An ethical conflict occurs whenever the rights of two or more people, or groups of people, come into conflict. Put another way, it occurs when everyone can?t get what they want, and tough decisions need to be made about the allocation of scarce resources.

It is particularly likely that ethical dilemmas will arise during the redesign of the healthcare system as a response to peak oil. This is because there will be a conflict between what is best for society as a whole, versus what is best for the individual.

It is also likely that the quality of life, safety and material abundance that we currently enjoy will decline once oil becomes scarce and expensive. It is probable that the next few decades will be characterized by the scarcity of many things, necessitating the need for rationing of healthcare and other important services.

Why ethics?
Ethics are important because:

• Reasoned and ethical action is a sign of a civilised society.
• Ethics includes the ideas of fairness, equality and compassion. I believe that we must strive to remain as ethical as possible, so that the best qualities of humans and their society may survive for the benefit of future generations.
• Ethical societies value and care for their young, old and infirm.
• A more ethical approach to the environment is needed for its survival, and our own.
• Medical practice has always been informed and guided by ethics.
• Doctors have an ethical duty to patients that should be absolute, regardless of the society in which they practice, or the conditions in which they find themselves.

A physician has three main ethical duties to patients:

• Beneficence ? ?do good?
• Non-maleficence ? ?do no harm”
• Respect for autonomy ? ?a patient?s rights and preferences are important?

These ethical duties are inviolate, and should form the foundation upon which all further activity (including considerations of rationing) is built. Ethics must be considered in our response to peak oil if we are to remain a just and compassionate society.

Healthcare rationing
Rationing presents peculiar ethical challenges, because the conflict between community and individual rights is brought into stark relief. And while health care systems already have some rationing (in the form of the Pharmaceutical Benefits Scheme and public hospital waiting lists in Australia, for example), it is likely that much tougher decisions will need to be made in the future. These decisions are likely to involve issues of life and death, such as who may have access to potentially life-saving treatment, and who may not.

The case of renal dialysis
Consider the example of renal dialysis (as it has been discussed extensively in the bioethical literature). It is a complex and expensive undertaking, and is already being rationed in New Zealand. They have introduced a strict and explicit system of rationing to determine who may have access to dialysis, and essentially who may die fairly quickly of end-stage renal failure. Their system relies on a set of clinical guidelines that were developed by a consensus process in the early 1990s, and considers age and the presence of significant co-morbidities. The intent was originally that no-one over the age of 75 years would be dialysed. The system has generated a large amount of controversy and public discussion, and has been tested in the courts at least twice.

Rationing inevitable regardless of peak oil
Even if oil peaking wasn?t imminent, it is likely that the ethical dilemma of rationing would become increasingly important anyway. There are two reasons for this statement:

1. Ageing populations in Western socities will need much more care as the get older, especially as the baby-boomers enter their seventies.
2. As medical technology continues to produce technological breakthroughs, the cost to access these treatments goes up. This is because ?designer drugs? and ?magic bullets? are becoming more common but have very high development costs. As these sorts of treatments (termed pharmacogenomics) tend to be targeted at uncommon or rare conditions, the cost per patient is high so that research and development costs can be recovered. They also tend to be targeted at age-related diseases like cancer, so demand will increase significantly in the coming years.

It is clear then that sooner or later, countries like Australia will need to make tough decisions about health care rationing, which will result in serious illness or death for those that miss out. There is no way to dodge the magic bullets! The rights of the individual will always collide with the good of society, thereby producing ethical dilemmas.

Developing ethical decision-making frameworks
Coming resource scarcity, whatever the cause, is adequate motivation to develop an ethically-based framework that can guide fair and just decisions about resource allocation. Such a framework ensures that the decision-making process is transparent, and that it satisfies the ethical duties of honesty and disclosure. It also ensures that the concept of justice (in this case distributive justice) is incorporated by including a process of public consultation. An honestly conducted public enquiry satisfies the ethical duty of fairness, and should reduce conflict down the track by seeking consensus up-front.

Having explicit guidelines for clinical decision making is one of the two ways that healthcare rationing can be achieved. Explicit guidelines are prescriptive and relatively inflexible. The New Zealand experience shows that they may be open to legal challenge, or trigger widespread debate and dissent in a population. Even though the idea of such guidelines is attractive, there are several potential problems in addition to legality and public opinion:

1. Fails to acknowledge that medicine is both art and science.
2. Difficult to incorporate new information or clinical developments once treatment has started.
3. Doesn?t acknowledge clinically-relevant differences between patients.
4. Relatively inflexible.
5. Susceptible to outside influence (such as political or media pressure).

The other way of rationing scarce healthcare resources is through an implicit process. Such a system relies on the making of discretionary decisions within a fixed healthcare budget. Strategies include:

1. Queuing (eg public hospital elective surgery waiting lists).
2. Decreased service intensity (eg monthly therapy sessions instead of weekly ones).
3. Substitution of less expensive services for more costly ones (eg generic medications).
4. Excluding some treatments from the public system completely (eg weight loss medications and the PBS).

So while at first explicit guidelines seem more attractive, implicit rationing (within a given budget) seems better able to respond to the complex, diverse and rapidly-changing environment likely to occur after peak oil. It will also be more likely to have the speed and flexibility required to cope with shortages, natural disasters, accidents and civil unrest, and allows physicians to make exceptions to rules that seem unfair or unwise in specific instances.

Distributive justice
It is a moral imperative that rationing be fair and just. It is also a practical one both politically and socially (to maximise the chances of re-election, and reduce the risk of revolt, respectively). Inequality in the distribution of goods is evident when favouritism or discrimination occurs: the process is then said to be unfair or unjust.

According to Kjellstrand (1996), there are three theories of justice that are frequently applied to medical decision-making:

1. Egalitarianism ? All people have intrinsic worth. Equal access to health care is a right. Need for services is the primary criterion to make decisions.
2. Utilitarianism ? Values the good of the community over the good of the individual. Equality subordinated to overall outcome.
3. Libertarianism ? Primacy of personal autonomy. No automatic right to healthcare. Healthcare is just another service for those who want and can afford it.

These three different views of the one ethical principle explain how conflict in resource allocation occurs. We need to recognise the difficulty, complexity and challenge of making decisions after oil peaking. We should favour processes that are as fair and honest as possible, but which retain their flexibility and are able to react to changing conditions quickly.

Values after peak oil
In the interests of stability and safety after peak oil (themselves utilitarian values), it is likely that the order of priority for the three theories listed above will be (1) utilitarianism; (2) egalitarianism; (3) libertarianism. This is because the good of the community will be of primary importance as our society adapts to changed and unstable conditions, and resource scarcity means that limited medical services must be allocated to maximise the greater good, and promote security and safety. For instance it is likely that workers and those with useful skills will receive treatment first, as the survival of the group will depend on the survival of the able-bodied and skilled. Although the order of the other two approaches will depend on local factors, one would hope that compassion and charity might remain important.

A new land ethic
Different ethical viewpoints make distinctions between those entities that count in a moral consideration, and those that don?t. At one extreme is the belief that only living humans with the capacity to think are worthy of moral consideration. This viewpoint excludes the foetus, unborn future generations, and the natural world from consideration.

At the other extreme is the viewpoint of deep ecology, whereby all things are seen as being equal, morally important, as having intrinsic net worth, and as deserving of being treated in an ethical manner. This includes nature. The current state of our environment serves as evidence that our globalised industrial society doesn?t extend basic moral protection to the natural world, thereby allowing phenomena such as the clear-felling of old-growth forests, strip-mining and global warming.

In contrast, many indigenous peoples held their environment in high regard, often to the point of sacredness. This reverence for the natural world is one of the factors that allowed some indigenous cultures to develop sustainable societies.

In a scarce oil future, it is envisaged that many of us will live in much closer approximation to nature, spend a significant part of our time working the land using low-tech methods, and depend on the health of local ecosystems for our own health and survival.

Although this article is about medical ethics and rationing, it is worthwhile considering the type of ethical approach to nature that will be required to achieve long-term sustainability in a relocalised future. The ?land ethic? of Aldo Leopold and the ethics of the permaculture system demand a respect for and partnership with nature that will be crucial to our survival. Both approaches acknowledge that natural things have intrinsic worth and moral standing. It logically follows then that they deserve to have the same ethics applied to them as we use for ourselves.

Once the place of nature in an ethical framework has been clarified, the preceding discussion on rationing can be used to determine the way that other goods (such as water, food, clothing, shelter and energy) are shared and distributed. Indigenous people used an oral tradition of stories, rules and taboos to disseminate and enforce their systems of land stewardship (for example a prohibition on hunting female animals during breeding season, or the way that water holes were to be managed during a drought). Hopefully we can formulate a similar system of ethics that includes all of nature as a moral being worthy of ethical consideration. Only in that way can we effectively deal with peak oil and energy descent.

This is the second and final part of my article about peak oil and general practice. Registered users can download a free pdf of the complete article from the “user extras” section. Part 1 can be found here.

A holistic view
While the focus of this article is on healthcare, we must remember that our medical system is a subset of wider society. While it needs to be seen as an essential part of societal redesign in response to peak oil, it will likely be made subservient to the wider design solutions that evolve in each country. It must be stated that the redesign of the healthcare system will be time-consuming and costly, as it will be for the rest of society. We have no time to waste.

Inclusion of Indigenous peoples
Any redesign of current healthcare systems must include and value the contribution that can be made by indigenous knowledge, as well as ensuring that adequate, accessible and acceptable health care is provided.

The challenges of providing adequate care to, and improving the health, longevity and quality of life of indigenous peoples are well known. While these challenges will continue to be present in any peak oil response, they must not be shirked or ignored.

A perhaps less appreciated issue is the potential that indigenous knowledge might have to help us navigate the next step in the evolution of our culture. It has been developed over the millennia by careful observation of and connection with the land, and passed to younger generations within a rich oral tradition. Indigenous peoples the world over have an in-depth knowledge of the ways to identify, find, prepare and use medicinal plant species. This information could well prove vital to our future survival, and should be urgently collected, collated, researched and disseminated.

There are two needs for urgency. The first is that the ageing and passing on of traditional healers results in a permanent loss of knowledge, as much has never been written down. Additionally, as traditional ways and practices may not seem so attractive to younger tribe members, and as there has been a general disconnection with the land in many places, there may have been no-one to pass it on to.

A second need for urgency is the uncertain timing of peak oil ? all efforts to prepare should be started as quickly as possible to maximise its mitigation and minimise the impacts.

It is also worth considering that traditional knowledge is intimately linked to the land and in modern terms has already been ?relocalised? (or more accurately, never ?globalised? or homogenised).

Some design questions to consider
This article perhaps raises more questions than it answers, but at this early stage of our response to peak oil, I think that it is important that our subsequent actions be guided by a series of questions and ethical principles. The way that the puzzle of providing health care in a scarce oil future is resolved is likely to be intensely local, heterogeneous and granular (focussed on the small scale and the use of appropriate technology, rather than large scale and high-tech). The unanswered questions relating to the future structure of general practice include, but are not limited to:

• How can most people be seen by a GP using a minimum of fuel?
• How can we redistribute general practices within the community to ensure local and equal access for people?
• What ethical principles need to guide this redistribution (to be discussed in my next post)?
• How can we ensure the continuation of medical research, professional education and peer review in the setting of significantly decreased personal transport?

Please leave any comments below.

It is clear that the current model of general practice (aka primary care or family medicine) will be unsustainable in a scarce oil future. So the question remains: How can it be remodelled to be more sustainable within the limitations imposed by peak oil, yet still deliver effective and ethical health care to the population?

Structure versus technique
One needs to separate the structure of a future healthcare system from the knowledge or techniques used by practitioners within it, to begin to answer this question. For example, consider a book: the chapter structure provides a framework for the knowledge contained within it. And while most books share the concept of chapters as an organising system, the content of each book is different. And so it will be for the pattern of healthcare. The reduction in travel and material flows brought on by peak oil will necessitate a greater reliance on local materials, knowledge and infrastructure, with greater heterogeneity in the way healthcare is delivered. It will be guided more by local factors than it is now, and feature a range of customised solutions to the problems of healthcare delivery in each region.

Focus on principles
This section will focus on some principles that might be used for designing the structure of a possible future system. Due to the difficulties of foreseeing the exact nature of the challenge posed by peak oil, I have attempted to provide a ?big picture? consideration of the more theoretical and ethical factors that need to be considered, rather than a prescriptive list of specific solutions. After your reading of this article, I hope to have raised more questions than I have answered.

Redefining general practice
The terms general practice and primary health care sometimes seem to be used interchangeably, although conceptually they are different. I make this distinction because primary health care, while including general practice, encompasses a wider sphere of activity, as it involves health care workers other than doctors, and activities other than medicine (such as health promotion and community nursing, for instance).

Bringing people together
After peak oil, the fundamental question to be answered will be: ?How can we bring doctors and people together without using oil-based transport?? Two related questions are ?Where should general practitioners be located within the community?? and ?How will people move around without using oil?? There are at least four possible ways to structure an answer to these questions:

1. Localised ?centrality?
One possible model of local medical reorganisation is through the related processes of delegation of healthcare responsibility and triage. As currently used in some developing nations, this model involves a large number of semi-trained health workers, scattered throughout the community, who would provide basic first-aid and simple medical treatments. Training in triage would allow these workers to identify the more unwell patients, who are then passed upwards through a series of facilities of increasing medical complexity, with most doctors sitting closer to the top of the organisational structure. They would provide more specialised treatment to those who needed it, as well as be responsible for passing education and feedback back down the chain to their subordinates.

2. GP dispersal
In this model, general practitioners would be dispersed throughout the community, ensuring that essentially all people in urban areas could access a doctor by walking or riding a bike (or horse in country towns). This system would involve a reversal of the current trend towards practice amalgamation, and would see many small one or two doctor practices developed in the same pattern as population clusters. This perhaps is most like the way that general practice developed in Australia, with many combined residence/surgeries scattered throughout a community.

3. Nursing home multi-use
This response recognises the ageing of our population, and the progressively increasing need for aged care that will result. It also acknowledges that the aged use proportionately more medical care than younger people (up to eight times more than children has been quoted), and also that there are likely to be flows of people (staff, relatives and visitors) and materials (including food and supplies) into nursing homes, making them a focus of activity within the community. It doesn?t consider whether or not nursing homes will remain as they are, or whether caring for the aged will once again be done by their own families at home. This strategy would see general practices established at nursing homes (to make use of the flows of people and materials), and perhaps an even greater expansion of the nursing home role to include other essential healthcare services, community gardens, urban farms, and other relocalising efforts. In this scenario, the nursing home becomes a hub of community activity.

4. Medical ?flying squads?
This is an old idea made new again and is possibly a subset of the first strategy: Mobile teams of general practitioners, surgical teams, medical specialists, allied health professionals, or multidisciplinary teams would move around community facilities and private residences to provide care as needed. This option could exist within the triage and delegation structure, and would be particularly important in rural areas.

Did you know: Registered users can access the full report right now in the ?registered users extras? section? You can register for free by clicking the link at the top of the right hand side-bar on any page.

The Australian Senate released their interim report into peak oil earlier this month. Unfortunately I could see no mention of healthcare at first glance, even though ASPO-Australia put in a submission (Jim Barson and I have subsequently sent in an in-depth supplement to the original submission which we hope might be considered for the final report). It does look like they considered that peak oil is a reality, as they referenced the Hirsch report extensively.

I have included a few excerpts from the impacts section of the report below. You can see the full Senate pdf here.

3. Economic and social impact of high fuel prices

3.1 Recent sharp rises in the price of oil have served to demonstrate that there are significant sectors within Australian society who have limited capacity to cope with sustained high oil prices.

3.2 Submissions and evidence to this inquiry on the effects of high fuel prices were mostly qualitative and anecdotal. There appears to have been little hard research on the effects to date or the likely longer term effects.

3.6 A recent report for the US Department of Energy, the Hirsch report, notes that end use sectors that are able to switch to other fuels such as natural gas, coal and nuclear will do so but that in the transport sector there are no alternative sources that are able to compete economically.

3.8 ……Farm costs are projected to rise 4.2% faster than farm gate prices in 2005/06 with farmers continuing to be price takers rather than price dictators…They have little capacity to pass on increased fuel charges. Net farm incomes have been falling with fuel being the fastest growing cost input. Fuel costs in 2006 are double what they were eight years ago, while farm revenues have risen by just a quarter.

3.10 A number of submissions raised concerns over expected impacts if the world is not prepared for peak oil. ASPO-Australia also claim that the economic and social impacts will be very serious unless we take the necessary precautions very soon.

3.11?..Oil price increases transfer income from oil importing to oil exporting countries, and the net impact on world economic growth is negative.

3.16 The Murdoch University Institute for Sustainability and Technology Policy expects global trade to continue in a post peak oil world, although the character of global trade is expected to change once the costs of this trade become expensive. Trade in future is likely to become more localised.

3.17 Treasury in the 2006-07 budget papers noted that given the low level of spare capacity for oil production, there remained a risk of further supply side disruptions. In particular it was concerned about the potential for instability in key oil producing countries to have a more pronounced impact than the demand driven rises experienced to date. Treasury noted that oil demand is unresponsive to price in the short run, and modest disruptions in world supply could raise oil prices very substantially, and for some time.

3.18?..ASPO-Australia argues that many adaptations are justifiable even without peak oil concerns. Certainly, preparing well in advance for Peak Oil is a very prudent strategy. Many of the possibilities are so-called no regrets options (those that are already justified on social, environmental, health or economic grounds).

3.20 The Committee notes that there are credible concerns that markets will not respond in time to provide a smooth transition to a post peak oil world without government action. Given the uncertainty about much of the information on world oil supplies and the geopolitical instability of the oil bearing regions, there may be a risk that markets will under invest in oil and energy technologies, resulting in economic and social hardship as supply falls below demand.

3.21 The information required to make a clear determination on whether peak oil will occur before the market can provide mitigating action is not available. The following chapters discuss possible mitigation actions that can be applied that would allow a prudent approach to managing the possibility that peak oil will result in substantially higher oil prices and a constraint on liquid fuel availability.

So why bother registering if there’s no benefits for you. Sure it allows you to comment on posts (which is very important by the way because I want this space to generate discussion and feature input from a wide variety of sources), and to be notified when new posts are published.

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I got an e-mail from a health professional last week, asking me what I thought about the types of training that might be useful to prepare for peak oil. I had been thinking about this issue for some time on a personal level, and thought that I would make some jottings to guide myself (and perhaps others), as well as answering my correspondent?s question.

Dealing with uncertainty
Firstly, let?s consider the setting. We need to acknowledge that the events of the coming decade or two are essentially unknowable. Even though there has been in-depth discussion about the collapse of previous societies (Diamond?s Collapse and Tainter?s The Collapse of Complex Societies spring to mind), there has never been a continent-spanning, interdependent, instantly-linked global civilization like ours. I would contend therefore that although there have been many useful predictions about possible futures (see for instance David Holmgren?s Permaculture: Principles and Pathways Beyond Sustainability), as well as the example of Cuba (but also Zimbabwe), they are ultimately conjecture. All that we can depend on is that we can?t depend on any one future prediction, no matter how desirable.

The only person you can rely on
So in times of uncertainty one must turn inwards and examine one?s self; after all, if you can?t depend on yourself, then who can you depend on? With this in mind, I believe that the only real, useful and anxiety-lowering way to manage future unpredictability is to manage your own inner environment ? your thoughts, feelings and skills. Psychologists call this having an internal locus of control (being ?the captain of your own ship?). It is having the confidence that you will find a way, no matter what happens. Siebert?s The Survivor Personality discusses this issue, as does Lundin?s 98.6 Degrees: The Art of Keeping Your Ass Alive.

You might also see some of my previous writings on the need to take personal responsibility:

• Personal responsibility and health care after peak oil
• Personal actions to improve your chances of post-peak survival
• Why ?healing? & ?wellness? are different to ?medical care? and what it means for peak oil.

Upgrading your current profession or skills
With that in mind, let?s consider a possible process for picking a peak oil upskilling course. Where possible, think about how your current work or profession might make the transition to a post-peak future. For instance, if you?re a farmer, perhaps you might pursue information about organic farming methods, or start breeding draught-horses. In contrast, if you are currently in a profession that you think won?t make the change to an energy descent future, you might consider changing careers altogether. Keep in mind that you will have gained a lot of ?transferable skills? since you became an adult (no matter what your job description), many of which will stand you in good stead to make the transition.

Minimum knowledge required
We will all need a minimum level of self-care skills and knowledge (like darning a sock or cooking a meal on an open fire) that you can begin to practise now, so don?t despair if you can?t think of anything to do ? just learn the basics. My other initial thoughts are to pick something that appeals to you, or that builds on a current hobby - you need to like something to learn and remember it, especially if you don’t have books and other resources in the future. Remember that any knowledge will be helpful if you know more about a certain topic than anyone else in your local community.

The rest of this article presents a framework that can help you to decide which courses to do, how long they should be, and whether you need formal qualifications or not. You should be able to apply these criteria to everything from choosing an alternative health field to weaving, blacksmithing and farming. A bold statement I know, but let?s see what develops.

A decision-making framework
Siebert says that the people who have survived major challenges and subsequently documented their experiences are those who have remained flexible and creatively used whatever resources were available. I think that the future may be so desperate that we cannot afford to neglect any possibly useful skill or body of knowledge (no matter how unpopular or marginal it seems at the moment). We must be willing to put our biases and prejudices aside.

Professional qualifications versus personal knowledge
You need to differentiate between knowledge that you’ll use for yourself and your family, and that which you?ll offer to your post-carbon community professionally.

The latter group needs more skills / training and (at least at the moment) a formal qualification. The former group you can do just with a book or two and a little practice on willing crash-test dummies (ie your family and close friends).

The main drawback of a formal course is the opportunity cost (time, expense, and learning other things). What does that mean? It means that if you commit to one thing, you can?t do something else at the same time or with the same money, and if you?re studying hard you can?t be working in your veggie garden. A second issue is that if the major societal changes that we all fear begin when you?re half-way through your course, you may never finish it. Still, half-finishing a nursing course gives you a great knowledge base to start from, and allows you to be an important resource for your community if no-one else has any nursing experience.

In contrast, the main reasons in favour of seeking a formal qualification include:

1. Greater depth of information (as opposed to just reading a few books).
2. Regulatory requirements (for instance if you want to change careers soon and become a herbalist).
3. Peer recognition and access to continuing education, courses and conferences.
4. Ability to conduct research, publish results, and write authoritative articles.
5. Greater experience (as a component of a formalised course ? for instance the clinical experience component of a university nursing course). Remember that although knowledge is important, it remains theoretical until put into practice.

Reliance on external supplies and transport
Once you decide on whether you need a formal qualification or not, you next need to consider the amount and cost of supplies required to keep your chosen vocation going. For instance, consider the difference between psychotherapy (no supplies) and herbalism (ongoing supplies).

Because the future is unpredictable, it’s impossible to tell what will happen, and how stable it might be. A corollary is that no-one will be certain if supplies will be available, which ones they will be, in what quantities, or for how long. One of the problems with conventional medicine is its reliance on globalised supply chains that need oil to keep running. Now consider herbalism as currently practised: many practitioners seem to use liquid extracts and capsules that they buy from large wholesalers - in terms of the reliance on oil-fuelled transport there is no real difference between it and conventional medicine! Of course this is different where the herbalist grows their own plants and prepares their own extracts.

There are two possible ways around this supply issue. Firstly, if the best visions are turned into reality, it is likely that organic agriculture / permaculture (including medicinal herb growing) within a local setting will be a dominant method of living. In that case, herbalists, weavers, spinners and other craftspeople might be able to source their supplies locally. Secondly, consider the idea of salvage. There are going to be a lot of rusting motor vehicles (and other oil-age artefacts) hanging around. They will be a great source of steel for the budding blacksmith (not to mention vinyl and fake leather for multiple domestic uses), and may partly overcome the possible lack of raw materials.

Appropriate knowledge and equipment
It is likely that the information that you will need to know for any contemporary course will be ?21^st century? and oil-dependent. So as you learn the information in your chosen area, always consider how you can apply it to a scarce oil future. You should also think about obtaining a basic set of tools and equipment while you can still get them. I would suggest a focus on well-made, reusable (and resharpenable) hand tools rather than power ones, or those that need ?consumables? (for example a hand drill, wood plane, files and hand saw rather than a power sander, cordless drill and circular saw).

I have noticed that the level of skill and types of techniques described in books published between 1880 and 1920 are approximately ideal in terms of their level of technology and lack of reliance on oil. Why? This was the period when predominantly ?oil-less? craftsmanship was at its peak, before descending into the oil-drenched future. So if you want to be a herbalist, buy some books from that period and learn how to prepare remedies from basic ingredients. Likewise, if you want to be a blacksmith, learn how to make your own tools, forge, and bellows.

Putting it all together
I have designed some simple tables with worked examples to hopefully make the decision-making process clearer. There is also a table that allows you to compare the costs and time commitments of specific courses once you?ve picked a broad discipline. You can download the file by clicking here to see the download page: PeakOilUpskilling

Most peak oil studies to date have focussed on trying to predict when peaking might occur. There is one notable exception, however. In 2004 the US Department of Energy?s National Energy Technology Laboratory released their landmark Peaking of World Oil Production: Impacts, Mitigation and Risk Management.

Background
Unlike the others, this study (informally called The Hirsch Report after the lead author ? who coincidentally appeared on the recent ABC-TV Four Corners episode on peak oil) made no attempt to predict when a peak might occur.

After identifying that peak oil would cause a liquid fuels crisis, it looked at how long it would take to replace oil as a transport fuel. The authors calculated that it would take 20 years of ?crash? programs to produce enough facilities to significantly replace oil with artificial fuels. In contrast, if the US waited until peaking was obvious, there would be 20 years of significant economic hardship (similar to, or worse than, the Great Depression).

Medical Hirsch Report
I contend that a study with a similar purpose would be a useful tool for the each country?s health care system. It would provide useful information for planning and implementing mitigation programs, allowing us to manage the significant expected impacts of oil scarcity and energy descent.

Hirsch Report Methodology
The authors purposely kept the analysis simple. They did this so that their results would be transparent. They acknowledged that no study could infallibly predict the impacts, and used a semi-qualitative approach, rather than a rigidly quantitative one. In simple terms the approach was:

1. Describe the current situation and identify the scope of the problem.
2. Consider any examples or analogous situations that might shed light on the analysis (they used the peaking of US domestic natural gas supply).
3. Only consider commercial or near-commercial processes (to maintain realism).
4. Calculate the timeframes and capacities of the necessary number of fuel-production plants.
5. Repeat the process for each technology (eg coal-to-liquids; vehicle energy efficiency).

Applying Hirsch to health care
In order to think about how this process might be applied to the health care system, I chose the hypothetical example of plastic syringes (with a proposal to replace them with glass ones):

• How many single-use plastic syringes are used each year? What sizes? Where are they used (eg hospital versus community)? What are they used for? Who makes them? Which countries do they come from?

• What happened in Cuba when their oil supplies were cut off? How about Zimbabwe (a country that has been called the ?first casualty? of peak oil)? How do NGO aid-agencies like MSF currently handle this issue in third-world countries? The idea is to try to distil some generalized lessons. For example: What alternatives are there? If glass syringes will be used, how can they be made, packaged and shipped safely? How might they be cleaned, sterilized and reused? What are the infection control issues? And so on.

• What viable processes currently exist to manufacture precision glass instruments in our country? Who might do it (eg consider scientific instrument makers but also manufacturers of glass bottles and jars)? What is their current capacity? Do they have the technology or would it need to be bought from overseas and adapted here?

• Educated guesses about how long it would take to build and tool up enough factories to make them (in the format of ?Complete X factories per year, each producing Y syringes per year, Z years lead time until the first one is operational then 1 per year thereafter?).

• Repeat this process for each important oil-based component of the current health-care system ( I would suggest that there are at least several hundred such “critical” areas if we are to maintain a resonable semblance of the current system). Such a study would be much harder to do than the original one, because Hirsch et al only considered one output; we need to consider many.

One would also need to try and predict the increased sterilizing load (both in staff and equipment terms), infection control issues, financial costs and benefits, patterns of use, etc.

Outcomes
The possible outcomes of such a study include:

• A reasonable idea of the enormity of the problem and the scale of mitigation required.
• An estimate of the number of years needed to significantly reduce our current dependence on oil-based materials, allowing timeframes for implementation to be developed.
• Identification of the critical areas of the current healthcare system that need urgent attention.
• The realisation that perhaps a stockpiling strategy might be favoured over developing domestic manufacturing capacity.
• A complete redesign of the current system (really a paradigm shift) to new ways of delivering satisfactory health care - now there’s an area to discuss!

Summary
Unfortunately I quite scared myself as I thought about this and the enormity of the problem. Please tell me what you think.

The current model of general practice (family medicine or primary care) in Australia is critically reliant on road transport. The average general practice has many transport-based ?interactions? each day. In common with the rest of our healthcare, it is currently an open system, typified by one-way flows of materials and energy, with relatively little recycling.

The various interactions of daily business can be characterised as inputs, outputs, and two-way flows. This discussion focuses on the oil-dependent processes that are an essential part of modern general practice.

Inputs
The main oil-based inputs are medical supplies and other consumables, drugs, and technology and equipment. The non-oil inputs include electricity, water, and financial transactions like rent, rates etc. This paper will focus solely on the first group.

Medical supplies and other consumables
Items in this category are often made of petrochemicals, contain embodied oil-based energy (during processing and manufacture), have been sterilized by an oil-derivative (ethylene oxide), are transported to the general practice by road, or a combination of these factors. A special case is plastic-containing items. They have become a ubiquitous part of daily practice, yet we have no ready substitute. Their replacement will pose many technical, economic, and infection-control challenges.

Drugs
While pharmaceutical company samples are currently prevalent in many practices, they are optional rather than essential. The important group is emergency drugs: many are derived from petrochemical feedstocks, packaged in plastic, and transported by road.

Technology and equipment
Most general practices these days are computerized. All computers rely heavily on plastic for manufacturing. These areas include the computer case, monitor, keyboard and mouse. Importantly it also includes many internal hardware components, including the insulation around electrical wiring (without which computers would short out and fail). Compact discs and DVDs also contain plastic. Other medical equipment may also contain plastic or embodied oil-derived energy.

Outputs
The main output of a general practice is the abstract idea of ?healthcare delivery? or ?medical care?. In general terms, inputs are consumed to deliver the service, and wastes generated that need to be disposed of.

GP service delivery
General practice services may be delivered at any of several locations. On-site delivery (at their practice building) is the focus of most GPs, and it probably consumes the most resources and generates the most wastes. Private dwellings and nursing homes are generally the other two most important off-site locations. Emergency service provision and on-call responsibilities are also important, and the auxiliary services of pathology and imaging will be considered as well.

*On-site*
Most of the work done by many general practitioners is in their surgery. This is the main place that most patients attend, and it is the location where most supplies are consumed and waste generated. The delivery of primary care in the general practice setting usually also requires pathology and imaging services.

Pathology is both transport- and time-dependent, and intensively uses road transport. The system is often based on road-couriers who drive to a ?run? of general practices several times per day, primarily to pick up specimens, but also to deliver pathology reports and supplies. The collected specimens are then driven to a laboratory to be processed. Note that this service is time-sensitive and requires rapid and reliable transport to be successful.

The current pathology system also uses a mountain of plastic, including disposable needles and syringes, plastic blood tubes and specimen containers, and then double-pocket ?biohazard? plastic bags for safe transportation.

Radiological services are less transport-sensitive as patients are required to attend a practice to have the imaging done. Imaging machines however contain plastics or are dependent on computers, while x-ray films also contain plastic (acetate or polyester) as well as embodied energy in the form of silver (diesel and other oils are used for mining, refining, processing, manufacturing and transport).

*Visits to private dwellings*
The majority of visits probably involve the general practitioner driving to the house in a car. Groups using this service include:

• Generally healthy but acutely unwell patients who can usually attend a practice but are too acutely unwell to do so.
• Elderly patients living at home who usually receive regular home visits.
• Disabled or otherwise infirm people (sometimes living in a group home with several other people) who also receive ?routine? home visits.

It is obvious that a sudden absence of car-based transport (due to an even short-term crisis) could severely limit home visits and put particularly vulnerable groups of people at high-risk of not receiving care. In contrast, a long-term shortage of transport fuel would ensure that alternative care arrangements would need to be made.

*Nursing home visits*
I have considered these separately because a general practitioner who regularly visits a nursing home often sees several patients during the visit. Any peak oil strategy must include consideration of nursing homes (unless a completely different model of aged care is pursued) because:

• Elderly nursing home residents use proportionately more healthcare services than younger patients.
• The number of elderly patients is likely to grow enormously over the coming decades as Australia?s population ages.

Caring for the aged in the future will impose a progressively greater burden on health and aged care services, and will be challenging in terms of staff and facility provision. In terms of transportation use, the provision of medical care to the aged in nursing homes is an interesting model because it is efficient in terms of both the doctor?s time, and fuel use.

Waste generation
Waste is currently removed from a general practice by local council garbage services (general waste) and specialized services (contaminated waste including sharps). Contaminated waste disposal is very oil-intensive, as well as being plastic-dependent.

Waste is collected from practices by light truck or van, and taken to centralized transportation points where it is loaded and shipped to disposal sites (either incineration or burying). All of these steps require oil-dependent transport, unless electrified rail is used as the final leg.

Contaminated waste disposal is also plastic-dependent. Sharps are placed in thick plastic containers that are destroyed with the sharps and cannot be recycled (aside from the issues of infection control and needle-stick risk). Non-sharp waste is collected in thick plastic bags inside large plastic waste receptacles. While the collection containers are cleaned and reused, the plastic bags are destroyed along with the waste.

Two-way flows
There are several two-way flows through the system. The ones included here are surgical instruments, linen and the most important one: patients. Each of these items are transported into the general practice, and at some point leave it essentially unchanged, and are not turned into waste.

Patients
The biggest group in the two-way flow category are patients. I have classed them as two-way because they travel to the practice; receive ?medical care?; and then travel back home. Currently, the general practitioner usually remains stationary, while patients travel to and from a fixed practice. A lot of petrol is used up by patients, given that an average general practitioner might see between 20 and 30 patients per day, and that (dependent on local facilities) many patients may drive to their appointment.

In the Australian system, patients are allowed to choose whichever GP they want. They may live 90 minutes or more away, and drive past several other practices on the way to their preferred one. After the consultation they may have received a medication prescription, so they drive to the pharmacy before heading home. Hence there is sometimes a lot of petrol involved in attending the doctor, and possibly a round trip of 100 kilometres or more, even in urban areas. Attending a rural general practice may be even more fuel-intensive, depending on the location. And even in the capital cities where public transport is available, people may prefer to drive for reasons of convenience, safety, or accessibility.

Linen and surgical instruments
Linen is often collected from the practice and laundered off-site before being returned. This is often done by car or van, depending on the amount of linen. There is therefore an embodied fuel cost. While not as important to general practices as it is to hospitals, linen services do increase the amount of fuel consumed by general practice. Surgical instruments may be sterilised by a specialised off-site service before being repackaged and returned, again by van or car. The same transport issues apply as for linen. Where the sterilising is done on-site, plastic-lined sterilising pouches are often used, and supplies like distilled water are needed (currently packaged in plastic bottles).

Practice location and ownership
Many practices are small businesses that are owned and operated by a small number of doctors. A relative few belong to the large corporate operators who have been active over the last few years. Because they are privately owned, practices are free to be set up and operated where and how their owners wish (within local, state and federal regulations).

While practices are spread throughout the country, it is well known that rural, regional and some suburban areas are relatively underserviced by GPs, while the more affluent areas are overserviced. So while practices are generally located within communities, they are not evenly distributed. Some patients can easily walk to their local GP, while others (especially in larger urban areas) can use public transport. In urban areas where public transport is unavailable or unsafe, patients may chose to drive. In contrast, rural families may need to travel a long way to the doctor, and have no choice but to drive, regardless of petrol prices or availability.

Because of the heterogeneity of general practice distribution, any re-organisation of the healthcare system, as a response to peak oil, would require some general practices to relocate, so that all communities had equal and local access to primary care. The issues of practice ownership and compensation would need to be resolved if any such action was contemplated.

Summary
Most aspects of the current model of general practice require fossil fuels (especially oil and its derivatives). Transport is a major issue and the most important short-term vulnerability of the system (see our discussion about the UK crisis). Our current primary care system can only stay as it is, and retain its stability, as long as there are cheap and abundant oil supplies available. Any disruption to oil supplies, even of a few days, could cause serious community impact.

I’ve added a new survey / polling feature to the blog. You’ll find it near the top of the side-bar. I hope to gauge some beliefs and attitudes of peak oilers, and will share the results of the polls after they close. I’m not exactly sure how long each will stay open for, but this first one will be at least a week - I’d like to get enough votes so that the results might be at least semi-meaningful (at least 50 and hopefully more like 100 or more), and until I run a few I won’t know how long that will take. The first question asks your opinion about the timing of peak oil. If you have any suggested questions please e-mail them to me: admin AT peakoilmedicine DOT com (replace the capitalised words with the appropriate symbols).