Oil Vulnerability of WA`s Health System

Report
Peak Oil, Energy Descent and
Healthcare
Dr Jim Barson
MBBS, Adv Dip Clin Hyp,
DRCOG FANZCA
Convenor of the Health Sector
Working Group
ASPO-Australia
Will Global Oil Shortages Occur
in the Short-Medium Term?
Bruce Robinson, Convenor
16th May 2012
Key takeaways:
40
1. Serious global oil shortages are quite likely in the near term.
The evidence is mounting.
30
Peak Oil
but
when?
20
2. Forward planning should include serious consideration of
"Peak Oil" scenarios
10
3. Oil vulnerability assessment could be a valuable precaution
0
1930
1
21
1970
41
61
2010
81
101
2050
121
● What is Peak Oil ?
It is the time when global oil production
stops rising and starts its final decline
● When is the most probable forecast date ?
2014 +/- 5 years
Why is the risk being largely ignored?
● “Peak Exports” will arrive sooner, as exporting countries use more of their own oil internally, leaving less for export
www.ASPO-Australia.org.au
An Australia-wide network of professionals working to reduce oil vulnerability
Working groups
Oil & Gas industry
Urban and transport planning
Finance Sector
Health Sector
Social Services Sector
Regional and city
Defence and Security
Conservation and Environment
Remote & indigenous communities
Active transport (bicycle & walking)
Agriculture, Fisheries and Food
Biofuels
Construction Industry
Public transport sector
Economics
Tourism
Children and Peak Oil
Young Professionals working group
Revised edition, 2008
Why do leaders consistently ignore looming signs of crises even when they
know the consequences could be devastating?
Most events that catch us by surprise are both predictable and preventable,
but we consistently miss (or ignore) the warning signs
Is Peak Oil a "Predictable Surprise" which is being ignored??
Sydney Morning Herald, 10th July 2008
Oil prices to double by
2022, IMF paper warns
with sweeping implications for
the global economy, according to
a report commissioned by the
International Monetary Fund.
(West Australian 15th May 2012)
Global oil production limits are in sight.
Macquarie report, 2009
Peak Oil, Energy Descent and
Healthcare
The anaesthetist, by training and
disposition, is a vigilant pessimist.
Introduction

The Impact on Healthcare Delivery of Peak Oil &
Energy Descent

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Global
National
Regional
Local
Professional
Barriers to progress and possible strategies
Global
The medical industrial complex is global
 Globalisation has been based on

Low costs

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Wages
Materials
Energy
Transport
It has resulted in
 Extreme centralisation

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For example most of the world’s disposable syringes are made in just
a few factories in Asia
Very long and vulnerable just-in-time supply chains
Global
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Our healthcare system is part of a global system that is
optimised for efficiency at the expense of resilience
Container ships have halved their speed to save fuel
Efficiency vs. Resilience trade-off is unwinding.
Just-in-time delivery becoming unreliable
Warehousing and redundancies necessary
New model should be ‘Just-in-case’
Systemic Risk
Economic
Global
Oil is Growth
Systemic Risk
The global →
financial crisis

Not enough capital
for alternative
energy projects
← Peak oil &
energy descent

Not enough oil to
grow out of
unsustainable debt
Systemic Risk
Structural
The Diminishing Return on
Increasing Complexity
Highly complex and
interconnected systems are
inherently unstable and prone to
collapse
(1)
Energy and Complexity

High energy inputs are
required to sustain
complex systems.
Energy and Complexity

High energy systems
allow niche specialisation
Energy and Complexity
Low energy inputs
result in low complexity
systems
Energy and Complexity
 Low
energy input
favours flexibility
Less energy = Less complexity

Our future will not be a linear extrapolation from the
past through the present and beyond because we are
approaching a period of unprecedented change.

What to do with our diminished capacity?

Stem cell therapy?


The pursuit of esoteric individual therapy
Vaccine production?

The pursuit of public health
Systemic Risk


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Modern healthcare is an open, high energy, extremely complex
system of material and human inputs and outputs.
Each material input to the system eg. pharmaceuticals, is in
turn a network (often global) of subsystems.
Each material output eg. contaminated waste, is likewise a
network of subsystems.
Staff and patients require some mix of transport systems to
provide around the clock mobility.
Each system and subsystem consists of a chain of steps, each
of which is in some way dependant on the ready availability of
low cost, high energy petroleum.
Systemic Risk


Peak oil is a ‘Preconditional Crisis for
Healthcare’ (2)
Healthcare delivery is a highly complex
system that requires huge inputs.
Energy per se
 Petroleum derived products

It’s not just energy
Anaesthetics, antibiotics, anti-histamines, antiseptics, artificial limbs, aspirin, balloon pumps, bandages,
bottles, blankets, bypass pumps, cameras, cannulae, carpet, catheters, CDs, computers, condoms,
contacts, cortisone, creams, CT scanners, dental equipment, deodorisers, detergents, dressings,
dryers, ducting, DVDs, endotracheal tubes, glues, gowns, fibre-optic equipment, hearing aids,
heart valves, heating equipment, ink, insulation, IV fluid bags and tubing, laryngeal masks,
lubricating gel, masks, mops, mortuary supplies, MRIs, needles, offices supplies and equipment,
ointments, oxygenators, paraffin, pathology equipment, pens, petroleum jelly, plastic chairs,
plastic cups, plastics bags, plastic wrap, packaging, pharmaceuticals, refrigerators, rubber bands,
rubber boots, rubber gloves, rubbish bags, scrub brushes, solvents, speculums, sterilisers, sterile
packaging, stethoscopes, stomal therapy supplies, suppositories, syringes, surgical drapes, surgical
stockings, sutures, tape, trays, trolleys, tyres, ultrasound equipment, vaporisers, video equipment,
water pipes, water filters, wheels, X-ray films.
And all the trucks, fuel and logistical support to move this stuff and all
the masses of food, linen and non petroleum supplies into and out
of every healthcare facility everyday without any delay.
Systemic Risk



Cascading system failure is a real risk
Failures in manufacturing, transport or delivery
of critical components could bring widespread
chaos
Standardisation and stockpiling
Risk Management

Exposure
Transport fuel
 Medical plastics
 Pharmaceuticals
 Equipment and spare parts

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Susceptibility
Resilience
Adaptive management
Adaptive Management


Developed to cope with non-linear variables in
the resource industries
Applicable to public health and peak oil
Adaptive Management
Elements
1.
2.
3.
4.
5.
6.
Management objectives regularly revisited and
accordingly revised
Model the system
Monitor and evaluate outcomes
Range of management options
Mechanisms to incorporate learning into decisions
Collaborative structure for stakeholder participation
and learning
Adaptive Management
Steps
1.
2.
3.
4.
5.
6.
Assessment
Planning
Implementation
Monitoring
Evaluation
Adjustment
Transport


Healthcare accounts for 11% of the workforce
Public transport


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Not suitable for the sick
Not available at night
Active transport

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Limited radius
Good for staff, if supported
Will result in decreases in:

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Obesity
Diabetes
Heart disease
Road trauma
Air pollution
Impact on climate
Regions, hospitals and clinics may need to provide


Targeted medical public transport
SmartCard fuel allocation
Plastics


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Plastics manufacture accounts for 4% of
petroleum usage (mostly NG)
Medical usage accounts for about 4% plastic
consumption
Logistic and economic factors more important
than feedstock
Disposable vs reusable (silicone)
Infection control dogma
Pharmaceuticals
Pharmaceuticals


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Pharmaceutical manufacturing accounts for
about 4% of petroleum usage
Extreme case of value adding
Logistics and distribution
What do we really need?
WHO list of essential medicines
Plant based medicines
Traditional therapies
Equipment and Spare Parts

What do we really need?
General practice
 Anaesthesia
 Intensive


What will happen to global supply chain
Just-in-Case rather than Just-in-Time
 Warehousing



What can make in Australia
Generic/Modular
Global

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Refugees from famine and climate change could arrive
in large numbers
The post peak oil carrying capacity of Australia is
unknown but likely to be lower
Famine promotes infectious disease

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MDRTB
Malaria
HIV
Avian influenza
The ethical dilemma of the life boat may arise
National
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The national economy will contract
Demands on the public purse will increase
Tax revenues will decrease
Private health insurance will decrease
Private hospitals will treat more public patients
Fee for service private practice will decrease
Local manufacture of generic equipment, drugs and
supplies


What do we really need?
The WHO formulary and catalogue (6)
National



Health system is already
severely stressed
Peak Demand & Peak
Oil will overlap
All costs are Energy
Costs
Rationing

Fuel drought

Rationing Healthcare
Level Five Water Restrictions
Need for novel Solutions
National Rationing

Already happening by stealth
Public: Waiting lists
 Private: Cost

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In the near future capacity constraints will
become obvious, unavoidable and unfudgable
The discussion must be open and honest
Rationing is sharing
National - Rationing
The Big Questions best handled at a national level
 Who?
 Gets what treatment?
 Where?
 When?
 How?
 From whom?
 At whose expense?
National - Rationing
Guidelines for entry into northern regions end stage renal failure program.
Auckland: Northern Regional Health Authority (3)

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Treatment would be of little physical and physiological potential benefit to
the patient
End stage disease in any other system which will not be improved by
treatment
Disease processes from which the patient will die within two years
The compliance potential is not positive in that the patient is not able to cooperate with an active therapy
Treatment is not in the best interests of the person as perceived by the
assessing team, or is considered futile. (Examples would include those
patients suffering from a severe dementia who are unable to feed, dress or
toilet independently.)"
National - Rationing

The Oregon Experiment (4) needs to be
reassessed
A community consultation process that generated a
list of treatment priorities
 Developed a 16 box matrix

Life cycle stages: Infancy, childhood, adult, elderly
 Level of care: Critical, short term, long term, preventative

Priority: High, medium, low
 Ranked list of conditions with a cut off line for
public funding

State

Redefining boundaries
Geographic mobility
 Procedural complexity

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Urban
Urban fringe
Regional
Rural
Remote
Access to all resources
Access to most resources
Access to most resources
Access to some resources
Access to few resources
ARIA
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Highly Accessible (ARIA score 0 - 1.84)
Accessible (ARIA score >1.84 - 3.51)
Moderately Accessible (ARIA score >3.51 5.80)
Remote (ARIA score >5.80 - 9.08)
Very Remote (ARIA score >9.08 - 12)
Specifically excludes ‘Transport
Disadvantage’ from assesssment
Regional

Relocalise

Integrate GPs into pre and post hospital care

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↑ Level of primary care with support and resources
Triage (+/- treatment) before travel
Redistribute

Develop local facilities
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Consulting
Day surgery
Allied health
Regional
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High speed broadband

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‘Stranded’ Patient ↔ Consultant
‘Stranded’ GP ↔ Consultant
Live in facilities for staff
Smart card fuel rationing
Community discussion and comment

Rationing is sharing
Professional

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All doctors try to ‘work the system’ to advantage
each individual patient (and themselves)
What is best for the sum of all individuals is not
necessarily what is best for the community as a
whole
Rationing of service provision is inevitable
We will need to be frugal, inventive, innovative,
conservative and courageous as we power down
General Practice

Increased demand especially on outer suburban and
country doctors

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Historical comparison

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Training and support
What can be done?
Where can it be done?
Increased role for small hospitals
Alternative Therapies

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Claims of efficacy without scientific trials are unjustified
‘The therapeutic trance”
Some are potentially harmful
Those that actually can be proven to work will have a valuable
role to play
10% 30% 30% 30% rule of general practice as applied to
‘successful’ ineffective therapies.
Pursuit of alternative therapy can delay definitive treatment
In a time of diminished funding only proven treatments should
be funded from the public purse
Medical Indemnity and Risk


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We can’t eliminate all risk now and will be even
less able to with decentralised care
Care will have to be the best that can provided
with the manpower and resources available
Medico-legal decision making is not be
sustainable, defensive medicine is very resource
intensive
No fault compensation would be will be
essential for rural GPs servicing stranded
populations
Governmental Responses

Urgent Oil Vulnerability Analysis

In the mean time develop ‘No Regrets’ strategies
Active Transport
 Public transport
 Enhance community centred health services
 Broaden and deepen general practice training

Professional Responses

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Discuss peak oil and energy descent
Oil vulnerability analysis
Plan for the decentralisation of service delivery
Develop, enhance and support GP training
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FARGP
ACRRM
Specialist GPs: O&G, Surgery, Anaesthetics, Psychiatry etc
Expanded to non-rural practitioners
Reduce waste and plan return to reusable equipment where
possible
Trailing edge vs leading edge technology (7)
Discuss the Cuban model of healthcare
Barriers to Progress -1

Bureaucratic Paralysis
It is easier to rely on ‘Plausible Deniability’ than stick
your neck out
 Errors of commission are seen to be worse than
errors of omission
 It’s good to be correct, but if you have to be wrong
it is best to be wrong at the same time as everyone
else

Barriers to Progress -2

Human nature

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Our personal and social resources are seriously depleted

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Our brains run on ‘The Get More Energy Operating System’
The maturity of the individual.
The general mindset of the society as a whole and the local community
(peer pressure).
The mental and physical skill set that each person possesses and the skill
sets that exist as a whole. (5)
The mainstream media are actively antagonistic


Sell advertising not news
‘The Iron Triangle’


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Real estate
Finance
Car industry
Education Campaign

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Promote open discussion about peak oil
Accept limits to growth and progress
Steady state economic theory
Develop and promote new models of individual
and social success
CARPE DIEM

A Predicament


A situation that can not be changed and must be
accepted
A Problem

A situation that might have a set of a solutions
Personal Reponses
Responsibility
 For health and wellbeing




Prevention is essential when cure is not possible
For food security
For family members
For neighbours
Personal
To maintain physical and mental health we should learn:
 How to get around without a car, teach kids as well

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Frugality, patience and self restraint
Useful skills: gardening, knitting, use of tools
Tolerance, how to get along with boring, annoying and difficult
people
To lose any delusions of autonomy and learn how to cooperate
and defend the commons
To produce, preserve and cook food
To reduce, reuse, repair and recycle
To make ones own fun
Personal
To maintain financial health one should endeavour to:





Get out of debt, economise, think of how you might live on half
your income
Move to the non-discretionary side of the economy, aim to
satisfy needs not wants
Reduce, reuse, repair, recycle
Produce as much as you can of what you need and something of
value to others
Get to know the neighbours, share skills and resources, nobody
can do everything but everyone can do something.
Community Reponses

Create local employment

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Recycling
Light industry
Food and farming
Support local healthcare providers
Promote intergenerational skills transfer
Community discussion

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Progress is not a preordained certainty
Better can be the enemy of good
Community vs individual focus of care
Prevention vs cure
Quality vs quantity of life
Rationing is sharing
The Theory of Black Swan Events is a metaphor
The event is a surprise (to the observer) and has a major impact. After the fact, the
event is rationalized by hindsight.
"If a path to the better there be,
it begins with a full look at the worst."
-- Thomas Hardy
Global
Rising oil prices are resulting in
 Huge wealth transfers






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

All wealth is energy wealth
Extreme poverty and energy deprivation
Rising food prices and malnutrition
Problems for global disease control
Destabilisation of governments
Reduced aid to poor countries
Potential forced movements of population
Distortions of world trade
An increasing risk of global recession/depression
More resource wars
Global
Oil is People
Food is Energy
and it takes Energy to get Food



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With petroleum 2% of our population feeds 98%
Modern farming uses land to turn petroleum into food
With limited petroleum in parts of rural India 80% of the
population work at food production
Global grain production has failed to meet demand for seven of
the last eight years
40% of protein in every human body on the planet comes from
petroleum derived ammonia fertiliser (9)
To meet projected demand over the next fifty years we will have
to grow as much food as we have in the last one thousand years

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