by Stuart Jeffery

“The true measure of any society can be found in how it treats its most vulnerable members”

Gandhi’s famous quote is highly relevant when considering the health care that is available to a community. But in these volatile, uncertain, complex and ambiguous times of Covid-19 and the coming likely collapse through the twin emergencies of climate and ecology, how will we care for our most vulnerable members, including those who require health care?

In her article on people centred health, Asiya Odugleh-Kolev usefully points out some of the challenges that health systems and communities have faced during the Covid-19 pandemic, particularly around integration of services and emotional health. Given that Covid-19 is just a forerunner of the series of collapses that the world faces, and that there is generally very little written about how health care might realistically change over the coming decades, these future scenarios seem to be ripe for discussion.

The Covid-19 pandemic has highlighted our desire for health care in a way that many of us in the west have never really experienced before, one that is perhaps less about desire and more about the need to be saved from death. This need, born out of our deep fear of death, is one that during my time as a nurse I witnessed repeatedly. The need for external fixes that abdicate personal responsibility is only exceeded by the desire to save our own lives or the life of a loved one at any cost. The idea that death is an essential part of life remains stuffed down the back of the sofa of our collective unconsciousness.

Our ancestors had to deal with death in a fundamentally different way. A few years ago while researching my own family tree, I discovered a many-great’s grandmother who gave birth to 16 children, most of whom died before their first birthday, before she herself died in childbirth. I cannot begin to imagine what she would have experienced each time a child died. Today in the UK these infant and maternal deaths are so rare that they become national scandals.

As I write this, the UK’s latest Covid-19 surge is underway under the grip of the latest variant, but this is in a country that has vaccinated two thirds of its adult population, and will certainly have enough ITU capacity to cope with new variants as long as the vaccine remains broadly effective. The global south, in particular India where this strain originated from, is not coping; a problem exacerbated by the fact that rich countries are buying vaccines at a far greater level than low and middle income countries.

The UK’s NHS relies on its ability to recruit clinicians from Africa and other less well-off countries in order to maintain our health care workforce, a recruitment ability that is founded upon global economic injustice. The failure that is our unsustainably low levels of training in the UK is only matched by our failure to see the demographic shift that will see the number of older people, those over 85, almost double by 2043 (ONS, 2018). Per capita cost of health care is highest in this age group, five times higher than for 60 year olds (Public Health England, 2019). The NHS is not sustainable now and certainly not into the medium or long term. Of course a new variant or two may just change that demographic over the coming years – the future is volatile, uncertain, complex and ambiguous after all.

If the UK’s NHS is struggling to sustain itself, the picture globally is worse. Half of WHO countries have fewer than 3 nurses per 1000 population compared to the UK, at around 8 (WHO, 2021). The situation is similar for doctors; there are simply not enough clinicians globally to meet current health care needs.

Adding to the demographic challenge and the global insufficiency of trained clinical staff, we must ask what happens as climate change, the ecological emergency, resource depletion and pollution increase their grip on the world. How can we maintain health and healthcare in a world that is in collapse or decline? Achievement of the UN’s Sustainable Development Goal of universal health care will certainly become harder in the face of collapse.

There is at least one example of a country that has been through economic collapse and yet seen health care thrive. Cuba’s oil crisis in the early 1990’s destroyed its economy, but a commitment to maintaining health care – and possibly more importantly a focus on training clinicians – meant that health care in Cuba was one of the areas least impacted by their crisis (Jeffery, 2008).

It may be that the aftermath of Covid-19 will provide a renewed global focus on health care with a step change in training, international cooperation and support, public health coming into the front line of policy and so on. I live in forlorn hope.

We can, however, be sure of significant increases in anxiety as demand for, and affordability of, health care increase while global health declines in the future. This anxiety, born of our current refusal to face our mortality and our clinging to the need for quick cures for every ill, will likely make governments protect health care to a greater extent than some other areas of the economies, at least it will if those governments wish to stay in power for long.

While the societal and economic collapses will be tangible, there is already a crisis of meaning and purpose, a spiritual crisis that is driving the wider collapse and that is played out in our refusal to accept death. Perhaps there is learning from Nature, knowledge and understanding that was lost to us when we turned our allegiance towards the false gods of progress and perpetual growth?

Coming to terms with death and illness as part of the richness of life would be a huge leap for modern societies, one that may see us trying to learn from how our ancestors dealt with it and how the rest of Nature deals with it too. Perhaps, that learning combined with our greater knowledge of public health might just make the collapse of health care less painful than it might otherwise be?

Stuart Jeffery is a nurse and former NHS executive who now lectures at the University of Kent on sustainable global healthcare. He has started a new Deep Adaptation task group on the future of health and social care and is looking for people to join that discussion.

Image: “Protection” by Rini Widariyanti, from her “Behind The Mask 2020” exhibition. Rini and her husband Made are Indonesian contemporary artists, based in Bali. Their livelihoods have been severely impacted by the impact of the pandemic on tourism in Bali. They no longer maintain a website, but you can contact Katie in the DA Forum editorial team who can connect you with them if you if you wish to support them by purchasing some of their work.