Session Two: How do Transformations Happen?
Public Health in the Time of Great Transition
Public health is the science and discipline of health and disease in populations. Its salience for a transition to a planetary society is evident, especially as the high degree of interconnectedness has led to a qualitatively different set of public health problems. Public health in the US has undergone a number of changes in the last 150 years and is undergoing yet another today. We contend that the direction public health is taking is especially dangerous and make some suggestions as to how the current state of public health reality can guide us in a more sensible direction.
I have been involved in medicine and public health for forty years, but I have always worked at immediate problems. What I am going to say about the longer-range future of public health is therefore the product of my thinking out loud. In fact, the subject of public health in the next 40 years is a relatively neglected subject. There is, however, a great deal to be done in this area, especially since public health seems presently to be headed exactly in the wrong direction, not only in this country but around the world. We are on the threshold of a fundamental transformation into a planetary society, but the shape and consequences of that transformation are very uncertain.
Clinical medicine is different from public health. In the first, we deal with people one at a time; in the latter, with groups of people. In addition, public health undertakes public enterprises that affect communities, groups of communities, and groups of groups of communities. Let me start with a little history. In the latter half of the 19th century, public health was concerned primarily with the social conditions of populations. It believed that human nature was at least partly a function of social conditions and could therefore be altered by changing these conditions. Although health required a clean environment, it was also necessary to convince the poor to adopt moral lifestyles that coincided with those of the American middle class.
This morally explicit point of view collapsed between 1890 and 1920, undermined by three developments. The first was Germ Theory and the new science of bacteriology, which could dispense with morality in its project of improving conditions. The second was the transformation of the medical profession from a low-status, faction-ridden marginal profession to a high-status, self-regulating professional organization. The third was the tremendous social upheaval of the period, which included labor unrest and violence as well as socialist ferment and organization. Responding to these three pressures, public health reconceptualized the source of disease and turned away from an interest in dangerous environments and toward dangerous people. Typhoid Mary is a dramatic emblem of this shift, but it was quite deep and general.
When this shift occurred, people who would have belonged to the previous movement simply turned away from public health and moved into the conservation movement. They left the world of people and moved into the wilderness, leaving policy to be formulated by technocratic scientists who sought the origins of disease in the pathology of individual people. Thus, another effect of this shift was to place public health under the domination of the medical profession.
People who work in public health today do not recognize the picture I am sketching, but it nevertheless accurately describes the field up until the 1960s. Things changed for the better then, and the field is now considered a form of social engagement which draws on a moral vision that also informs political action. As a result of the upheavals of the 1960s, many bright young people go into public health as a way of finding work that is consistent with their moral values.
There are two lessons to be learned from this history. The first is that our own experience of public health belongs to a specific historical moment. The second is that our present era of public health has already gone. Public health is now being marginalized, its resources cut, and its prestige undercut by the appointment of leaders whose main qualification is their ineffectiveness. In addition, new sciences like the Human Genome Project are reversing some of the progress we have managed to achieve. Most recently, public health is being reorganized into a militarized hierarchical system that serves foreign policy goals primarily. This represents just another cycle in the history of public health, but it comes at a very bad time. Worldwide, rates of infectious disease have almost doubled in the last 20 years, and not only because of AIDS. We may well ask if this trend is just an anomaly or if it represents something more fundamental.
It may be that the patterns of social relationships of our species are undergoing a phase of transitions, which are tipping points, like when water turns from a disorganized liquid into a highly organized crystal called ice, or when metals become paramagnetic. Tipping points also describe other more complicated networks and are relevant to the kinds of analyses we do in public health. For example, continents are infecting each other with diseases the way countries, cities, or individuals do. While this is happening, we are transforming the public health system into a form of the Fortress World by adopting command and control policies like quarantine rather than encouraging a spirit of interdependence and support.
If we are to make the transition to a planetary society, we need to see ourselves as embedded in a highly interconnected system, in which no community or single person is safe unless we all are. Large numbers of people are presently laboring at making communities safe, healthy, and comfortable without thinking of themselves as public health workers. After September 11, I tried to organize a new kind of public health institution, where disparate kinds of knowledge and skills could be brought together to solve practical problems. Scientists studying infectious diseases conferred with scholars studying the spread of rumors; transportation engineers learned from taxi drivers.
The project was going pretty well, but then it disappeared when a feeding frenzy instigated by the Bush administration caused institutions to scramble for homeland security money. People with genuinely good instincts and the wish to contribute to a better world were left with nothing to do. Instead of adopting a language and a vision of nurturance, the country retreated into a bunker mentality.
There are certain public health topics we need to start discussing. The first is the longer-range future of public health. Another is that the most widely admired and effective humanitarian groups operate without national borders. Issues of race and ethnicity are also extremely complex issues. While we should oppose their political use for nationalistic or tribal interests, they have their uses. There are many forms of the human family. People are different, and their uniqueness and diversity are fundamentally important to preserve. Last of all, we need to emphasize what we have in common rather than what sets us apart. We are just about arriving at the global village of the future. We had better get our bearings straight pretty quickly or we are going to be lost.
The Demographic Transition: Instinct, By-product, or Design?
Beginning in the late 18th century in Western Europe and North America, one population after another has experienced a demographic transition. From a situation of high mortality and high fertility rates, with extremely slow growth rates, populations have progressed, at different times and speeds, to an end-state of low mortality and low fertility rates, with slow or even negative growth rates. In between these two states, population growth can be extremely rapid. Profound change need not be slow: the demographic transformation is much more recent in what are now the rich countries of the world than is commonly realized, and it is fresh in the memories of old people in most developing countries. The momentum of growth (due to changing age distributions) ensures continued growth of the population in developing countries long past the achievement of low fertility.
How did the transformation happen? In particular, what were the respective roles of private, small-scale decision making and collective action? How much of the demographic transformation is a by-product of contemporaneous economic change and the spread of mass education? Should we be optimistic about the prospects for finishing the transition within the next few decades, as most population projections imply?
The answers to the “how” questions differ in important ways between the populations which began the process early and those which began after 1945. The transformation has become more a product of conscious choice as it has spread. The “demonstration effect” has changed expectations of government, to include health services and in most places accessible and safe control of fertility. The prospects for the future seem better for mortality control than for fertility control, though in each case, there have been serious setbacks and delays in different parts of the world. Political will may not have set the transformation in motion, but lack of it may delay its humane completion.
[Editor’s Note: Dr. Haaga’s presentation relies significantly on graphs, charts, and other visual representations, which are not reproduced here.]
I would like to discuss the possibility of changing demographic regimes through a combination of collective action and individual choices. First I will discuss the transition and then go on to two of its components, mortality and fertility declines. I would also like to pay some attention to the question of how fast populations reach their presumed stable end states. In our thinking it is important that we not reify the idea of transition, since reversals are quite possible.
Parenthetically, although the question of what makes people happy is difficult to answer, one of its components that is almost universal is that people wish to die in the correct order. That is, they want each generation to follow the other in a kind of natural progression. It is only recently that this idea has been democratized and spread throughout the world.
Let us start with the classic model of the demographic transition. One of its striking characteristics is urbanization. For the first time in world history, people living in villages and hamlets no longer form a majority. This demographic transition was classically described by Frank Notestein, who shortly after World War II plotted crude birth and death rates. Populations grow very slowly, as do the development of familial institutions, economics, and cultural traditions. Fast transitions begin when mortality rates start to fall. The gap between birth and death rates is the rate of population growth. Early writers on the transition recognized an early state with high mortality and fertility rates, and a late stage with low mortality and fertility rates, both of which sustain low rates of population growth. The middle stage, however, is characterized by high population growth. We are interested in how long and painful that middle stage is.
Notestein’s model, which contradicts Malthus’s, proved to be remarkably prescient for the Third World, although it was not a very good model for European and North American development. Demographers are seeking to explain the pace and interrelation of the two declines. No country looks exactly like the stylized model. When we look at population growth in the United States and Mexico, for example, we notice a dramatic difference in time scale. The transition that took two centuries in the United States required only a couple of decades in Mexico. In general, developing countries have very fast rates of growth, while those that started their transition earlier have slower rates. While the gap between the mortality and fertility rates never got that big for early starters, it can be enormous for developing countries. With a four percent growth rate, for example, a population will double in a single generation, thus putting gigantic strains on social institutions. Fertility transitions often occur without being fostered by public health systems or effective medical practices. Easy explanations for what has triggered a transition often prove false and are historically uninformed.
General trends in life expectancy have grown in the last 30 years, and international differentials have closed. Patterns of growth by individual countries or cultural and ethnic groups, however, are far more disorganized. Once transitions begin, they proceed at very fast rates. For example, in my father’s lifetime life expectancy in this country has risen from a level that characterizes present-day Ghana or Togo. Rates are even faster in developing countries.
Declines in mortality rates are often triggered by governments that impose law and order, suppress violence, avoid or mitigate famine, and control the worst excesses of epidemics. Much of this is conscious and intended and can involve managing famines, building railroads, or encouraging effective child care. In the past, education did not affect infant mortality rates significantly, but nowadays it has a tremendous effect. Programs of immunization and control of infectious diseases have also become important factors.
As for the fertility transition, around 1980 half the world sustained a fertility rate of approximately four. Only 16 percent lived in countries where fertility was below replacement levels. By 2000, these proportions had reversed. These aggregate measures are, of course, largely affected by what has happened in China and India, but fertility declines are now spreading all over the world, including to Muslim countries that once resisted them.
What about collective action? Each country has its own story to tell. Nowadays over half of all married women in developing countries of a reproductive age use some form of modern contraceptive. The decline has started everywhere, except in West Africa. The effect of the International Family Planning Movement and the International Planned Parenthood Foundation has been terribly important.
Is the end in sight? Some claim that the crisis is over and that the real problem now is population aging. They are mistaken. The diagram Notestein published in 1945 is still valid, although the rates of change are faster than we had expected. Pace matters. For example, an uncertainty period of plus or minus ten years affects billions of people. There are presently 1.2 billion teenagers, one of the three or four largest generations that will ever exist. They will put enormous strains on social institutions and will have to work extremely hard just to stay in place.
To conclude, people often argue for what they consider the single most important trigger for transitions. It may be curative or preventive services, women’s education, wars, or revolutions. But the situation is not so simple. Each trigger is a necessary precondition for the others. In addition, new technologies and managements respond to periods of crisis. As for proximate and ultimate drivers of change, we have found in our work that behavioral and attitudinal change occur in tandem. Finally, I would like to caution you not to pay too much attention to social scientists. I myself have issued warnings about the difficulty of change, and then everything changed. Let us recall J. P. Morgan’s words to his lawyers: “Damn it, I did not hire you to tell me what I can and cannot do. I hired you to tell me how to do what I want to do.” That is our function.
Energy Transitions Past, Present, and Future
The history of human culture can be viewed as the progressive development of new energy sources and their associated conversion technologies. These have increased the ability of humans to exploit both additional energy and also other resources, and hence to increase the comfort, longevity, and affluence of humans, as well as their numbers. In particular, there are three important ways in which energy is related to human development: a) energy as a source of environmental stress, b) energy as a principal motor of macroeconomic growth, and c) energy as a prerequisite for meeting basic human needs. Significant changes in each of these aspects of human existence are associated with changes in energy sources, beginning with the discovery of fire, the advent of agriculture and animal husbandry, and, ultimately, the development of hydrocarbon and nuclear fuels. The eventual economic depletion of fossil fuels will drive another major energy transition; geopolitical forces and environmental imperatives such as climate change may drive this transition faster than hydrocarbon depletion would have by itself. There is a diverse palette of alternative energies including a new generation of nuclear power, myriad solar technologies, and hydrogen. A wide range of opinion exists on the economic, political, technological, and environmental attributes of these energy systems. Hence, projections of the nature and timing of future energy transitions show a wide range of possible futures. This paper discusses our current and future energy situation in the context of previous transitions and their impact on the trajectory of human culture.
Changes in the ways people have used energy have been fundamental in shaping every aspect of human existence and the environment. Energy prices and usages are tightly linked to macroeconomic growth, unemployment, and inflation. It is also an important motor of overall economic growth in the way it determines stock market performance. As we all know, it causes environmental change on local, regional, and global scales. Recently, we have come to think about energy as a fundamental social force that provides basic life support service, education, clean water, and so forth. The impending depletion of fossil fuels and the way energy usage is affecting climate will have major effects on the coming transition.
History has witnessed many energy transitions. I would like to list a few of them. A major shift occurred away from living off the sun and the products of photosynthesis toward using nonrenewable hydrocarbons. Corresponding to this shift was a change in energy converters from animate sources—human and animal—to inanimate ones such as the steam and internal combustion engines and turbines. We also moved to better qualities of energy and to more useful heat units when we switched from wood to coal and then to gas and electricity. This resulted in a great net energy surplus as energy production increased faster than the energy consumed to extract it. We have also seen a shift from noncommercial trade in wood to commercial energy traded in formal markets. This trend has accompanied a general shift from rural to urban. Looking ahead, we can foresee a similar shift as the demand for energy moves from the North to the South. In general, energy is being used more efficiently and the amount of carbon released per heat unit has decreased.
I would like to speak about a couple of these transitions and develop some scenarios about what is technologically possible, economically feasible, and socially desirable. The first was the Industrial Revolution, where animate energy converters (men and draft animals) and renewable energy sources (primarily wood) gave way to machines and coal. The second occurred between the First World War and the 1960s, when oil and natural gas replaced coal. The accompanying unprecedented economic growth was driven by this shift from coal to oil and natural gas. Human beings can generate about one-tenth of a horsepower, a draft animal ten times more, and steam engines hundreds or thousands times more. From a physical perspective, this is what the Industrial Revolution was about. Internal combustion engines and electric generators made the second wave of that transition possible.
These transitions were extremely important from an economic point of view, as the surge in productivity since the beginning of the Industrial Revolution led to higher expectations among workers. One of the reasons poor nations remain poor is their use of low-quality energy sources and animal energy converters. Of course, these progressive changes have deleterious consequences as well, especially in the area of climate change. If we are serious about stabilizing the climate, we will have to devise almost astronomical changes in the way we use energy.
Our present social environment relies on an extremely high density of production and consumption systems. Shifting to energy sources with lower power densities than fossil fuels will involve restricting the free allocation of energy. Related to this is the problem of productivity. In almost all industrial nations and in some developing countries, we are more efficient at converting energy by shifting from low- to high-quality fuels. Other recent developments include the substitution of capital and labor for energy as well as the encouragement of energy conservation. These, however, are not autonomous technical changes, but technical change of a certain character. Specifically, in the future, three-quarters of energy demand will be located in the South. It is unclear how we will finance such a massive capital investment, or even if the free market can generate and sustain this type of transition fast enough, especially if climate stabilization becomes a principal issue.
Let me sketch some future scenarios. The first I call “Coal is King Again.” If climate stabilization does not become a primary issue, this is not an unlikely scenario, since 90 percent of the carbon still in the earth’s crust is coal, not oil and gas. This particular scenario both relies on very high rates of economic growth and technical change and disregards environmental consequences. It postulates the generation of large amounts of wealth, which it hopes to distribute relatively fairly. The distinctions between the developed and the developing world therefore disappear, and new technologies would control the effects of pollution.
The second I call “Oil and Gas Forever,” which employs the same economic scenario as the first, but concentrates on extracting as much oil as possible from the earth. Eventually this supply will be exhausted and some kind of Grand Transition will have to occur, which will employ a high degree of international cooperation and many policy instruments to deal with climate change. A carbon tax will be enacted, which would produce an economic drag on the North. On the whole, people would be a little less rich, but everyone would overall be better off.
Other scenarios have been developed that depend on the exploitation of biomass, as well as renewable energy and hydrogen to generate electricity. They envision great technological improvements in gas turbines and predict no significant adverse effects on natural systems. There are also nuclear scenarios that begin with conventional boiling water and pressurized water reactors. In 30 or 40 years, however, natural uranium will be depleted, and there will be a shift to plutonium or thorium systems. In any case, this scenario requires a massive project of building new nuclear plants.
Comparing these scenarios reveals great differences in what is economically feasible and desirable. Investment costs can be huge, perhaps amounting to $100 trillion by 2050. Much of that sum will have to come from private markets, but energy projects tend to have low rates of return and are considered risky investments. Equity issues are also difficult, especially in the rural sections of developing nations. On the other hand, all these models assume continuous and significant cost reductions to follow new energy technologies. Those that involve nuclear power will have to reduce their costs significantly.
Finally, the free market will not lead the way. There is still too much cheap fossil fuel left in the earth’s crust to make these innovations likely. If climate change is a serious issue, significant international cooperation and commitment will have to develop non-carbon-based sources of energy in a relatively short period.
This is a chapter from Making the Great Transformation (Conference).
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