The Problem Domain

Tracing the Problem Domain for Medicine in the Anthropocene: Trajectories of Change and Minimum Specifications for Adaptation

Problem context

Part 1: Trajectories of Change

Health systems in the Anthropocene will need to adapt to pressures at the confluence of planetary ecology, the global political economy, and cultural meaning systems. This post will draw together the socio-ecological trends that are converging to transform health and medicine, both at the institutional level and in the informal ways people in diverse local worlds perceive and pursue health in their daily lives. It is intended to capture challenges, tensions, and possibilities, tracing the edges of the problem domain surrounding medicine in an era of social and environmental instability.

I propose that the following trajectories will define the transformation of health systems in the Anthropocene:

  1. Declining resource and energy flows. We have already passed peak production of many nonrenewable resources that industrial capitalist societies rely on for continued economic and technological growth (e.g. oil, copper, and rare minerals that are essential for renewable energy and other advanced technologies). This means that if we are to avoid catastrophic climate change, the material and energetic inputs into all sectors of the economy, including healthcare, will have to be reduced.
  2. The end of economic growth. Evidence from ecological economics and natural sciences suggests that economic growth and environmental sustainability are irreconcilable. Attempts to increase efficiency or to redirect growth to the green economy have not resulted in absolute reductions of material or energy use at a global scale. Projections of potential future efficiency gains offer little hope of continuing to expand the market economy while accomplishing sustainability goals (economic activity would have to be taking carbon out of the atmosphere by 2100 to stay within safe levels). Further, addressing inequality between rich and poor countries and between the rich and poor within countries in a context of ecological constraints will inevitably require wealthy nations to reduce their levels of consumption. Work in degrowth economics shows that the end of growth opens up opportunities to reorient the economy, positioning care as a central organizing principle.
  3. Vulnerability to rapid losses of social complexity. Complex systems theories coupled with historical studies of civilizations such as the Romans and the Maya suggest that increased connectivity and social complexity require ever-expanding material and energy inputs that, when they can no longer be acquired, can precipitate societal collapse. The degree of integration of elements in a complex system has a strong effect on its rigidity and vulnerability. Highly connected systems like our current globalized society are particularly vulnerable to tipping into a phase of creative destruction (for an ecological metaphor, think forest fire in a mature forest). Creative destruction is devastating to the established order, but also releases resources that have been tied up in the existing system to be used in new ways. Health systems will be dramatically affected by any broad-scale social collapse that, for instance, curtails industrial production of medical technologies and pharmaceuticals or that limits their international distribution.
  4. Geopolitical conflict. Warfare in Syria has witnessed hospitals, medical facilities, and medical professionals becoming military targets. Doctors have been forced out of conflict zones or made to work in hospitals without basic equipment or supplies, sometimes even without electricity. In modern war zones, experiments in remote consultation and trauma surgery are emerging out of necessity in the most painful circumstances.
  5. Extinction of medicinal plant species. Climate change is pushing many medicinal plants, central to the medical care of most of the world’s population, toward extinction. The loss of local plants deprives people who lack access to biomedical treatments of their primary mode of healing. It could also limit the availability of plant compounds that are essential ingredients in common pharmaceuticals.
  6. Changing ecologies of disease. As the planet warms, disease vectors that were once confined to tropical regions are migrating into new environments, increasing the incidence of endemic diseases like Malaria and spreading new infectious diseases across a broader geography. Growing antibiotic resistance is also pushing us into a post-antibiotic period. Without antibiotics, the success of cancer therapies and surgeries, which rely on antibiotics, could be seriously reduced, while old diseases once thought to be eradicated begin to reemerge.
  7. Aging demographics. Declining birthrates and increased life expectancies in affluent regions have culminated in an aging population that will live longer and require ongoing care for chronic conditions including heart disease, respiratory health problems, cancers, and dementia. With fewer people of working age to support government provision of healthcare services in the global North, and in a context of shrinking economies and ecological constraints on resources, the demographic transition will strain healthcare services and call for new arrangements for elder care.
  8. Reimagining the welfare state. The end of economic growth creates a crisis for the welfare state, which currently depends on taxation of individuals and corporations for funding. If growth cannot be assured, social welfare will need to be provisioned in new ways. Austerity measures have already gutted healthcare services in countries like Greece that have experienced economic collapse. Options such as a universal basic income funded through global resource rents offer to relieve pressure on overstressed services, but require a radical reorientation of the state’s role in the provision of welfare and social security.
  9. The rise of diseases of modernity. Diseases of modernity like type 2 diabetes, cancer, osteoporosis, and depression emerge due to the wide gulf between the environment in which humans evolved and the behavioural patterns of industrialized nations. Depression, increasingly affecting young people, is associated with diets lacking in essential micronutrients, low levels of physical activity, a reduction in the number of hours slept each night, and intensified social inequality, competition, and isolation. In modern societies, embodied states once within the normal range of human variation are pathologized and treated. Medicalization contributes in some instances to social emancipation for people with disabilities while in others extends the scope of social control over perceived undesirable behaviour or is driven by pharmaceutical companies intent on marketing new cures for new illnesses.
  10. Individualization. Individualization pervades all aspects of modern life, manifesting in medicine as a determined focus on curing individual bodies and extending the lifespan. In societies where health is understood to be an individual responsibility, illness comes to be seen as a personal failing. Individualization masks the social aspects of illness, psychologizing social, economic, and political issues and leading to rising levels of anxiety and psychological disorders. Individualization in healthcare is currently realizing diminishing gains at the level of society and ecology. For example, the quest to extend the lifespan is rapidly expanding the ecological footprint of medical interventions while in some instances decreasing quality of life close to death and contributing to widespread isolation and loneliness among the elderly).

Part 2: Minimum Specifications for Adaptation

With these trajectories as a backdrop for the continued adaptation of human health systems, hope lies in the reinvention of social arrangements of care, the development of low-impact technologies that enable prosumption in healthcare, the growth of captivating meaning frameworks to orient the life course, and the recombination of elements from modern and traditional medicines. I will consider these possibilities in detail in future posts. For now, I will end with what I see to be the minimum specifications for health systems in the transition to an ecologically viable society. Based on the trajectories listed above, effective strategies for medicine in the Anthropocene may attempt to:

  1. Decrease the social and technological complexity of modern medicine as part of a broader project to align society’s energy and material throughput with the capacities of the biosphere.
  2. Extract the best of modern medicine from reliance on industrial production, consumption, and distribution, grounding these processes in an alternative political economy that is radically different from the one in which it developed.
  3. Re-embed aspects of healthcare in networks of family and community reciprocity.
  4. Leverage disruptive technologies (e.g. 3D printing) and ontologies (e.g. cultural understandings of health, illness, the good life).
  5. Question the unit of analysis in medicine (the individual), integrating broader recognition of social, cultural, and ecological health.
  6. Re-frame the problem of death through culture change and re-enchantment.

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