Friday, January 20, 2017

Regional overload, planetary health and population displacement

On the same day that President Trump was inaugurated, the BMJ blog published a version of this as "Regional overload and the consequences it has for health".

This is a rather bland title, but at least they kept "regional overload" in the title. It was originally called "Regional overload, planetary health and population displacement". I had submitted it as an opinion piece. It got reviewed, and I hoped they would then publish it in their journal. It increasingly looks as if the BMJ thought it was too controversial, which is a pity. Some dialogue with the anonymous reviewer is here.

The version in the BMJ blog is very short - there was a 600 word limit. I'm slowly adding links.

I'll also gradually annotate this, in bold red.

Almost 1% of the world population, mostly children, is forcibly displaced (including 11.7 million Syrians), an increase of over 50% from 2011. [1]  

This should be regarded as one of the biggest public health problems in the world, as well as a humanitarian and a security problem. However, violence and health, especially state violence and health, has long been on the periphery of public health. Many doctors are uncomfortable about mixing politics with public health, however, public health and social medicine are inextricably political.

Here I propose that the public health catastrophe in Syria be conceptualized as a canary (or sentinel) case of “regional overload,” relevant to the emerging public health sub-specialty of planetary health. [2,3,4].

However, it is only recently that I thought of the term "regional overload", which I first used in a paper now under review for several months for Current Opinion in Environmental Sustainability, and then in a book chapter, also still under review, co-written with Dr Kerryn Higgs. Kerryn, like Ian Dunlop, is an Australian member of the Club of Rome. She is the author of "Collision Course: Endless Growth on a Finite Planet", reviewed here by Ian Lowe. The chapter is called "Health, population, limits and the decline of nature", for the Sage Handbook of Nature.

I submitted a longer version of the blog published in the BMJ to the Lancet. It was rejected without review, but the forthcoming journal Lancet Planetary Health expressed interest in publishing a longer version, but only if I pay US$5,000. This is more than I can afford, though I am sympathetic to the dilemmas of making academic publishing viable; eg see "Predatory publishers in science" and "A call for publishers to declare their conflicts of interest" in the Journal of the Royal Society of Medicine, in 2007.”

In 1990, Maurice King warned, in a prominent article in the health literature, of “demographic entrapment.” [5]

I first met Maurice in London, in early 1990, when I was studying for a diploma in tropical medicine and hygiene, and he was working on this paper. I had known of Maurice's foundational work in primary health care since being advised to read his edited book “Medical Care in Developing Countries", which I still recall buying, second hand, near the Newcastle (NSW) railway station, in 1984. I took it with me when I first went to Africa, in 1985.
Maurice and I got on so well in 1990 (Maurice was born in the late 1920s, just before my father) that soon after I visited him and his family, in Leeds. I stayed overnight with them - and again, in 1994). I remember him talking of the hopes and fears he had for his paper. These fears were well-founded, as Maurice soon found himself vilified. My first paper in the Lancet, in 1994, in part defended Maurice concerning these attacks. I wrote, in part:

"Verkuyl did not claim that contraception alone will solve Third World problems, any more than King(4) proposed the denial of medical care to children in developing countries as a means of avoiding closure of the demographic trap."

At that stage I was bemused by the fact that King's critics had not only not given him the benefit of the doubt, but had not even read it carefully. His character and intent were attacked by people who seemed to have no idea of his very large contribution, sustained over decades, to improving health in developing countries.

Soon after, the leading epidemiologist Tony McMichael wrote of “planetary overload.” [6] 

Tony, who was my most important teacher and mentor, from 1993 until his death in 2014, published a book by this tile in the same year that I first met him. It was influential in public health circles.

Both concepts are related to Malthusian thought, and thus to the theory of evolution, which accepts, as fundamental, competition for finite resources, often between co-operating groups. [3,7] 

It has long been fashionable to ridicule Malthus, yet the theory of evolution remains widely accepted. Each of the two main scientists (Darwin and Wallace) who developed this theory acknowledged their debt to Malthus. Malthus is ridiculed for ideological reasons, not that different to the reason the BMJ appear to have declined to publish this (it would be nice if I am wrong about this!)

Demographic entrapment is argued to occur in extreme cases when population growth outpaces that of development, triggering population “checks” including from conflict, famine, epidemics, and out-migration. [5] Examples include in Ireland (mid-19th century), Rwanda (1994), and, arguably South Sudan and Syria today. [6]

My paper in the Lancet in 1994 was published in the same month as the Rwandan genocide, a 
chilling coincidence which has strengthened my interest in that part of Africa, and these demographic factors in general.

Annotations to be continued, when I find time.

Planetary overload posits that the human impact on Earth is non-sustainable. [3,7] Planetary overload is unlikely to be homogenous; some regions will be overloaded before others. Plausible contemporary examples of regional overload include Yemen, the Sahel and Bangladesh; here I focus on Syria, given the magnitude of its current situation.

Two key papers have reviewed substantial evidence to conclude that climate change has aggravated the recent Syrian drought, unprecedented in severity, and, in turn, this contributed to food price shocks, rapid internal migration, and ultimately its civil war and population displacement crisis. [8,9] Analysts in support of the link between environmental stressors and conflict stress violence emerges in a “milieu” whose elements in Syria include rivalry, grievance, inequality and outside interference. Importantly, this is not “environmental determinism,” as some critics have asserted. Instead, climate change acts as a “threat multiplier” of conflict. [3,10]

The total fertility rate in Syria before the war was falling, but far above replacement. [2] High Syrian population growth reduced the “demographic dividend,” which helps to promote economic and human development in low-income settings with high population growth. A consequence of Syria’s high fertility rate was growing youth unemployment, reported as 48% in 2011, a five-fold increase from 2000. [2] Large numbers of young, underemployed, under-fulfilled men (“youth bulges”) often accompany high population growth, and have long been linked to violence. The need for economic growth to reduce Syrian poverty, accelerated depletion of groundwater, another key resource. [8,9]

The Planetary Health Commission argued that many health gains are achieved by eroding Earth’s natural systems that provide essential services “on which human civilisation depends”. It suggested that if populations attain health by exploiting the environment unsustainably then this is likely to be at the expense of other populations, now or in the future. [4]

Although humans have always modified nature, today, too many humans are feasting on the ecological underpinnings of global and planetary health. Those with ample “feed” thrive, but at an increased cost to others, including many of the Syrian population, whether killed, living in fear, or displaced.

I have argued that the population displacement from Syria can be conceptualised as a form of regional overload, in turn related to planetary health. But not all causes of regional overload are from overconsumption by the rich. Conditions in Syria, much of the Sahel, Burundi and elsewhere will be greatly improved by education, human rights, slower population growth, and greater scientific acknowledgement of these imperatives.

The problems besetting planetary health are formidable. Scientists and medical practitioners cannot, themselves, alter human destiny, yet have a duty of care to be as accurate and dispassionate as possible. A proper diagnosis may yet enable the remedies which can alleviate much future human suffering.

Colin Butler is an adjunct professor of Public Health at the University of Canberra, Australia, and co-founder of the NGOs BODHI and BODHI Australia. He is founding co-chair of Health Earth and lead author for the section on health in the forthcoming flagship Global Environmental Outlook report of the United Nations Environment Programme, called Healthy Planet, Healthy People.

Not commissioned, Peer reviewed.

  1. UNHCR. Global Trends Report. Forced Displacement in 2015: UNHCR 2016.
  2. Taleb ZB, Bahelah R, Fouad FM, et al. Syria: health in a country undergoing tragic transition. International Journal of Public Health 2015;60(1):63-72. doi: 10.1007/s00038-014-0586-2
  3. Butler CD. Planetary overload, limits to growth and health. Current Environmental Health Reports 2016;3(4):360-69.
  4. Whitmee S, Haines A, Beyrer C, et al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet 2015;386:1973–2028. doi: 10.1016/S0140-6736(15)60901-1
  5. King M. Health is a sustainable state. The Lancet 1990;336:664-67.
  6. McMichael AJ. Planetary Overload. Global Environmental Change and the Health of the Human Species. Cambridge: Cambridge University Press 1993.
  7. Butler CD. Human carrying capacity and human health. Public Library of Science Medicine 2004;1(3):192-94.
  8. Gleick P. Water, drought, climate change, and conflict in Syria. Weather, Climate, and Society 2014;6:331–40. doi: 10.1175/wcas-d-13-00059.1
  9. Kelley CP, Mohtadi S, Cane MA, et al. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proceedings of the National Academy of Sciences (USA) 2015;112(11):3241-46. doi: 10.1073/pnas.1421533112
  10. Schleussner C-F, Donges JF, Donner RV, et al. Armed-conflict risks enhanced by climate-related disasters in ethnically fractionalized countries. Proceedings of the National Academy of Sciences 2016;113(33):9216-21. doi: 10.1073/pnas.1601611113

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