Health is a sustainable state
MAURICE KING
"If in this world misery must exist, so be it: but let some little
loophole, some glimpse of possibility at least, be left, which may
serve the noble portion of humanity to hope and struggle unceasingly
for its alleviation ... Fate has allowed humanity such a pitifully
meagre coverlet, that in pulling it over one part of the world,
another has to be left bare." - RABINDRANATH TAGORE, 1893
The
World Health Organization opens its report From Alma Ata to the
Year 2000 [1] with Tagore's words. In
it WHO acknowledges for the first time the terrifying spectre of human
communities destroying their ecological support systems as the result of
population growth. However, the report neglects the health of the planet
itself, and the contribution to planetary ill health made by the industrial
one-fifth of the world, [2] which makes greater
demands on the global ecosystem than do the remaining four-fifths.
The high rates of population growth in the developing world are the result of falling death rates, and of birth rates which have risen, and in some cases are still rising. [3] Notestein's [4] model of the demographic transition from high birth and death rates to low birth and death rates was largely built on the experience of the industrial world. He described a first stage, when both birth and death rates are high and the population grows only slowly. During the second stage living and health conditions improve and death rates fall, but birth rates remain high and the population grows rapidly. In the third stage economic and social gains combine to reduce poverty and lower the birth rate, so that birth and death rates are in equilibrium again, but at a much lower level.
Populations with rapid and sustained growth in the second stage are in danger of exceeding the capacity of their local ecosystems, especially if these are fragile, as in much of the tropics. They face a three-phase ecological transition, which contrasts with their demographic transition in having a disastrous third phase. In the first phase expanding human demands are well within the sustainable yield or carrying capacity of their ecosystem; in the second phase human demands exceed the sustainable yield, but are still expanding as the biological reserves are consumed; and in the third phase human consumption is forcibly reduced as the ecosystem collapses.
An essential feature of a demographic transition is that it is a transition. The unstable second stage must be completed quickly, otherwise the population will enter the demographic trap-if the birth rate does not fall, the death rate will ultimately rise again, so the population is stuck in the trap and finds itself in an unsustainable state with a high birth rate and death rate, with ever increasing pressure on its resources, and with a rapidly deteriorating environment. Whether a population gets trapped depends on its rate of growth, and on the ability of the local environment to support that growth. The possible outcomes are limited: the population can: (a) die from starvation and disease; (b) flee as ecological refugees; (c) be destroyed by war or genocide.) or (d) be supported by food and. other resources from elsewhere, first as emergency relief and then perhaps indefinitely.
The demographic trap [5] is a new term and a good one, although the idea is old. Malthus [6] did not foresee the demographic transition, or the need to pass through its second stage quickly; nor did he foresee that negative feedback could destroy the biological support system and cause ecological collapse. Such a collapse and ecological refugees have already occurred in parts of Ethiopia, until now on a limited scale. [7] How far are the earlier stages of the same process operating on a wider scale elsewhere? Early signs would be a slowing of the expected fall in the child death rate followed by a rise. Ominously, UNICEF report that, after decades of decline, the infant mortality rate has stopped failing in at least 21 developing countries, and is rising in others. [8] Incipient ecological collapse is one of the possible causes.
The huge and rapidly growing cities of the developing world are in an ecological predicament which is no less grave. Unlike rural areas, cities are normally fed, watered, and supplied with energy and materials from elsewhere. Many are fed from the grain surpluses of North America. Many of these cities are even now barely viable, [9] and the human condition of most of their citizens defies adequate description and promises to deteriorate.
There is a widespread assumption that the necessary and sufficient condition for reducing the birth rate is to reduce the child death rate. The reasoning is that if families see that their children no longer die, they will have fewer of them. [10] Preston has already questioned this notion. [11] He found "... hopeful policy declarations resting on a thin research base", and wondered how much mortality decline can be expected to translate into fertility decline and the strength of this relation in "setting levels of mortality control". He also found that an addition child death in a family leads to far less than one additional birth, especially in pre-transitional .high-fertility societies, and concluded that: "The picture is not attractive for those who look to mortality reduction as a means of reducing fertility through familial effects, let alone those who advocate such measures as a means to reduce growth rates. Nor does it lend much support to models of fertility decision-making that view couples as proceeding deliberately ... towards some target number of surviving children".
The association between declines in child death and -birth rates is complex. The view that, if the child death rate declines sufficiently, the birth rate must decline also, and that there is a causal relation between them, is untenable. Such association as there is, is best explained if both rates respond to other common factors. In particular, the birth rate is unlikely to be lowered by measures designed to reduce the child death rate that are imposed on people by vertical programmes - e.g., those for mass immunization and for oral dehydration for diarrhoea - and that do not simultaneously change people's behaviour, lifestyle, and standard of living.
A fall in the birth rate leading to a demographic transition seems to require the harnessing of social and economic gains to the reduction of poverty and the promotion of socio-economic development. Unfortunately, serious constraints prevent such development happening and the birth rate falling as fast and as widely as is necessary to escape the demographic trap. These factors include lack of agricultural land and its poor quality, poor supplies of energy and other raw materials, limited access to education, and lack of political representation. There is also the economic stranglehold exerted by the rich over the poor, and by the industrial over the developing world; the time needed for structural and cultural change must also be taken into account. . For many countries these constraints appear to be so great that a demographic transition is unlikely to occur before excessive pressure is exerted on the ecological support system.
Thus, to the argument that the most effective way to bring down the birth rate is to lower the child death rate, the tragic reply has to be that, even if this were true, there is no certainty that a community will not destroy its ecosystem first. It has been argued that, even if this were not true, the effect would "not be very great", and that a halving of the child death rate overnight would add only 10% to the elected 10.5 billion people in 2110. [12] As if to confirm this Prediction, the United Nations Population Fund now report that mainly due to slower than expected declines in fertility "...the world has overshot the marker points of the 198 most likely medium-term projection and is now on course for an eventual total that is closer to 11 billion than 10 billion". [13] This extra billion will be mainly added to the world's most tragically trapped. I believe this outcome is due not only to declining efforts in family planning, but also to declining child mortality not having its alleged effects on fertility.
During
the next century world population will probably double and could triple.
[13] It is difficult to escape the conclusion
that there are going to be population crashes as the result of diseases
old or new (e.g., human immunodeficiency virus infection [HIV] in parts
of Africa), or of famine. The African famine
in the mid 1980s is expected to have been the first of a modern series
which will strike Africa again, and also India, in the 1990s and beyond
(J. Seaman, Save the Children Fund, personal communication). 10% of India's
starving will soon be a 100 million people.
The reduction of human death rates has always been seen as an absolute good in public health, and unease about population increase has never been an accepted constraint on any public health measure. Will visions of the ultimate effects of population expansion alter this view? Hill called it "the most solemn problem in the world" and wrote: "If ethical principles deny our right to do evil in order that good may come, are we justified in doing good when the foreseeable consequence is evil?" Are there some programmes which, although they are technically feasible, should not be initiated because of their long-term population-increasing consequences? In Preston's words, should one deliberately "set levels of mortality control"? Is what is done corporately in public health ethically different from what is done individually? How far is it necessary to look into the future to decide between immediate and distant goals? How much should ecological sustainability influence health programmes?
The ultimate in unhappy choices is to be faced on the one hand with not doing all that is possible in public health, and on the other with increasing ecological deterioration, leading eventually to starvation and to the destruction of the very population it is intended to benefit. Are ecology and compassion incommensurate? To say that the ecological state is never simple, that prediction is uncertain (HIV was not predicted), and that no single public health programme will have any significant demographic effect, does not provide an escape from the dilemma.
Belated recognition of the need for global sustainability is destroying one of the deepest convictions of Western civilization - that our ability to control the natural world will ultimately allow all communities to develop indefinitely in an endless progression. It is also destroying the illusion that if the problem of equity can be postponed for a while, in the hope that if all peoples get richer and technology gets better, sustainability will be easier to deal with. Unfortunately, irreversible changes in the environment will make equity even more difficult to achieve in future. Although Tagore's meagre coverlet is keeping the early achievers warmer, they are mostly responsibility for wearing it out.
At the root of our difficulties lies the fact that, on one hand we share with all other animals a dependence on the same ecological constraints of territory, food, and population as they do, and yet on the other hand we have a unique ethical view of ourselves as people. In humanist terms this is the absolute value of each single human being, and in theist, or at least Christian, ones it is the value of each one of us in the eyes of the Creator. This brings the argument into metaphysical dimensions - what is the purpose of man?
What
do philosophy and particularly ethics contribute to all this? Logic
can monitor the arguments as to how a man should act, but cannot show that
one set of premises from which these arguments are developed is better
than another, hence the interminable nature of much ethical debate.
The choice of initial premisses is influenced by the social and metaphysical
position of the contestants. Hitherto, living man has been the measure
of all things; now many people are beginning to wonder if this measure
should not be the integrity of the ecosystem or the welfare of future communities.
Unfortunately, these premises conflict. Adherence to them also seems to
be changing.
Broadening concepts of health
Health was originally an individual concern, then a concern of the family (family health), and then of society (social medicine). More recently WHO has introduced the concept of Primary Health Care. All current concepts of health focus on the present, in that they take no account of either future individual health, or of the health of future communities. In effect, concepts of both individual and public health end with the death of the patient.
In most parts of the world, the ecological threat to health is a problem for the future not the present. It can be argued that any concern with the future must be the luxury of those who are healthy today, and cannot be a concern of the world's present sick and starving. Surely the response to this is that, of all the criteria of human achievement, none more universally commands respect than the transcendence of self to care for what is not oneself; care for what happens in future is merely an extension of concern for what is not "ourselves".
According to the Brundtland Commission [16], concern for the future is a concern for "sustainability - the ability to maintain the desirable elements of the status quo into the future". If the concept of health is to include the health, and even the existence, of future populations, WHO's celebrated definition should become "Health is a sustainable state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity". It is sustainable for the individual in that it enables him to live out his normal lifespan; more importantly, the means of achieving it must be consistent with the health and existence of future communities. However, the Brundtland definition is incomplete. Since social and economic change is inevitable, sustainability should be "The maintenance of the capacity of the ecosystem to support. life in quantity and variety".
Although health has many established ecological relationships, such as
those between man and his parasites, his food, and his water, the concept
of sustainability extends these and takes proper account of the ecological
foundations of health. Sustainability is also the theoretical basis for
necessary action, with important implications for lifestyle. A healthy
lifestyle must now encompass a sustainable
lifestyle, in that to live healthily one must also live in a sustainable
relationship to one's environment. Unfortunately, the modest demands of
a healthy lifestyle are trivial for those who live in the industrial world
compared with the demands of a sustainable one.
The strategies of WHO and UNICEF for Primary Health Care and for Health for All by the Year 2000 are majestic "political directions" in which "the global health machinery" is being mobilized. From Alma Ata. .. reviews their, and they have accomplished much. However, they do not address the new threats and the new dilemmas. Somehow, we must courageously enter the era of measured and managed sustainability. Some of the challenges, especially massive famine and huge numbers of refugees, are so unmanageable that it will have to be a long-term goal.
There needs to be a major change in the structural relations between North and South, as well as within each of them. Most difficult for those in the industrial North, with its unsustainable economy, a sustainable lifestyle means consumption control-intensive energy conservation, fewer unnecessary journeys, more public transport,- fewer, smaller, slower cars, warmer clothes, and colder rooms. It also means much more recycling and a more environmentally friendly diet with more joules to the hectare. The deliberate quest of poverty (for the privileged North the reduction of luxurious resource consumption) has an honoured history. Sustainability supports this, and means that any further increase in living standards must be achieved in a way that does not increase resource consumption, and may require that consumption be reduced.
In the South the grave nature of the demographic trap should be widely publicized. Time for manoeuvre is critical; for populations entering the trap there is insufficient time before disaster for the ordinary processes of development, assuming they occur, to lower the birth rate. Family planning programmes must be promoted with renewed vigour, and the objective of sustainability used as the impetus to drive them. Sadly, there is much unfulfilled demand for family planning, especially in sub-Saharan Africa. [17] An ecological view of the world must be shared by as many of the world's people as possible. Each community must decide what immediate consumption should be forgone, and by whom, in the interests of future generations. Reduced childhood mortality must no longer be promoted as a necessary and sufficient condition for reduced fertility.
The demographic and ecological implications of public health measures must be understood at all levels, especially by the community. If these are desustaining (sustainability reducing), complementary ecologically sustaining measures, especially family planning and ecological support, must be introduced with them. If no adequately sustaining complementary measures are possible, such desustaining measures as oral rehydration should not be introduced on a public health scale, since they increase the man-years of human misery, ultimately from starvation. [See Doctor says let sick children die] However, the individual doctor must rehydrate his patient. Surprisingly, health services may not be a priority for these communities (Seaman, personal communication). Mother Theresa has reminded us that the world's poorest need our love and compassion. Tragically, such programmes may not necessarily be part of that love.
These are disturbing reflections, setting, as they do, levels of mortality control. What should our personal response include when we are faced with the consequences of unsustainability , and especially with famine, for which we can do almost nothing?"' We should: (a) resolve to live a sustainable lifestyle; (b) promote the sustainability of our own community with the utmost determination and (c) refrain from advocating public health policies for other communities which, unappreciated by them, worsen their sustainability so that they ultimately starve.
Such
a strategy needs a name. Why not call it HSE 21 00 - Health in a sustainable
ecosystem for the year 2100? WHO has been exclusively concerned with the
health of the people of the world. Ale recognition that their health
is dependent on the health of the planet means that WHO now has a shared
concern for the health of the planet as a whole. Only in this way will
it properly care for them, and will it truly become ne World Health
Organization.
I thank the following for their many contributions: Dr Jane Adam,
Dr John Blacker, Prof David Bradley, Dr Leslie and Mrs Ann Burgess, Rev
Charles Elliott, Dr Andrew Green, Prof Adrian Hastings, Dr Alan Hill, Mrs
Dorothy Hobson, Dr Gunnar Holmgren, Dr Jennifer Jackson, Prof Urich Loening,
Prof David Morley, Prof Philip Payne, Dr Peter Poor, Dr John Seaman, Dr
Rudi Slooff, and Dr George Ross.
This paper is based on the 1990 Swellengrebel
Lecture given by MK to the Netherlands Society of Tropical Medicine.