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].
Planetary health has been defined as
"the health of the human civilisation and the state of the
natural systems on which it depends. I
have published the central ideas in this essay many times before, starting in
1991, but not in a high impact journal for several years.
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.
References:
- UNHCR. Global Trends Report. Forced Displacement in 2015: UNHCR 2016.
- 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
- Butler CD. Planetary overload, limits to growth and health. Current Environmental Health Reports 2016;3(4):360-69.
- 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
- King M. Health is a sustainable state. The Lancet 1990;336:664-67.
- McMichael AJ. Planetary Overload. Global Environmental Change and the Health of the Human Species. Cambridge: Cambridge University Press 1993.
- Butler CD. Human carrying capacity and human health. Public Library of Science Medicine 2004;1(3):192-94.
- 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
- 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
- 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
