Neoliberalism, degrowth and the fate of health systems

There are unprecedented and widely unappreciated dangers posed to public health, nursing, medicine and allied health professions by the ongoing global economic contraction. This is a multilayered and, frankly, emotionally difficult topic to digest. Before discussing how health systems are affected we first lay out the larger social-ecological context of modern society’s predicament. This includes a brief overview of the idea of degrowth,[i]^,[ii],[iii] which is a response to ecological overshoot and reaching the physical resources and ecological limits to growth, and why it must supplant growth as the cardinal metaphor of modern culture. Then we outline how the inability to perceive that the world has reached the end of growth –by mistakenly seeing the present as a Great Recession- threatens health systems.

Understanding economic contraction is not merely a cognitive process of evaluating arguments and evidence. The modern mind is ensconced in a mythology that sacralizes technological progress, mastery of nature and economic growth. These convictions make it difficult or impossible to see the unfolding socioeconomic descent as anything other than a deep economic recession that will end when the correct policy measures, stimulus, austerity or some combination, are enacted. As children and throughout adulthood we moderns learn in sublime, tacit and explicit ways that a constantly expanding economy is good, has no downside, validates our sense of self-worth, and is therefore the natural state of human affairs. (We also are socialized to believe that nature is passive and subject to the dictates of humans, meaning we can use our intelligence and technology to get out of environmental dilemmas such as peak oil and other resource depletion, climate change, overpopulation, acidification of the oceans and so on through the long list of ecological insults and damage we have wrought.)

For instance, French Premier Francois Hollande in June said, “If there is no growth then no matter what we do we will not meet our debt and deficit reduction targets.” President Obama at about the same time told Charlie Rose, in an interview broadcast on CBS, that running for president is about laying out your “theory for how to grow the economy.” This year Prime Minister Steven Harper said, “… we’ve tried to focus on what we can do to sustain growth in the Canadian economy.” In short, economic growth is the quintessential policy goal of all Western governments. Imagine seeing any of these three leaders giving a speech announcing that humanity has reached the limits to growth and therefore will have to redesign the social world.

This brings us to our bedrock argument: economic expansion is thermodynamically impossible because there is no longer sufficient net energy flowing into the global economy to restart and sustain growth.[iv]^,[v] In support of abandoning the quest for growth ecological economist Tim Jackson points out: “The global economy is almost five times the size it was half a century ago. If it continues to grow at the same rate, the economy will be 80 times that size by the year 2100.”[vi] This 80-fold increase will, of course, never happen. The two-part rhetorical question we have is, how long it will take and how much further damage will be done before this is absorbed into humanity’s collective consciousness?

The contradiction between the mythology of perpetual economic growth and the realities of its physical limits that Jackson implies is playing out in the modern world. This conflict between cultural belief (one can argue that mythology is a collective illusion or even delusion[vii] experienced as truth[viii]) and thermodynamic and ecological reality is having devastating socioeconomic consequences because contemporary societies are organized to function with an expanding economy.

The predominant 21^st century political/economic embodiment of the mythology of growth is neoliberalism. In all its various forms it refers to governments promoting private property rights, deregulation and free markets, globalization and free trade, ostensibly to ensure economic growth, political liberty, the elimination of poverty, and promotion of rising living standards. A beloved phrase of neoliberal politicians is, “A rising tide lifts all boats.” Left unstated is the premise that wealth and income do not need to be redistributed since growth solves all social problems and economic needs.

Neoliberalism is cast as inevitable, a manifestation of humanity evolving politically and economically to The End of History.[ix] As was her wont, Margaret Thatcher expressed this as an in-your-face ultimatum: TINA[x], “There is No Alternative.” This means that socialism has been invalidated and neoliberalism is the apotheosis of capitalism, QED.

Nevertheless, any semblance of its viability ended with the public bailouts of private financial institutions in the fall of 2008, a set of actions that violated the principles of a “free market” and demonstrated how finance and banking have captured government.[xi]^,[xii] Most telling has been the inability of neoliberal governments to restart growth. Three additional points are first, neoliberalism is congenitally unable to recognize that growth has ended, and second, it is incapable of an egalitarian or even utilitarian policy response to the crisis, as is evidenced by mounting unemployment and income and wealth disparities in most western nations, particularly the United States. Third, it discounts the economic value of the future to zero, which means natural resources are extracted and exploited to create monetary wealth in the present with no concern for future generations. Currently, neoliberalism has produced policies calling for governments to reduce spending –except on military and security activities and apparatus- and privatize and auction-off more and more of the public sector and the commons.

Accordingly, it is no accident that the primary policy tool in the crisis has been austerity for the vast majority of citizens and indulgence of the financial sector, including its criminal[xiii] and unethical[xiv] conduct.[xv] To cite an example from health care, “austerity” policies in Greece, Portugal, Latvia, Spain[xvi], and Italy are ravaging national health systems,[xvii] as well as leading to widespread socioeconomic decline, which in turn places added stress on these health systems. This is reminiscent of Naomi Klein’s[xviii] “Shock Doctrine” thesis, which holds that neoliberals make use of or fabricate disasters to impose economic policies favorable to elites[xix] and exploitative of the rest of society’s citizens.

Reaching the limits to growth is not a manufactured crisis; however, austerity reeks of class-based opportunism. It is critical to understand that most progressives[xx] fail to recognize that the limits to growth[xxi] and ecological overshoot[xxii] are genuine while they instinctively grasp the class-conflict roots of austerity. Most on the political right see neither of these factors in play; in rote fashion they call for lower taxes and less regulation.[xxiii]

Economist Michael Hudson critiques neoliberalism this way:

The term “neoliberalism” misrepresents and even inverts the classical liberal idea of free markets. It is a weaponization of economic theory, kidnapping the original liberal ethic that sought to defend against special privilege and unearned income. To classical economists, a free market meant one free of unearned income, defined as land rent, natural resource rent, monopoly rent and rent-extracting privilege. But to neoliberals a free market is one free from taxes or regulation of such rentier income, and indeed gives it tax favoritism over wages and profits.[xxiv]

This brings us to why growth cannot recommence. The scaled down answer lies not in monetary, fiscal or economic policy per se, but in understanding the interplay of net energy supply with a debt-creates-wealth & growth-based economy.[xxv]^,[xxvi] Frederick Soddy, 1921 Nobel Laureate in chemistry, sought to ground economics in physics, that is, the laws of thermodynamics. While he was ignored as a meddling unsophisticated crank by the economists of his era, his basic insight is today the foundation of comprehending what is taking place in the world: “Soddy wrote that financial debts grew exponentially at compound interest but the real economy was based on exhaustible stocks of fossil fuels. Energy obtained from the fossil fuels could not be used again.”[xxvii]^,[xxviii] In other words, debt and interest can increase infinitely while natural resources cannot. This has led his followers to reason as follows:

We developed our world economy with oil as our security against future debt, always able to borrow more with the ‘certainty’ that cheap oil would provide future income to pay it off.

… This is the fundamental truth that eludes our cornucopian economists: our economy functions on energy input, not money output. Without endless cheap energy you can’t have endless employment. Our infinite demand has hit the wall of finite resources…[xxix]

Timothy Garrett, a contemporary physicist, has developed a model of economic activity as a heat engine -complete with a coefficient of output- which, expressed in lay terms means the economy is dependent for its output on the amount of energy –not capital or money or labor- flowing into it.[xxx]

The amount of light, sweet crude oil available to the world hit a plateau in 2005 and has remained more or less flat since then. This in our estimation is likely the signal that we have reached the geological limit to the amount of oil that can be extracted from the earth on a yearly basis, in other words, “Peak Oil.” Consider that at the end of 1998 a barrel of oil cost $13 (US) and in the summer of 2008 it topped out at $147 (US). Currently, it hovers in the $100 range. We suggest Canadians ask themselves how their lives might be different if they were paying approximately $.51[xxxi] (1998 Canadian) per litre for gasoline instead of the current $1.39 (Canadian). Further, as important as oil is to transportation –it provides 90% of all vehicle fuel- it has multiple uses in agriculture and is involved in a dizzying array of products and processes of industrial economies.[xxxii] So in addition to gasoline, recognize that food, clothing and many other products[xxxiii] and services would be less expensive in a $13 per barrel world.

It follows that unemployment, home foreclosures, bankruptcies, and debt loads also would be lower with cheap oil. Nonetheless, we suspect there is far too much debt in the world to be repaid,[xxxiv] because these debt levels are “synthetic”[xxxv] and unanchored in tangible resources –like oil- and therefore can increase exponentially. Most important, without growth debt interest –and in many instances principle- cannot be serviced. Here’s one example from Spain, as it creaks under austerity and the high cost of energy:

Gross domestic product will fall 0.5% in 2013 instead of rising 0.2% as the government predicted April 27, Budget Minister Cristobal Montoro said after the Cabinet met today in Madrid. The government will spend €9.1 billion ($11 billion) more paying interest than in 2012, he said.[xxxvi]

(Space considerations prevent us from presenting evidence from the larger context of ecological overshoot and reaching the limits to growth, but we invite readers to examine these references.[xxxvii]^{,[xxxviii],[xxxix],[xl],[xli],[xlii]} For a succinct and elegant overview, see this interview of Bill Rees.[xliii])

Those who believe growth can restart claim that peak oil is unimportant because of tar sands, oil shale, shale oil, and shale gas. With all respect, we regard these as the mythological chorus of cornucopian chanting to make it so. There is a plethora of empirical evidence and analysis revealing why these sourcessignify not a new era but the last gasp of fossil fuel energy.[xliv]^{,[xlv],[xlvi],[xlvii]} (Who thinks $13 oil is going to return?) While non-fossil fuel energy alternatives –wind, solar, geothermal- are critical, we see no evidence that they can as yet scale up in volume and as well provide the net energy return[xlviii] to prevent degrowth. Should we develop “clean” energy? Absolutely, it is indispensible. Should we believe that it might allow “Smart Growth?” There is no convincing evidence to think so.

David Korowicz offers a feedback cycle interpretation of the energy-economy-finance dynamic, which neoliberal austerity measures combined with peak oil are producing, most dramatically (for now) in Greece:

Less credit-money in the economy flowing more slowly through the economy means less for businesses. Some businesses fail, leading to growing bad debts, rising unemployment, less taxation income, reduced confidence and investment. Asset prices fall, GDP declines, and the real cost of debt rises. Rising bad debts means bank capital is destroyed, risking bank’s solvency, and the general economic outlook worsens. Bank issued credit-money and its velocity in the economy declines further. The cycle continues, and GDP falls further. The cost of credit on international markets for the country and banks rises due to fears of default, which increases the vulnerability of both. Confidence falls further.[xlix]

We do not know how contraction will unfold, slowly over decades; in a stepwise fashion where social and technological complexity[l] is lost and then the system stabilizes for a period of time before slipping down another notch; or in a sudden –a matter of weeks or months- “phase shift.” Korowicz observes,

Generally, we tend to assume that change is gradual; a dependent condition changes and the system responds proportionally. Our assumption of gradual change tends to imagine that the effects of economic contraction, debt deflation, climate change, energy depletion, or biodiversity loss will gradually grind us down, snipping away at our wealth and welfare over years or decades. This may be so. However, all those changing conditions need to do is drive the globalised economy, or keystone-hubs within it, out of their stability domain, after which the system’s internal interdependencies come out of synch with what they have adapted to and the system can be at risk of collapse. The speed of that collapse is related to the levels of integration and complexity in the system.

… The operational fabric could cease to operate and the systems that are adaptive to maintaining our welfare could cease or be severely degraded. As a society, we would have to do other things in other ways to establish our welfare. Functions and specialties, a diversity of goods and services, and complex interdependencies would be lost.[li]

While little attention is being paid to the deterioration of health systems in several European counties, speculation is mounting about the departure of some nations[lii] from the Eurozone.[liii] Regarding Greece, a recent news story in the Athens News reads,

According to an article that will run in Monday’s [July 23, 2012] edition of Der Spiegel magazine, Greece could go bankrupt by September, with the IMF running out of patience with Greece and backing out of supporting its troubled economy.[liv]

In Spain[lv] the government and demonstrators are clashing as, “The Spanish economy has finally come to the brink of collapse threatening to take the euro down with it.”[lvi] The outlook from observers who still believe[lvii] in growth is revealing a hint of degrowth thinking. One financial analyst writes,

The Eurozone is increasingly looking like a zero sum exercise to its members: that there are no win-win strategies, only dividing up a fixed pie. And with austerity on in full force, it’s actually worse than that: the power[s] that be are haggling over a pie that is shrinking before their very eyes. There’s declining trust and no willingness to consider alternatives that would put economies on a better trajectory. There’s now lip service being given to the need for growth, but the neoliberal budget-cutting religion is very much intact: the only alternatives under consideration are delaying the wearing of hairshirts, not considering completely different options.[lviii] [Emphasis added]

In summary, the economies of the social world are contracting and giving signs of destabilizing per Korowicz’s analysis, and they show no sign of returning to the pre-2007 state. Again, while we cannot predict a slow or intermittent descent or rapid collapse, we feel confident claiming that neoliberalism, which is rooted in a social construction of reality derived from a mythology divorced from ecological reality, has no egalitarian or utilitarian impulse to face the challenges of contraction. Degrowth has this impulse and the very term is rooted in recognition of entropy.[lix] We suggest that neoliberalism is not the best of all possible worlds, rather, it is leading to a dystopian world where, Der durchschnittliche Bürger wird verarmen oder ärmer.[lx] (The average citizen becomes impoverished or poorer). And a burgeoning indigent population in modern society is fertile ground for public health and medical catastrophes.

Health Systems at the End of Growth

If degrowth is an enlightened cultural response to the laws of thermodynamics and ecological dynamics, it follows there are massive institutional changes needed to promote and protect the health of societies.

Stated positively, degrowth allows humans to think and act cooperatively with nature as contraction occurs. It redefines neoliberalism as a virulent form of capitalism. Parenthetically, some argue all forms of capitalism are socially invidious and ecologically irrational; this is a discussion we cannot here develop, although we are adamant that perpetual economic expansion is no longer possible.

While they do not (yet) share our social-ecological perspective, a small but growing number of health professionals in many nations are experiencing cognitive dissonance due to, on the one hand, their personal and professional commitment to treating illness and promoting health and, on the other hand, working under draconian and even life-threatening conditions created by austerity. Neoliberal politicians tell them to endure until normalcy returns, yet they see mass human tragedy unfolding in their work along side the coddling of elites –especially financers.

Consider Greece in light of degrowth. Its health system has been denuded by severe budget cuts[lxi] in step with the economic “meltdown”[lxii] occurring in the nation. In 2010 –before the worst of the cuts were introduced- the World Health Organization released its assessment of the Greek health system. Its report reads,

In 2010, the Greek economy entered a deep structural and multi-faceted crisis, the main features of which are a large fiscal deficit, huge public debt, shrinking GDP, growing unemployment and the continuous erosion of the country’s competitive position. As part of the conditions of a financial support package from the EU and IMF the country has adopted strict austerity measures aimed at reducing the fiscal deficit and restoring market confidence in the future of the economy[lxiii].

Plainly, the WHO tolerates austerity and it is difficult to imagine a scenario in which it and other health organizations would challenge the status quo, primarily due to the TINA dogma and financial reliance on nation states.[lxiv]^,[lxv] Similar measures are beginning to degrade the health systems of Portugal, Spain and Italy, among others. (In Canada[lxvi] Prime Minister Harper’s budget calls for reductions on health car spending over the next several years.)[lxvii] A report on Italy informs us of this but it too does not challenge neoliberal policies,

While justified by the risk of a national debt default, present fiscal policies might increase inequalities in access to care, deteriorate overall health indicators and population wellbeing, and sharpen existing difference in the quality of care between regions… This cost-cutting strategy may have negative long term consequences … It is essential that in such a period of public funding constraints health authorities monitor incidence of diseases and access to care of the most vulnerable groups and specifically target interventions to those who may be disproportionally hit by the crisis.[lxviii]

There is an added dimension[lxix] -hinted at in the above passage on Italy- to the health systems crisis beyond the plight of medical care to those individuals needing it. It is what health professionals term the social (or non-medical) determinants of health –the foundation of public health, which helps prevent sickness and disease. This concept includes such factors as education, income, employment, and community support networks.[lxx] The World Health Organization defines the concept broadly as, “the conditions in which people are born, grow, live, work and age, including the health system.”[lxxi] Within this far-reaching definition we can include clean water, food, essential energy, sanitation, public safety, transportation and communication –all taken-for-granted in industrial society but jeopardized by austerity measures. Thomas Frieden has developed a health impact pyramid, in which the social determinants are the foundation of a viable health system:

A 5-tier pyramid …[which] provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health. … Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort.[lxxii]

In real time Greece is undergoing a decline in the social determinants of health –and it would not be easy to restore them even if growth were to restart. This deterioration appears likely to extend to Italy, Portugal, Spain, Ireland, and Cypress –and it appears to have taken hold in Latvia,[lxxiii] a nation touted as an example of how austerity has worked.[lxxiv] Eventually it spreads to all modern societies as long as neoliberalism prevents recognition of economic contraction and defines financial institutions as the preeminent indispensible foundation of social existence.

It is important to contrast the situation of one nation, Iceland, which has rejected the neoliberal policy of austerity that in Greece, Italy, Ireland and Spain has been imposed to prop up “Zombie[lxxv] Banks”[lxxvi] by transferring private banking losses onto the public. In 2011, “Icelanders … rejected the latest plan to repay the UK and Netherlands some 4bn euros lost when the country’s banking system collapsed in 2008.”[lxxvii] The UK and Netherlands governments were outraged by this plebiscite in which the Icelandic public refused to take on the debts of private Icelandic banks. As a consequence Iceland’s health system, though it has problems, is not collapsing:

The health care sector has been struggling with cost containment programmes for most of the last decade, so the cuts now came on top of that. This has thus been tough for staff and management but all indications are that the previously high standard of quality has been maintained to the largest degree.[lxxviii]

Iceland’s prime minister explains:

“We cut the budget but we preserved as much as possible in education, health, social security and infrastructure like law enforcement,” [Johanna] Sigurdardottir said. “In the years leading up to the crisis, the gap between the richest and the poorest in society widened and our measures in the crisis focused on diminishing this gap, with more equality.”[lxxix]

Iceland is not consciously implementing degrowth policies, but its response to the financial crisis is consistent with them.

Discussion

It would require an epiphany or a deus ex machina for government supported health organizations, like the WHO, or professional associations, like the Canadian Medical Association, to speak ecological truth to neoliberal power, that is, to resist the neoliberal “regime of truth.”[lxxx]^,[lxxxi],[lxxxii] It is conceivable, however, that as the crisis deepens some health organizations will use their voice[lxxxiii] to call for economic stimulus, as it is an acceptable alternative to austerity for restarting growth. Neoliberal governments may turn to stimulus in desperation as they see their political legitimacy slipping away.[lxxxiv] Stimulus does not disturb the existing hierarchy of wealth, status and power and will, we propose, be seen as a second best means of protecting it. However, there is no empirical evidence from the crisis that began in 2007 to believe stimulus will work any better than has austerity.[lxxxv]

From our vantage point, a call from health leadership for economic stimulus amounts to seeking a restoration of pre-crisis health systems. In contrast, if growth is ending, then we have a difference in kind not degree –the structure of health services must be redesigned in terms of less complexity and fewer available resources to operate institutions. This includes in health care such dimensions as range of services, capacities, specialties, models of medical practice and, also, what constitutes public health prevention and promotion. Critically, this scenario assumes there will be no sudden collapse as outline above by Korowicz.

Adopting a degrowth worldview would introduce a radical shift in social consciousness, and this would in turn alter the overarching terms of policy-making discourse. However, a smooth –“soft landing”- transformation is rare, and probably without historical precedent. The history of science[lxxxvi] and the sociology of knowledge[lxxxvii] inform us that conversion from one paradigm to another is multidimensional and features political struggle- and not merely intellectual persuasion. For instance, Max Planc allegedly said, “science progresses one funeral at a time.” Thomas Kuhn[lxxxviii] notes that paradigm shifts begin in “young Turks” vying to unseat established “old guard” figures; additionally, these shifts occur after the accumulation of unresolved anomalies, repeated policy failures that heighten the contest between competing paradigms and policy experimentations.[lxxxix] This is at the policy-making level; at the cultural level this shift is unprecedented, as illustrated, for example, by Occupy Wall Street, Quebec Carre Rouge student demonstrations and Spain’s Indignados.[xc]

At present the degrowth metaphor has no voice in the halls of policymaking, corporations and mass media, despite its grounding in empirical science. For historical example, the now blatantly relevant act of hand washing by doctors between patient contacts was ridiculed as a waste of time in 19^th century medical practice –because germ theory was not understood- and its advocates initially were ostracized.[xci]

So we have an untenable situation: the political, cultural, economic and financial crisis deepens as neoliberal governments remain in power. In Canada, Steven Harper’s initiatives are, if anything, a “Shock Doctrine” doubling down to weaken or eliminate a wide array of progressive government regulations and social programs. Even though his policies are widely unpopular and are beginning to undermine his[xcii] legitimacy,[xciii] “There Is No Alternative” still works, primarily because the discourse of degrowth exists –like hand washing for 19^th century medicine- on the fringes of modern culture.

Blyth[xciv] explains that once paradigmatic ideas –like growth is good and natural, the market solves all problems- become successfully embedded within an institution (or a culture), policymaking is only possible in terms of these ideas. “Cognitive locks” are formed when policies become firmly embedded within a society, or institution, and makes change or retrenchment of such policies increasingly unlikely. Regardless of the actual conditions of a situation, cognitive locks channel the course of action –this is why degrowth conversations presently are absurd in the halls of power. This helps to explain the policy-making patterns of countries,[xcv] and is relevant to other forms of governance. It also explains why the urgency and desperation of crises mount to produce sociological legitimacy for fresh “radical” perspectives and solutions not previously considered –what Foucault terms “epistemic ruptures.”[xcvi]

To reiterate, accepting degrowth requires a massive cognitive (paradigm) and emotional (mythical) shift in consciousness. As desperate as things are ecologically, and as unstable and corrupt as they are culturally, politically and economically the modern world remains attached to the shibboleths of neoliberalism as opposed to the anthropologically strange[xcvii] and personal sacrifice demanding worldview of degrowth.

To add to the complexity of this situation, many health professionals we know realize something is terribly askew in the world, but they hope it will be resolved under the current political/economic order. At a minimum, they hope the system will not fully collapse until they are retired or dead. (Some have asked one of us, “How long do we have?” in the sense of “Maybe I won’t have to deal with this.”) Some also know –especially in the United States- that the health systems where they work are unsustainable, for economic as well as ecological reasons. But the vast majority of them –despite their superior intelligence and great dedication to their work- are naïve, even childlike, and do not recognize how their government is captured by a parasitic financial sector and is willing to cut or even eliminate social services to save “the system.”

So what is the future of health systems as the modern world remains locked in the neoliberal worldview as thermodynamic and ecological forces inexorably reduce our collective degrees of freedom to act?

There are two polar approaches to redesigning health systems. The first is through complex bureaucratic organizations, such as the World Bank[xcviii] or World Health Organization. We find this approach unworkable because, first, such organizations are dominated by neoliberal agendas and, second, the survival and efficacy of complex organizations in a degrowth world is not assured –they are as much reflections of the diminishing returns on complexity.

Congruent with this first approach, the myth of growth promises ever-increasing amounts of material goods and comforts. Four decades ago Ivan Illich saw where this “promise” would lead –to the ravages of neoliberalism, which became ascendant in the 1980s under Ronald Reagan and Margaret Thatcher:

The energy policies adopted during the current decade will determine the range and character of social relationships a society will be able to enjoy by the year 2000. A low-energy policy allows for a wide choice of life-styles and cultures. If, on the other hand, a society opts for high-energy consumption, its social relations must be dictated by technocracy and will be equally degrading whether labeled capitalist or socialist.[xcix]

The alternative path Illich described is localization. In a recent book on preparing for energy descent De Young and Princen[c] offer three premises about how localization the movement is unfolding:

1. In terms of ethics and morality, “It doesn’t plead,” attempt to shame, or coerce people. Instead, these authors surmise “that high consuming societies will be adapting whether they are environmentally enlightened or not. What is more, behavior change may precede any change in attitudes, values, or worldviews.”
2. In terms of politics and public policy, “It holds little faith in centralized approaches.” Such top-down “models do not draw on the extensive research that shows how to engage people in reasonable behavior.”
3. In terms of social organization and liberation, “It is affirming. Localization affirms self-organization, self-reliance, self-limitation, and self-rule.”

Summary

Degrowth recognizes that humanity’s access to the earth’s resources and services of the biosphere are constraints upon socioeconomic activity. It also holds that politics and economics cannot trump thermodynamic and ecological realities. It places the limits to growth and ecological overshoot at the center of the predicaments Homo sapiens confront. It connects to culture and political/economy through this root public policy question: How to equitably distribute a shrinking economic pie?

From the neoliberal perspective, the biosphere is subject to human control, the market solves all problems, and therefore the analogy of a shrinking economic pie is false.[ci] The only possible policy question is, How to remove government obstacles to allow the market to naturally produce economic growth? The resulting prosperity that accrues to the wealthy –also considered natural- will “trickle down” to all members of society wiling to work to achieve it. The value of future generations is nil, despite all rhetoric about responsibility to “our grandchildren.” We claim that the neoliberal ideology is wholly at odds with the biophysical realities that make human existence possible.

Even if all governments turned to degrowth tomorrow, there are no longer any pain-free solutions to what Jim Kunstler has aptly labeled The Long Emergency.[cii] It is in the context of entering this protracted emergency that the future of health systems will be worked out.

Dan Bednarz, PhD, is a co-editor of the website Health after Oil and is working to create sustainable health systems for a world at the limits to growth. He can be reached at his website or at danbpgh_@_gmail.com.

Allana Beavis, BHSc., is finishing her MSc. in Global Health this August 2012 at McMaster University and beginning a MSc. in Physical Therapy at the University of Toronto in September 2012. She is very interested in health systems strengthening and policy-making.

Footnotes & References