particularly worries me - the effects of these two looming issues (that will occur more or less simultaneously) will be multiplied rather than additive.
7. If we take a holistic view of peak oil then we must also consider climate change, as using further fossil fuels (particularly coal) to mitigate its effects will accelerate warming.
8. Dealing with the effects of climate change (such as decreased food production or sea level rise) will increase the need for oil-based transport fuels, fertilisers, and other derivatives (unless we come up with effective alternatives).
9. It is my opinion that rapid climate change is a real possibility (discussed below).

So for all these reasons, I will attempt to integrate climate change and peak oil as much as possible this year.

Climate Change and Adverse Health Effects
As the planet warms there will be an increase in average temperature, along with increased climate variability. This will result in an increase in the frequency of very hot days and heatwaves, which in turn will cause adverse health effects.

Events like this have already occurred - for instance the 2003 European heatwave is now thought to have caused up to 50,000 excess deaths (in addition to melting 10% of the remaining Alps glaciers).

So while there is still debate over whether or not climate change will result in an increased burden of illness, and while it is methodologically difficult (at this stage) to attribute excess deaths solely to global warming, I believe that there is enough evidence to warrant further investigation (at the very least), if not full-out carbon dioxide reduction.

An increased frequency of excessively hot days is likely to be just one of the (milder) effects of full-blown global warming. Because climate is a complex system, it is almost certain that there will be many currently unpredictable effects. And while a few of these may be positive (for example longer growing seasons at high latitudes and warmer winters), most effects are going to be negative. So from that point of view, I think that the expected social disruption from peak oil is likely to be just a taste of what is to come.

Climate Change and Peak Oil
Both of these phenomena will have such far-reaching consequences for our society that their overlapping will multiply the challenges that we have to face. For example, consider agriculture. We are currently dependent on oil to eat: Petroleum and its derivatives power farm machinery and irrigation pumps; fertilize the soil; control insect and plant pests; transport the produce from the farm; process the food into finished products; package it; move it to big-box supermarkets; and transport it to your home in the back of a SUV. So what happens when climate change makes farming land drier, promotes the growth of insect pests, or drives the farmer to financial ruin? Just when oil reaches $100 a barrel (or $200)? We need to act now to break our oil habit so that (non-coal) alternatives are well-established before the main climate-change game begins.

Coming Next: Rapid climate change and why it could be starting now.

No Tags

Predicting Global Health Trends: Why Peak Oil Matters

By

Dan Bednarz and Paul Roth

Recently, Energy Bulletin posted a summary of a UPI story that described a WHO (World Health Organization) study projecting global mortality and disease patterns in developing countries to the year 2030. The UPI story is titled “Analysis: Wealth Brings New Health Threats,” and concludes:

“As the level of development worldwide increases, the greatest threats to health will shift from infectious diseases to non-communicable health problems like smoking-related illness, obesity and depression”.

At first glance, this story illustrates how economic growth and the associated consumerism create “diseases of affluence” (such as heart attacks, stroke, obesity and diabetes). As these illnesses are already rampant in the Western world, their increasing prevalence supports the notion of a reduced marginal rate of return on health expenditure, once basic public health measures (such as sanitation, safe drinking water provision, and mass immunisation) are implemented.

No Tags