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Is a Modest Health Care System Possible?
by Andrew Jameton
The health care system in the U.S. is generally regarded by economists and activists as over-scaled and inefficient. Health care consumes nearly 15% of the U.S. GDP (high as compared to most industrialized nations) while providing insured access only to about 85% of the population. Moreover, the provision of health care services has a relatively small effect on public health as compared to what people generally expect of it.
Substantial reductions in the overall scale of health care thus at first appear to be an excellent idea. However, health care also provides services key to the health and happiness of many individuals and vulnerable groups. So, reductions in energy consumption must be balanced against the struggle to maintain highly valued services. Moreover, whether energy consumption in health care can be reduced substantially depends on whether the 80% reductions in other economic sectors are likely to improve or reduce the health of the public.
Energy in health care
Some of health care’s problems with energy consumption can doubtless be solved by efficiencies in other economic sectors, such as in more efficient production of electric power, but not all problems can be so easily fixed. Health care in the U.S. (and to a lesser degree, in developed nations generally) has many features that reflect high levels of energy consumption. Indeed, the modern acute care hospital — spanking clean, brightly lit, packed with imaging machinery, complex medications, and highly trained personnel — is symbolic of the humane achievements of high-energy societies. We envision health care as though we believe that high levels of energy consumption are good for health. Some of the specific high-energy features of hospitals are: 
- Twenty-four/seven, hospitals maintain bright lights, intensive air filtration, sealed windows, and controlled temperature levels, which involve intensive use of heating, air conditioning, and fans. Hospitals are like hotels and restaurants; they clean and process tons of food and laundry.
- Large imaging machines such as x-rays and MRIs, computers, diagnostic devices, operating rooms, intensive care units, and emergency departments use lots of electricity. Our own medical campus has three power generating facilities.
- Health care uses energy in storing and transporting a wide range of materials and supplies, as well as disposing of them and cleaning up after their use. Many hospital tools and materials are manufactured globally, and so the production network is wide and complex. Since so many therapies involve exotic materials, it is difficult to save energy by localizing the sources of materials. Indeed, the pharmaceutical industry, at the end of the 19th century, was one of the pioneering global industries.
- Pharmaceuticals are often synthesized through long chemical paths and highly purified, requiring substantial energy inputs. Cleaning up the toxic wastes of such processes requires energy all the way from manufacture to use and disposal. Chemotherapeutic agents, for instance, are often sufficiently toxic that the waste after their use needs to be transported long distances for incineration.
- Re-use of tools and materials requires more processing than normal, since tools and materials must be very clean. Clean-up via incinerators or autoclave is a high-energy process.
- Hospitals are often large regional facilities requiring extensive parking lots to accommodate traveling patients. Helicopters ply the airways between traffic accidents and trauma centers. Better-paid clinicians often live in large homes in the suburbs, far from inner-city hospitals and academic medical centers, thereby increasing the energy costs of providing health care.
Because health care involves high energy consumption in so many of its functions, it is impossible to reduce its energy levels without also reducing materials consumption, together with services provided. So, in the balance of the article, I will treat the problem of reducing energy consumption largely as one of reducing the overall scale of health care materials, tools, buildings, and services.
Boiling health care down to its essentials
The good news is that, since health care is only a minor factor in public health, it can be down-scaled without much impact on prevailing health levels. However, it provides important additional services (which I will discuss in more detail later) which will be difficult to forego or even to provide in a more efficient manner.
We envision health care as though we believe that high levels of energy consumption are good for health.
Let us approach the reduction in the scale of health care by first considering a 50% reduction. Then, we can go for more. Cutting health care in half, contrary to reducing its effectiveness, is more likely to improve it. Some of the problems of bloated health care are:
- Because health care is so over-scaled, it is unmanageably complex. It has a huge administrative overload, costly in buildings, paper, computers, and personnel.
- Driven by the need for profit, new and dangerous drugs are released to market prematurely and advertised directly to patients. U.S. patients die of medical mistakes (about half of them related to pharmaceuticals) in greater numbers than Americans die of traffic accidents. Treatment of side effects of treatment accounts, by some estimates, for about a third of all medical care.
- Harm and toxicity (remember “do no harm?”) are thus major features of health care, and in general, energy must be expended to reduce the toxicity of manufacturing and disposal processes and to repair the harm done.
- Because health care is expensive, it is more difficult for the government to finance universal access. Moreover, a costly health care system requires a giant economy to support it, and thus, unhealthy environmental damage.
Yet, cutting health care 50% won’t be easy. We also need to expand access, and so lose about 15% from our 50%. Although there is agreement that half of health care is a waste, there is little agreement on which half that is; after all, every service has its constituency. And, the health care system has not so far been very successful in inducing patients to lead healthier life styles (Why should it? It’s not its job. And, we make our money on illness, not health).
U.S. patients die of medical mistakes in greater numbers than Americans die of traffic accidents.
This 50% reduction in end-user energy costs may be enough, if we can reduce the background costs of health care in transportation, buildings, power production, etc. But, we should also consider making more substantial reductions in the level of services, since we want to get to the bare bones of what is necessary.
Health care serves important social functions besides promoting public health. One important function — the rescue of the severely ill and injured — is a key humane function of society, and potentially an expensive one. Moreover, many people are vulnerable, dependent, chronically ill, and in need of health-related services to prevent their suffering and to support their inclusion in family and society. Simple assistance, such as a cane or prosthetic, or physical or speech therapy, can be very important in restoring and maintaining individuals’ functions and daily activities.
Cutting health care in half, contrary to reducing its effectiveness, is more likely to improve it.
So, if we have not already been charged with being inhumane for slashing health care in half, we will certainly be charged with cruelty for considering deeper cuts. Nevertheless, consider the following approach to rock-bottom energy consumption in health care.
The modest proposal
First, we cut health care 50% with an approach similar to the “Oregon Plan.”  In brief, we rank order the various health care services according to their value, as rated by public meetings, and according to their energy costs. We then cut out the half that offers the least value for the highest energy costs. We establish universal access to this level of care, while at the same time prohibiting systematic provision of higher levels of care.
At the same time, we should become less sanguine about “rescue” or “saving lives” as a function of health care. We should, for example, be more concerned about providing nursing care to patients who are dying, approaching dying stages, or suffering from long term illnesses. We should focus less on devices to cure, or to pursue the illusion of cure, and more on high quality nursing care and comfort.
We then shift our focus in health care research, both basic and clinical, to exploring ways to conserve energy in medications, devices, and maintaining health. So, instead of focusing on finding new diseases to treat and new therapies for them, we undertake an intensive effort to reduce the energy costs of caring for and curing people. The fruits of research should make it easier to reduce energy costs further without reducing the quality of services.
Health care basics
In 1993, the World Bank published a major study of public health and development internationally. One of its important findings was that at the very lowest levels of national per capita income (and therefore, at the lowest levels of access to energy sources), income strongly affected public health status. As income increases at these low income levels, general healthiness rises steadily. After a certain level of income is achieved, the health status curve flattens and increased income/energy levels make little difference. 
There are probably a couple of things going on here. First, high levels of income cannot do much to make people safer, freer from toxins, or more athletic. Instead, higher levels of income foster harmful aspects of excess consumption — obesity, sedentary work, substance abuse, and so on. At low income levels, it matters whether a nation can provide clean water, stable access to nutritious food, safe housing, and transportation, and can clean up toxins, monitor infectious diseases, provide contraceptives, and so on. And, can provide jobs: people who have jobs and incomes also have stability, hopes, a role in society, and like psychological benefits that promote health.
… higher levels of income foster harmful aspects of excess consumption …
Will cutting energy consumption by 80% keep society above the cusp in the curve and at an adequate and stable level of health, or will it plunge society into the perilous lower range? It is hard to know and will depend very much on our social choices with regard to every sector of the economy, since everything affects health.  One key choice is that of income equality; without it, more people will fall into those lowest income ranges where they lack what is needed for health, and many studies show that income inequality is a major factor in poor public health. 
The question has been asked whether societies can maintain good public health at low levels of income, and the answer seems to be that only a few countries — such as Costa Rica, Cuba, China, and Kerala in India — have done so, and high public health status in these nations depended little on health care. They had more to do with income equality, jobs for women, a radical commitment to public welfare, and universal accessibility of such public health basics as nutrition, water, and sewage control. 
Health care in these nations is different from that practiced in the U.S. It is more the concept of “primary care” promoted by the UN in its Alma Ata declaration and since. This approach combines access to the public health basics above with basic primary and preventive medicine for women, children and families. Key elements are well baby care, vaccinations, treatment of diarrhea, family planning, quarantine in periods of infection, and the like.  The public health functions of health care that need to be maintained are:
- Monitoring environmentally caused diseases;
- Providing services that have ramifying consequences on health, such as infection control, vaccination, birth control, and education; and,
- Providing technical advice to sewer departments, restaurants, agriculture, etc., where knowledge of human biology is needed to serve public health.
These health care services generally do not necessarily require high levels of energy consumption. In comparison, high-energy health care generally represents diminishing returns as compared to such primary care measures. So, we should think more in terms of what we need to establish and sustain to maintain health rather than in terms of what we must cut back.
“Alternative medicine” is not the answer, although some aspects of alternative medicine may be helpful. China, for instance, did well in its revolutionary years with traditional medicine. However, obtaining medications from natural sources has one of the same problems ethanol has: land for medications competes with food-growing land and wilderness preservation. And, ineffective medications are wasteful.
Miniaturization in medicine is not the answer. Small devices like thermometers, oximeters, pumps, pills, and so on, consume little at their point of use, but they have life cycles both up- and downstream with substantial footprints. Similarly, re-use and recycling in health care tend to be energy intensive because of the need for cleanliness.
In contrast, replacing equipment with staff is an answer because, instead of using energy to maintain machines, we use energy more directly to maintain staff. So, health care should emphasize clinics, home care, and nursing care facilities more than hospitals.
… replacing equipment with staff is an answer.
Philosophically, I think we are making a shift from viewing nature as something that we should be insulated from in order to enjoy good health, to a view that closeness to nature is healthy, as well as environmentally efficient. However, although nearness to nature has been shown in studies to be psychologically healthy,  there are physical risks, such as from mosquitoes, temperature variations, and so on.
There is now a substantial greening movement in health care. Science and Environmental Health Network has outlined basic principles of “ecological medicine” (at http://www.sehn.org). Health Care without Harm (http://www.noharm.org/) has been promoting materials and tools that are more environmentally friendly; they have also been working on waste streams, incineration, and cleansers. And, there is a “green hospitals” movement in architecture following the principles of LEED (see the U.S. Green Building Council at http://www.usgbc.org) and the Green Guide for Health Care (http://www.gghc.org).
These groups, however, are not working much to reduce health care over-scale, and so reductions in scale could synergistically help to reduce the environmental footprint, and thereby the energy consumption, of health care.
Concluding note: Obesity and climate change
A couple of points relating to energy consumption and climate change: There is a global epidemic of obesity, especially in the U.S. This represents an excess of food energy moving into people in relation to levels of energy output through work and exercise. The growth of obesity parallels the growth in energy consumption in society generally, and is likely aggravated by overuse of automobiles, computers, televisions, etc., which reduce activity levels overall. The “energy-saving” devices of the modern home and workplace do not really save energy; instead, they replace food-based energy expenditures with more expensive technologically based energy expenditures.
The growth of obesity parallels the growth in energy consumption in society …
There is thus a prevailing “excess energy consumption disorder” in the developed world that is fostering both climate change and poor health related to overconsumption. Fortunately, both can be mitigated to some degree by replacing technologically based work with simpler forms of labor. It is important that as levels of needed human labor increase and displace fossil fuels, that this be accomplished in a just and healthy manner, so that everyone participates in manual labor, rather than placing the burdens of the heaviest work on the poor.
Meanwhile, if climate change cannot be significantly mitigated, the expectable results of droughts, famines, floods, heat waves, expanded ranges of tropical diseases, ocean level rise, famines, habitat loss, despeciation, and massive migration are likely to vastly reduce the health status of everyone.  This very real potential of global warming to stimulate a global public health disaster is one important motive for undertaking significant reductions in energy consumption in all economic sectors of society.
If business as usual continues, the tragedy likely to ensue is that while health status declines rapidly during this century’s global warming, health care — because of its over-scaled energy and material consumption — will have a limited capacity to respond to these rapidly increasing health care needs. The prudent course is to reduce the scale of health care in order partly to make health care access universal, and partly to help it do its part in mitigating climate change.
Andrew Jameton is Professor in the Department of Health Promotion, Behavioral, & Social Health Sciences, College of Public Health at the University of Nebraska Medical Center.
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[25 jan 08]