Dan Bednarz, PHD
In this essay I argue that the rapid decline of Greece’s health system –and socioeconomic conditions throughout the nation- is proximately due to a fiscal/economic crisis that political and financial leaders have chosen to address by imposing draconian austerity measures upon most of the Greek people so as to: a.) protect the wealth, status and power of dominant elites, and b.) shield and resuscitate a moribund financial system. The distal cause of the deterioration of Greece’s health system, however, lies in reaching the earth’s physical limits to perpetual economic growth[i]. Therefore, attempting to restart growth –the taken-for-granted panacea- is not working and the case of Greece demonstrates that “austerity” has pernicious costs. (Stimulus is a nuanced option not developed here.)[ii] Finally, politicians, corporations and national governments are highly unlikely to recognize that the limits to growth are upon us, while local governments and grassroots citizens movements will by necessity be inclined “cyberneticly” to begin fashioning sustainable health systems (and all socioeconomic institutions) as a way surviving –even if they do not label their situation as entering a post-growth era.
Before reviewing evidence on the deteriorating health system in Greece an orientation is needed. My colleagues and I have for several years argued that as energy decline (colloquially “peak oil”) and other natural resource pressures and ecological crises emerge, industrial economies will hit the limits to growth. Then the debt-based economy and financial system will no longer function properly and socioeconomic activity will begin to contract and show signs of collapse. As this occurs modern medicine, public health and nursing will be unable to protect the health of the public and to deliver treatment medicine (health care) unless they are reorganized to be sustainable in a post-growth world. The case of Greece bears this line of reasoning out. We came to this view through peak oil, although it can be reached via a host of other portals.[iii]
This definition of the situation is not obvious because modern societies function within a paradigm (cognitive dimension) and a mythology,[iv] (affective dimension) whose cardinal metaphors are: the naturalness of perpetual economic growth and the ultimate control of humans over nature and all that is non-human. These metaphors no longer generate solutions to problems nor do they adequately supply meaning and identity to humans because the world economy no longer has access to a platform of cheap energy to operate, maintain itself and expand.
As any system approach would indicate, the crisis does not show up in a clear and visible way – instead, it will appear as a slow erosion of the capability to manage adequately an ever more complex and interdependent reality. It will take the form of a manifold of ecological, financial-economic and social crises.[vii]
This perspective is incomprehensible to institutional leaders. Instead they have reflexively turned with alacrity/desperation to austerity to restore the economic and financial cosmos in which they were socialized, came to power and (for many) continue to profit. For a revelation of the US government’s intellectual insolvency, Peter Orszag, formerly of the Obama economic team, recently told an interviewer: “The truth is that we don’t know how to fix the US labour market – we are in uncharted territory.”[viii] What the US government does know how to fix is the Bureau of Labor Statistics measurement of the unemployment rate.[ix]
With this overview we turn to the health crisis in Greece where they literally are having difficulty procuring aspirin[x] while battling what may be a “superbug” resistant to most antibiotics[xi]. In October 2011 The Lancet published an article examining the health effects of budget cuts to that nation’s health system.[xii] The following series of quotations are from that article. The authors write,
Although people were less likely to visit GPs and outpatient facilities, there was a rise in admissions to public hospitals of 24% in 2010 compared with 2009,9 and of 8% in the first half of 2011 compared with the same period of 2010.10 Major private health providers, although comprising a smaller proportion of care delivery than public providers, were also hit by pressure on personal budgets and registered losses after the onset of the crisis. A 2010 study reported a 25—30% decline in admissions to private hospitals.11
There are signs that health outcomes have worsened, especially in vulnerable groups. We noted a significant rise in the prevalence of people reporting that their health was “bad” or “very bad” (1·14, 1·02—1·28; figure). Suicides rose by 17% in 2009 from 2007 and unofficial 2010 data quoted in parliament mention a 25% rise compared with 2009.12 The Minister of Health reported a 40% rise in the first half of 2011 compared with the same period in 2010.13 The national suicide helpline reported that 25% of callers faced financial difficulties in 201014 and reports in the media indicate that the inability to repay high levels of personal debt might be a key factor in the increase in suicides.15 Violence has also risen, and homicide and theft rates nearly doubled between 2007 and 2009.16—18
Overall, the picture of health in Greece is concerning… Greater attention to health and health-care access is needed to ensure that the Greek crisis does not undermine the ultimate source of the country’s wealth—its people.
The authors offer no policy recommendations, so I conclude they see no alternative to waiting for the restoration of the world economic and financial system.
To supplement this Lancet study I have located anecdotal evidence of an economic Diaspora in Greece[xiii]; and of people so desperate and powerless that they are abandoning[xiv] their children at churches to have them fed, clothed and placed in an orphanage. A January 2012 Washington Post article reads,
“Conditions have deteriorated so dramatically that doctors in this country now believe that the Greek crisis is no longer just a financial crisis but a humanitarian crisis,” said Dimitris Varnavas, the president of the Federation of Greek Hospital Doctors’ Unions.[xv]
To keep the reader’s moral perspective focused the journalist writing this article quotes the familiar “unnamed sources:”
…[P]roponents of austerity say the country has no one to blame but itself…Slashing the deficit quickly is essential to ushering in a sustainable future, they have argued, and the resulting social pain is necessary to impress on Greek politicians and society that such excesses should never happen again.
I’d like to arrest these “proponents of austerity” on charges of moral turpitude and gross malfeasance. “Social pain” is justified by the culturally contingent belief that debt repayment is sacrosanct; it is not[xvi]. This pain is purportedly didactic and will insure that other nations soon to be in Greece’s shoes toe the line.[xvii] Omitted is the fact that Germany and France, among others, encouraged Greece’s debt binge to keep their mercantilist-like economies going. Furthermore, these next in line nations are no more capable of paying off their debts than is Greece.
From the limits to growth perspective Greece is a harbinger of economic contraction and debt deleveraging that is a logical outcome of net energy decline –or the arrival of unaffordable energy prices- in industrial societies.[xviii] The energy status of Greece, Portugal, Spain, Ireland and Italy, all deep in debt, shows that each nation produces little or no domestic oil. Bluntly put: they have been borrowing to buy increasingly expensive oil; and the cost (oil was $10 a barrel in 1998, now it fluctuates around $100 per barrel –and it can crash with further economic decline) now exceeds the potential for wealth and value generated by using the oil to manufacture goods and deliver services. Greece, as one of the world’s energy poorest nations, is the canary of forced energy[xix] decline[xx]and, it follows, reaching the limits to growth.
Unlike Euripides’s,[xxi] I cannot concoct a dues ex machia to fashion a sustainable social-empirical world. Things are rough -and will get rougher for some time to come. But let me in closing offer some thoughts –to be developed in a subsequent essay- on how to think about and build sustainable health systems.
First, all indications at present are that national governments –while having access to sobering viewpoints about the limits to growth[xxii]– are engaged in massive “extend and pretend”[xxiii] propagandistic activities, hoping that soothing words and magical thinking placebos will eventually produce a return to economic growth on this finite planet.
Second, at the local level of government we may see a positive development in the establishment of Departments of Economic Descent,[xxiv] as cities such as Detroit and Flint have no alternative but to contract, ostensibly for economic reasons.
Third, as long as operational resources continue to flow into medicine, nursing and public health in the United States their leaders –not all of the rank and file, however[xxv]– seem certain to continue to dream up band-aid solutions while systemic contradictions and conundrums proliferate. This is a classic example of failing to comprehend and adapt to changed environmental circumstances.[xxvi] However, we are beyond a strategic management conception of the problem. It is more like failing to see the differences between two worldviews. This failure of hierarchical bureaucratic medical leadership –dangerous though it is to the public- will open space for sustainable forms of health systems to emerge.
Fourth, modern health systems’ future is not just one of contraction but of incorporating knowledge about the localized, “small is beautiful” world that is emerging.[xxvii] For example, modern health systems have marginalized or excluded knowledge about the role of food and nutrition and environmental factors[xxviii] in health care.
Fifth, the sleeping giants in creating sustainable health systems are public health and nursing. Medicine appears too compromised (lots of corruption in a for-profit system) and committed to the dominant paradigm/mythology to be a source of change. Donella Meadows’ “Leverage Points”[xxix] and E.F. Schumacher’s Small Is Beautiful[xxx] are great places to begin thinking about how to make nursing and public health the backbone of a sustainable health system.