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.

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.

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.

Did you know: Registered users can access the full report right now in the ?registered users extras? section? You can register for free by clicking the link at the top of the right hand side-bar on any page.