BY now, after three other articles on disaster management, you probably imagine me to be a miserably pessimistic catastrophiser. Actually, I am generally cheerful and optimistic by nature. However, striving to be like a good chess player (which I am not), I am intrigued about long term complex interactions.
In my series of disaster monologues (here, here, and here), I have sought to encourage an open discussion of how we might best respond when things go wrong (good medical practice). Previously, I focused on disruptive events and the necessity for an agreed set of common values, goals and skills to guide our actions. Finally, I would now like to explore how, whether spontaneously or triggered by perhaps even a seemingly insignificant external event, a major disruption to supply can arise from within the complexity of our health care system, and how we might deal with it. I will be happy if this article stimulates open discussion of the hazards we face. I have not discussed the unknowable details, but focused on the principles.
Numerous colleagues and friends, many of whom, like me, benefit within the current system, have observed that the current rate of growth of expectations and costs in our First World health system is unstainable. By this we are acknowledging Stein’s Law:
“If something cannot go on forever, it will stop.”
An unrestrained health system might simply collapse slowly at first, but then rapidly, as resources are exhausted by demand. No one in a deckchair watching the erosion of a coastline by waves and rising sea level should be surprised when houses start to fall into the sea. But we are not passive observers, we are all players and will suffer greatly from disruption to the supply of health care, whether as providers or consumers.
An exploration of the literature on disasters reveals a world of study on the common themes of catastrophe. Many of the primary sources are incomprehensible to those who, like me, are without sufficient mathematical skills. For the common reader, I recommend Ubiquity by Mark Buchanan (which has no equations), Woo’s Calculating Catastrophe (in which I could skip over the equations without losing the thread), and Collapse: how societies choose to fail or survive by Jared Diamond.
Physicists seeking to understand landslides created computer models in an effort to understand how they might be predicted. They found that there is an inverse relationship between the severity and frequency of landslides. However, they also found it is not possible to predict the timing or severity of any particular landslide.
Since then, mathematicians, biologists, economists and historians, among others, have joined the fray and have applied such thinking to the natural world and human behaviour, and explored the patterns of our prior experiences with disaster. They identified that as systems become increasingly complex, they move towards a critical state where inherent instabilities manifest as unpredictable collapse, and found, repeatedly, the inverse relationship between the frequency and severity of individual events. A seemingly minor event can morph into an unexpectedly major collapse because it is not possible to comprehend all the interconnections of the vulnerabilities of complex critical states.
This pattern has been confirmed for earthquakes and volcanic eruptions, avalanches, ecosystems, extreme weather, economic crises, wars and other human behavioural phenomena.
Collapses reduce the overall level of instability of systems but at the cost of disorganisation. A minor slump can be repaired in a short time but that may simply restore the critical state. A severe collapse can result in the near destruction of a system. For example, in the remote past, complex worldwide coral reef ecosystems totally collapsed on a number of occasions and each time took many tens of millions of years to re-evolve, rather than repair.
While all of this may be regarded as rather abstract, there is no reason to think that our complex health systems are any less subject to unpredictable collapse than other complex and potentially unstable human systems such as financial markets and economies. Additionally, events outside systems of health care can change an environment in which they had previously seemed stable.
What particular issues contribute to the risk that our health services might destabilise?
I first started working as a doctor when renal dialysis was generally only available to people younger than retirement age. The starting point for decision making was whether the patient met that inclusion criterion. Our world has changed dramatically over the course of my medical career. As more resources became available, access was extended to include virtually anyone with renal failure, unless there was a medical contraindication or the person refused (assuming they were asked).
Across the board, our technological prowess in treating diseases is escalating in specificity, intensity and in cost. At the same time, the culture of health care has embraced the default response that we almost always start treatment with the goal of prolonging life (opt-out cardiopulmonary resuscitation), often even for people who are at the end of their individual maximum lifespan.
The primary goal has become to maximise the quantity of life for every individual patient with the result that new, life-prolonging health care discoveries and inventions are almost immediately incorporated into standards and guidelines as mandatory best practice. This paradigm encourages, and has been encouraged by, the commercialisation of individual disease opportunities. The system has become a free-standing, inward-looking, circular argument somewhat disconnected from any consideration of the broader interests of the community in which it sits.
High technology medical services are only sustainable with the smooth operation of hugely complex interconnected networks of technology and skills which depend on very long globalised supply chains, many of which operate on a just-in-time basis. The forms of these reactive, opportunistic and relatively laissez-faire health service systems have evolved with little coherent long-term planning and with no consideration for their impact on the long-term overall sustainability of community as a whole.
Some “known knowns” are well known. We know the size of our Baby Boomer population (me included) and the burden of ageing and disease that we bring with us. Recently, our Treasurer commented on the “fiscal time bomb” of our ageing population. The Royal Commission into Aged Care Quality and Safety has gathered extensive evidence that systems are failing our expectations and will, no doubt, make further recommendations for higher standards and increased expenditure.
The “known unknowns” exist as a range of disastrous but complex internal and external threats. These are the phenomena of nature (earthquakes and cyclones), human affairs (economic collapse and international conflict) or a combination of both (pandemics, global climate change, environmental damage, and ecosystem derangement). There will be another severe global influenza pandemic, another San Francisco earthquake, ongoing political upheaval and war, another global financial crisis, and there is no doubt about the enormity of the threat of human-induced changes to complex ecosystems and the global climate.
Connectedness, complexity and randomness bring a range of “unknown unknowns” that can cause even known and predictable events to generate unpredictable and catastrophic consequences. Nobody can possibly understand the full impact of global interdependency on the stability of our health care systems, and it is not knowable how far our health care systems may have progressed towards a critical state of instability. We live on a globe of fixed surface area while practising an economy that includes health care systems founded on perpetual growth.
Economic crisis disrupted health care in Greece, exacerbating entrenched inequalities (here and here). In Venezuela, health services have collapsed; paediatric mortality exacerbated by starvation has soared, many women cannot obtain basic obstetrical care, paediatric oncology treatment has been ceased, and hospitals frequently have no electricity (here, here and here). One hospital required that a patient’s family bring a piece of paper so that the doctors could make notes.
Many of these issues seem very remote from our experience here in Australia. Perhaps we take comfort in the belief that by becoming self-sufficient we can avoid a disaster of supply due to causes external to Australia. Unfortunately, most of the drugs and equipment necessary for high technology treatment are manufactured elsewhere.
In the face of the growing climate emergency and global economic uncertainty and interdependency, there are many plausible scenarios that would require us to curtail expenditure on health care. Australia is only another year or two of continuing widespread drought away from major environmental, economic and community disruption; and as our summer of drought and horrifying bushfires continues, the rest of the world is watching.
As the evidence of uncontrolled human-induced climate change mounts (here, here and here), we are starting to understand the scale of the global problems we face: the impact of changes in weather patterns on food production, inundation of coastal communities by sea level rise, turmoil in the world economy. Each of these will have an impact on how we are able to live our individual lives, and the resources available for the health care we have come to expect.
So, what can we do to stabilise our health systems to reduce the risks of social, financial and/or environmental disorder?
The first step is to accept that we have no choice but to act on the known threats.
This starts with a candid introspective assessment of our health system, including how the complexities of its design and the interplay of vested interests contribute to inefficiency, inequality and systemic vulnerabilities.
Concurrently, we can consider the gravity of the external threats to which, peculiarly, so many in our community seem to have developed a tin ear. These are the “known knowns” of large scale national and global risk.
- All of those of us who are or will become elderly and die in the next 30 years already exist as the middle-aged or elderly.
- Most of the children and grandchildren who will find themselves funding and managing our care are all already alive in insufficient numbers to provide for us. In a few decades the ratio of working-age people to the elderly will be 2.7 to 1.
- The fact of global climate change induced by human activity is indisputable.
- No one seriously challenges the laws of physics and chemistry that drive the impacts of rising ocean temperatures and CO2 levels (ie, reduced oxygen solubility and expansion of seawater with increased temperature, and the relationship between the pH of seawater and dissolved CO2).
- The volume of water melted from the Greenland and Antarctic icecaps and the associated rise in sea level are measured almost in real time by highly accurate satellite-based technology.
- Multiple environments across the world are being disrupted, including the decimation or extinction of a huge variety of animals and plants.
Without accepting the reality of such challenges, we will never be able to engage in a discussion about how we might start to deal with them.
It will not be easy. Open conversation will expose the tension between our personal desire to prolong our own lives and those of people close to us, and the need to focus on the viability of our community for the long term.
Just as patients expect us as doctors to raise difficult issues of life and death, we should require our leaders to avoid bland reassurance and facilitate discussions on these threats to our community. Our responsibility is to encourage them, rather than focus on our individual short term interests.
In the natural world, redesign generally follows on from collapse, as an evolutionary process. A controlled move from one complex state to another is an unprecedented challenge (Ubiquity, pages 104-122).
Here in the developed world, we have become unaccustomed to broad restrictions to our access to health care based on the limits to supply. In the event of a severe involuntary contraction of health care, we would have to deal with both limits to established treatments and refusal of the new – the withdrawal of that to which we have been told we have a right and on which we may have become dependent, sometimes for just staying alive. Many people would resist such policies. We would all need reassurance that the processes of a reprioritised system of resource allocation were just and included clear definition of the goals and ethical principles for decision making (here and here).
The innate unpredictability of complex open systems, be they health care or the global environment, means we cannot measure every interaction and can never know exactly what will happen. Complex human systems can collapse spontaneously, with the risk exacerbated by the clearly identified consequences of global climate change, as well as the surprise of less predictable disasters. The further the can of “known knowns” is kicked down the road, the more painful the options become.
In line with the thread that runs through most of my articles in InSight+, everyone benefits when as a culture and as individuals we integrate the reality that each individual life is finite. That realisation shifts our sense of humanity’s locus of control towards the realisation that the complexity and uncertainty of our world shapes our destiny. While we may back our own intelligence and ingenuity, we have little understanding of the complexity of the human systems that we have created, let alone those of the dynamic natural world that we disrupt with so little thought. We are vulnerable to catastrophic collapse of either and both.
This is a challenge to all of us to choose broad science over narrow ideology.
Dr Will Cairns is loitering on the brink of retirement from his role as a palliative medicine specialist based in Townsville
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.