Interview with Norman Swan
The Health Report, Radio National, 02 Feb 1998.
Summary: You might have noticed that it's rare for a month to go by without news about the resurgence of an old epidemic, or the appearance of a new one. A fair question to ask is Why is all this happening? And a new book claims to have the answers. It's called 'Green or Gone' and one of the authors is Emeritus Professor of Medicine at the University of Adelaide, David Shearman.
You might have noticed that it's rare for a month to go by without news about the resurgence of an old epidemic, or the appearance of a new one. Investigators have been in Kenya to work out what might have caused a mysterious disease outbreak there. The new Hong Kong flu is scaring people, and in Australia we've had our fair share of frights too, what with the Lissa Virus, the Equine Morbillivirus, the meat-borne food poisoning episode, and even the threat of malaria spread on our continent.
A fair question to ask is Why is all this happening? And a new book claims to have the answers. It's called 'Green or Gone' and one of the authors is Emeritus Professor of Medicine at the University of Adelaide, David Shearman. David has taken on health, the environment and economics - a pretty big task.
David Shearman: Well it is, but one has to develop some view on this. I mean for the general reader we try to put this message across. You can look at the definition of health and what it means to everybody, and I put this in the context of the world's environment and ecology. But on any item, if you really look at what's wrong, and you trace it back, you trace it to two fundamental problems. Firstly, world population growth and secondly, economic growth and economic values. You just can't get away from them. So whether you like it or not, you end up studying economics as I did, to try and find out what the problem is. And hence the book.
Norman Swan: You're a Professor of Medicine, in a fairly high-tech area, gastroenterology, and you're looking at the way the bowel moves, how do you translate this into the environment? Was there a frustration in practice that led you to that?
David Shearman: Yes, I think there was a frustration. I think you spend 20 years in a high-tech position, your professional life totally controls you; you look at the task in hand, the patients, the dreadful committees, the deteriorating services, the abominations and horrors of university administration, and the scramble for research money. And then something happens to you, and you have some time off and you actually look at what you're doing, and you realise that this is a different planet that you've walked onto to the one you entered 20 years ago.
Norman Swan: In what way?
David Shearman: Well you suddenly realise how mechanistic medicine has become, and how financially orientated it is, and you realise the world's in an environmental mess and this is affecting population health and you trace both these to a change in values. I'm not in any way blaming my colleagues, we all adopt the values, the economic values in particular and the judgmental values of our society, and again we explain that in the book. So I'm not knocking mechanistic medicine, in fact I've benefited from it myself.
Norman Swan: By mechanistic, you mean what?
David Shearman: Well I mean actually taking a cure, whether it's a surgery for hips, or coronary arteries, or whatever, there's specific mechanistic actions that take place to cure a specific disease. But of course that isn't health, that's disease at the end of or towards the end of life in many of us. Health in population is a hundred other things, and I try and explain these. I mean it's everything from housing, nutrition, appropriate representation, value in society; if you're an Aboriginal it's attachment to your land; if you're in Bangladesh it's clean water, no absence of war and famine, and so on. I mean it's a huge definition that covers world health and wellbeing of each person.
Norman Swan: Is that health that you're talking about there, or is that what people would call the things that lie behind health? There's the World Health Organisation definition of health which is - I can't think of it for the moment, but it's the absence of infirmity in a sense, and a sense of wellbeing.
David Shearman: Yes, the definition is a state of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity, it says social wellbeing. And if you look when that definition was made after the Second World War, the social wellbeing basically what it was talking about was clothing, housing and feeding the millions of people who'd been displaced, and effecting that type of wellbeing. We're not talking about whether you've got another motor car or something.
Norman Swan: Let's talk about the environment before we back up to the values that you've been talking about. What evidence do you have that the environment and the population explosion, even though it's beginning to tail off, is causing ill health in the world? Because there's been a lot of criticism that people such as yourself have over-stated the issue, and it's not quite as bad as people thought. The disaster scenarios have not occurred.
David Shearman: Well again, it's a matter of predictions, and it's not simply a matter as you and I know, of taking a drug in a particular class and saying, 'Look, this drug is likely to cause disease of the blood, we must test it carefully.' That's a prediction that you can sort out in a year with appropriate tests. A lot of things that you're worried about may take 20 years to have an effect. Now what effect are they having during that 20 years we have to measure a little effect, and extrapolate that. So the 'word precautionary' principle has come into environmentalism, and that par excellence covers the question of global warming. And it's interesting to watch how these things evolve. I mean ten years ago people worried about global warming were denounced. Gradually scientists accumulate information and climb on the bandwagon, so we've reached a position where President Clinton said yesterday, 'Oh we've got global warming, we will agree on that.' But now the next argument starts What are the effects of global warming to be? Now you're asking me what effects we have that the environmental situation in the world is affecting health. We know it's affecting health in many ways. I mean we can look at a country like China which is grossly over-populated, has massive environmental degradation, has acid rain, has various pollutions, it is losing land at a very great rate, and that will affect nutrition as it is doing, and so on. I don't believe the stories about such countries saying that health is improving etc. etc., it's a debt that is being incurred and it's an environmental debt that is being incurred, and it will have to be paid like many of the debts that have arisen in Asia.
Norman Swan: But it's hard to convince countries of that, because apart from, and even in sub-Saharan Africa, around the world, life expectancy is increasing, and it increases in proportion to economic development and the reduction of poverty. So the cynics say, 'Well yes, you see all this environmental destruction, it doesn't look good and certainly every bone in your body says it shouldn't happen, but when you actually get economic development and the reduction of poverty in those countries, health does seem to improve.'
David Shearman: Well of course appropriate economic development, that is so. But if you look at the increase in lifespan in many of these populations, we could equally argue - and I'm persuaded by this that it's simple public health measures that have effected this. Now you're saying to me, 'Well these have to be brought about with money from economic development to some extent.' But much of the economic development, or perhaps much is too big a word, some of the economic development is detrimental. For example, if you look at the displacement of indigenous farmers, self-sufficient farmers for plantations, with the erosion that causes, the despondency that relying on world market prices causes, the disruption of their society and so on, then that is a health issue, they're no longer feeding themselves, although the country may have some particular export. It's a huge debate Norman, I accept all that. And I think both sides of the argument are perhaps put in this book, with the warnings and the channels by which these matters can affect health.
Norman Swan: You asked the question in the book "What's wrong with economics?" So I'm going to ask it of you, What's wrong with economics?
David Shearman: Well, what's right with economics?
Norman Swan: You say you went off and studied it.
David Shearman: Well I think if you start to read economics, you're absolutely amazed that people say the things they do. I mean it is not in any way a science. I mean it purports to be a science, but it's an imposter. It has no scientific rules, rationale and so on, it's more like a conjuring trick or it's more like fortune-telling, and so on.
Norman Swan: So you came to economics with a scientific background, hoping to find a science, and found it wanting.
David Shearman: Yes, that's exactly right. And what I found horrified me even more than that, because I found it was totally impersonal, that it's been erected on an altar and worshipped that is something that is inviolate and can be proved, and so on. It's nothing of the sort, and once you've read some of the things that are being said and done, you have grave fears for the future of the world, and in fact this book was finished last year, and reading between the lines, it predicts the collapse, economic collapse in Asia, which I refer to as 'rogue elephants, not tiger economies', it predicts that and inevitably this is going to happen in future on a much wider scale unless economics is brought under control by communities. Because it is now out of control.
Now you've asked me in particular, how it affects health. Well, in so many ways. It affects in so many ways. I mean if you look at agreements that are being made now on international trade, they overwhelm and supersede totally any health considerations on many issues.
Norman Swan: Give me an example.
David Shearman: Well importing foodstuffs with high pesticide residues. One country can take another to international trade agreements and insist that such considerations are not taken into consideration to prevent import of that particular foodstuff. And you'll find international companies and countries will be doing this more and more. If our government stopped an import because of pesticide residue, it would be regarded as an infringement of international trade rules.
Norman Swan: You also question the health effects of policies such as privatisation.
David Shearman: Yes.
Norman Swan: Can you give me an example of where you see a problem there?
David Shearman: I think there are many problems. Water privatisation is a major worry. You see, it's an ideological problem as I see it. If you go back to the Brought Street Pump and cholera in London.
Norman Swan: To explain: this apocryphal pump, well it did exist, where this doctor in London called John Snow thought it was the source of the cholera epidemic, and he knew it came from a certain private water company, and he removed the handle, so they say, from the pump and stopped the epidemic in that part of London.
David Shearman: He stopped the epidemic of cholera. If you trace the public's interest in water from that day, there's always been enormous interest. I mean all the fuss about chlorination and fluoridation and so on, is the public wishing to be involved in their own destiny, in the recognition that water and air and things like this are of great public concern and we should have a say in them. And there's a lot to be said for running water supplies in the public system and having major public representation in that system. And we have very good systems in many parts of the world that are now being privatised. And of course they're privatised because it's equivalent to printing money: you have to have water, and the companies do very well out of it, enormously well out of it. But are we receiving any better supply? I think the answer is not. You'll have seen the reports from the British Medical Association on what's going on in the UK, and there's great concern about the way these companies behave, cut off people's water.
Norman Swan: And of course you're at the cutting edge of that in Adelaide.
David Shearman: We're on the smelling edge, after the big pong. Clearly the privatisation in Adelaide took place against a background of what was regarded as a very efficient service, so they've taken that over. They've cut a lot of staff out, so they're making a profit. The Government likes that because it can divest responsibility. I mean that's the way Governments operate, isn't it? They can divest responsibility onto the private sector now.
The reason given for this was that our expertise could be exported to Asia, and we could make money. Now I'm not sure that's a good international world health problem to do this by privatisation. I think countries are being sold a methodology which is too expensive, too involved, doesn't fit with their energy needs and so on.
Norman Swan: So what values are the problem here, from your point of view?
David Shearman: What values? I think the values that are the problem are that everything, everything has to be looked at from an economic point of view. You can't do anything unless it is costed. Even the environment has to be costed, and if it can't be costed it's of no value.
Norman Swan: And you're concerned about - to use a medical expression - the evidence base for that, given that medicine practices by evidence and economics doesn't, that that value is based on ideology and belief rather than knowledge, rather than fact.
David Shearman: Yes, that is so. I mean the level of a physician of course, if there is something that you can correct immediately in terms of a patient, there is an ulcer which you can cure, you can give them antibiotics, that's fine, that's good, curative medicine. But for every one such issue, there are five others that can't be costed, there are patients that need extensive counselling, they need support.
Norman Swan: When people offer solutions to a critique such as this, they often sound quite utopian. Do you believe there are realistic solutions?
David Shearman: Yes, I think there are. What we point out in this book is that all our systems, particularly our educational system have been usurped to economics, growth and international competition. And the takeover of our universities is a case in point. Somehow we have to get back to some basic ways of looking at the value systems that we impart to our children, that's the point you start at. Essentially it's consumerism that engulfs them from a very early age, and the type of competitivism, I think these have to be looked at. We could equally translate to them more valued systems, systems of interaction, caring and so on, rather than the values we do impart to them. And if you follow this through to what is being done in our universities, with the supplication to business, the orientation of work in terms of producing jobs, which in itself is quite laudable, but it's become all embracive and overwhelming, then we clearly have to have some change in tack. So that's just one line that is explored in this book, and that applies of course --
Norman Swan: I mean we're still living in a mixed economy, business still has to make a quid, is it possible in your view to make a quid without those values coming through?
David Shearman: Oh absolutely yes. Yes, absolutely. What I don't agree with is really what a lot of people are complaining about now, from the Pope downwards: it's the unbridled and unfettered actions of business and international capitalism. If you look at what is happening, you have to be concerned about this wherever you are in the political spectrum.
Norman Swan: Just finally David Shearman, what do you think is the time frame we're talking about, because people talk about an exponential curve with the environment that takes away slowly, and then there's a sudden collapse. Do you see the same thing happening in health, and if so, what's the time frame?
David Shearman: Well in terms of international health, there have to be major problems in the next 50 years. I mean global warming will just be starting to have a serious effect then, and various infectious diseases will be spreading to Australia and so on. I mean I think that can be covered, but what can't be covered in terms of health is the fact that we've probably reached some limit in our food production, with losing arable land worldwide. And in terms of countries like India and China, there has to be some crisis, and I don't see what the technological side of life can do to help them. There has to be some crisis. So we're talking about the next 50 years, and therein lies our problem psychologically, that people just can't think 50 years ahead. So essentially they feel you know, we have to look at the here and now, they really can't look at the health of their grandchildren, perhaps unborn, and that's what we're asking them to do.
Norman Swan: David Shearman is Emeritus Professor of Medicine at the University of Adelaide, and his book, written with Gary Sauer-Thompson is called 'Green or Gone: Health, Ecology, Plagues, Greed and our Future'; the publisher is Wakefield Press.
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