664
VIEWPOINT
Health is
a
sustainable state
MAURICE KING
"If in this world misery must exist, so be it: but let some little loophole, some glimpse of possibility at least, be left, which may serve the noble portion of humanity to hope and struggle unceasingly for its alleviation Fate has allowed humanity such a pitifully meagre coverlet, that in pulling it over one part of the world, another has to be left ...
bare."—RABINDRANATH TAGORE, 1893
The World Health Organisation opens its report From Alma Ata to the Year 20001 with Tagore’s words. In it WHO acknowledges for the first time the terrifying spectre of human communities destroying their ecological support systems as the result of population growth. However, the report neglects the health of the planet itself, and the contribution to planetary ill health made by the industrial one-fifth of the world,2 which makes greater demands on the global ecosystem than do the remaining four-fifths.
The
demographic trap
The high rates of population growth in the developing world are the result of falling death rates, and of birth rates which have risen, and in some cases are still rising.3 Notestein’s’ model of the demographic transition from high birth and death rates to low birth and death rates was largely built on the experience of the industrial world. He described a first stage, when both birth and death rates are high and the population grows only slowly. During the second stage living and health conditions improve and death rates fall, but birth rates remain high and the population grows rapidly. In the third stage economic and social gains combine to reduce poverty and lower the birth rate, so that birth and death rates are in equilibrium again, but at a much lower level. Populations with rapid and sustained growth in the second stage are in danger of exceeding the capacity of their local ecosystems, especially if these are fragile, as in much of the tropics. They face a three-phase ecological transition, which contrasts with their demographic transition in having a disastrous third phase. In the first phase expanding human demands are well within the sustainable yield or carrying capacity of their ecosystem; in the second phase human demands exceed the sustainable yield, but are still
expanding as the biological reserves are consumed; and in the third phase human consumption is forcibly reduced as the ecosystem collapses. An essential feature of a demographic transition is that it is a transition. The unstable second stage must be completed quickly, otherwise the population will enter the demographic trap-if the birth rate does not fall, the death rate will ultimately rise again, so the population is stuck in the trap and finds itself in an unsustainable state with a high birth rate and death rate, with ever increasing pressure on its resources, and with a rapidly deteriorating environment. Whether a population gets trapped depends on its rate of growth, and on the ability of the local environment to support that growth. The possible outcomes are limited: the population can: (a) die from starvation and disease, (b) flee as ecological refugees; (c) be destroyed by war or genocide; or (d) be supported by food and other resources from elsewhere, first as emergency relief and then perhaps indefinitely. The demographic trapS is a new term and a good one, although the idea is old. Malthus6 did not foresee the demographic transition, or the need to pass through its second stage quickly; nor did he foresee that negative feedback could destroy the biological support system and cause ecological collapse. Such a collapse and ecological refugees have already occurred in parts of Ethiopia, until limited scale.7 How far are the earlier stages of the process operating on a wider scale elsewhere? Early signs would be a slowing of the expected fall in the child death rate followed by a rise. Ominously, UNICEF report that, after decades of decline, the infant mortality rate has stopped falling in at least 21 developing countries, and is rising in others.8 Incipient ecological collapse is one of the
now on a
same
possible causes. The huge and rapidly growing cities of the developing world are in an ecological predicament which is no less grave. Unlike rural areas, cities are normally fed, watered, ADDRESS. Department of Public Health Medicine, University of Leeds, Leeds LS2 9LN (Dr M. King, FRCP)
665
and
supplied
with energy and materials from elsewhere.
Many are fed from the grain surpluses of North America. Many of these cities are even now barely viable,9 and the human condition of most of their citizens defies adequate description and promises to deteriorate. How is the birth rate to be reduced? There is a widespread assumption that the necessary and sufficient condition for reducing the birth rate is to reduce the child death rate. The reasoning is that if families see that their children no longer die, they will have fewer of them. 10 Prestonll has already questioned this notion. He found "... hopeful policy declarations resting on a thin research base", and wondered how much mortality decline can be expected to translate into fertility decline, and the strength of this relation in "setting levels of mortality control". He also found that an additional child death in a family leads to far less than one additional birth, especially in pretransitional high-fertility societies, and concluded that: "The picture is not attractive for those who look to mortality reduction as a means of reducing fertility through familial effects, let alone those who advocate such measures as a means to reduce growth rates. Nor does it lend much support to models of fertility decision-making that view couples as proceeding deliberately ... towards some target number of surviving children". The association between declines in child death and birth rates is complex. The view that, if the child death rate declines sufficiently, the birth rate must decline also, and that there is a causal relation between them, is untenable. Such association as there is, is best explained if both rates respond to other common factors. In particular, the birth rate is unlikely to be lowered by measures designed to reduce the child death rate that are imposed on people by vertical programmes-eg, those for mass immunisation and for oral rehydration for diarrhoea-and that do not simultaneously change people’s behaviour, lifestyle, and standard of living. A fall in the birth rate leading to a demographic transition seems to require the harnessing of social and economic gains to the reduction of poverty and the promotion of socioeconomic development. Unfortunately, serious constraints prevent such development happening and the birth rate falling as fast and as widely as is necessary to escape the demographic trap. These factors include lack of agricultural land and its poor quality, poor supplies of energy and other raw materials, limited access to education, and lack of political representation. There is also the economic stranglehold exerted by the rich over the poor, and by the industrial over the developing world; the time needed for structural and cultural change must also be taken into account. For many countries these constraints appear to be so great that a demographic transition is unlikely to occur before excessive pressure is exerted on the ecological support system. Thus, to the argument that the most effective way to bring down the birth rate is to lower the child death rate, the tragic reply has to be that, even if this were true, there is no certainty that a community will not destroy its ecosystem first. It has been argued that, even if this were not true, the effect would "not be very great", and that a halving of the child death rate overnight would add only 10% to the expected 10.5 billion people in 2110.12 As if to confirm this prediction, the United Nations Population Fund now report that mainly due to slower than expected
fertility "... the world has overshot the marker points of the 1984 ’most likely’ medium-term projection and declines in
is now on course for an eventual total that is closer to 11 billion than 10 billion" .13 This extra billion will be mainly added to the world’s most tragically trapped. I believe this outcome is due not only to declining efforts in family planning, but also to declining child mortality not having its alleged effects on fertility. During the next century world population will probably double and could triple. 13 It is difficult to escape the conclusion that there are going to be population crashes as the result of diseases old or new (eg, human immunodeficiency virus infection [HIV] in parts of Africa), or of famine. The African famine in the mid-1980s is expected to have been the first of a modern series which will strike Africa again, and also India, in the 1990s and beyond (J. Seaman, Save the Children Fund, personal communication). 10% of India’s starving will soon be a 100 million people.
Ethical dilemmas The reduction of human death rates has always been seen as an absolute good in public health, and unease about population increase has never been an accepted constraint on any public health measure. Will visions of the ultimate effects of population expansion alter this view? Hill called it "the most solemn problem in the world" and wrote: "If ethical principles deny our right to do evil in order that good may come, are we justified in doing good when the foreseeable consequence is evil?1’ Are there some
which, although they are technically feasible, be initiated because of their long-term population-increasing consequences? In Preston’s words, should one deliberately "set levels of mortality control"? Is what is done corporately in public health ethically different from what is done individually? How far is it necessary to
programmes
should
not
look into the future to decide between immediate and distant goals? How much should ecological sustainability influence health programmes? The ultimate in unhappy choices is to be faced on the one hand with not doing all that is possible in public health, and on the other with increasing ecological deterioration, leading eventually to starvation and to the destruction of the very population it is intended to benefit. Are ecology and compassion incommensurate? To say that the ecological state is never simple, that prediction is uncertain (HIV was not predicted), and that no single public health programme will have any significant demographic effect, does not provide an escape from the dilemma. Belated recognition of the need for global sustainability is destroying one of the deepest convictions of Western civilisation-that our ability to control the natural world will ultimately allow all communities to develop indefinitely in an endless progression. It is also destroying the illusion that if the problem of equity can be postponed for a while, in the hope that if all peoples get richer and technology gets better, sustainability will be easier to deal with. Unfortunately, irreversible changes in the environment will make equity even more difficult to achieve in future. Although Tagore’s meagre coverlet is keeping the early achievers warmer, they are mostly responsibility for wearing it out. At the root of our difficulties lies the fact that, on one hand we share with all other animals a dependence on the same
666
ecological constraints of territory, food, and population as they do, and yet on the other hand we have a unique ethical view of ourselves as people. In humanist terms this is the absolute value of each single human being, and in theist, or at least Christian, ones it is the value of each one of us in the eyes of the Creator. This brings the argument into metaphysical dimensions-what is the purpose of man? What do philosophy and particularly ethics contribute to all this? Logic can monitor the arguments as to how a man should act, but cannot show that one set of premises from which these arguments are developed is better than another, hence the interminable nature of much ethical debate.15 The choice of initial premises is influenced by the social and metaphysical position of the contestants. Hitherto, living man has been the measure of all things; now many people are beginning to wonder if this measure should not be the integrity of the ecosystem or the welfare of future communities. Unfortunately, these premises conflict. Adherence to them also seems to be changing.
The way ahead
Broadening concepts of health Health was originally an individual concern, then a concern of the family (family health), and then of society (social medicine). More recently WHO has introduced the concept of Primary Health Care. All current concepts of health focus on the present, in that they take no account of either future individual health, or of the health of future communities. In effect, concepts of both individual and public health end with the death of the patient. In most parts of the world, the ecological threat to health is a problem for the future not the present. It can be argued that any concern with the future must be the luxury of those who are healthy today, and cannot be a concern of the world’s present sick and starving. Surely the response to this is that, of all the criteria of human achievement, none more universally commands respect than the transcendence of self to care for what is not oneself; care for what happens in future is merely an extension of concern for what is not
"ourselves". Health is
a
sustainable state
According to the Brundtland Commission16 concern for the future is a concern for "sustainability-the ability to maintain the desirable elements of the status quo into the future". If the concept of health is to include the health, and even the existence, offuture populations, WHO’s celebrated definition should become "Health is a sustainable state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity". It is sustainable for the individual in that it enables him to live out his normal lifespan; more importantly, the means of achieving it must be consistent with the health and existence of future communities. However, the Brundtland definition is incomplete. Since social and economic change is inevitable, sustainability should be "The maintenance of the capacity of the ecosystem to support life in quantity and variety". Although health has many established ecological relationships, such as those between man and his parasites, his food, and his water, the concept of sustainability extends these and takes proper account of the ecological foundations
of health. Sustainability is also the theoretical basis for necessary action, with important implications for lifestyle. A healthy lifestyle must now encompass a sustainable lifestyle, in that to live healthily one must also live in a sustainable relationship to one’s environment. Unfortunately, the modest demands of a healthy lifestyle are trivial for those who live in the industrial world compared with the demands of a sustainable one.
A
new
global strategy
The strategies of WHO and UNICEF for Primary Health Care and for Health for All by the Year 2000 are majestic "political directions" in which "the global health machinery" is being mobilised. From Alma Ata reviews them, and they have accomplished much. However, they do not address the new threats and the new dilemmas. Somehow, we must courageously enter the era of measured and managed sustainability. Some of the challenges, especially massive famine and huge numbers of refugees, are so unmanageable that it will have to be a long-term goal. There needs to be a major change in the structural relations between North and South, as well as within each of them. Most difficult for those in the industrial North, with its unsustainable economy, a sustainable lifestyle means consumption control-intensive energy conservation, fewer ...
unnecessary
journeys,
smaller, slower cars, also
more
warmer
much
public transport; fewer,
clothes, and colder rooms. It
recycling and a more diet with more joules to the environmentally friendly hectare. The deliberate quest of poverty (for the privileged North the reduction of luxurious resource consumption) has an honoured history. Sustainability supports this, and means that any further increase in living standards must be achieved in a way that does not increase resource consumption, and may require that consumption be reduced. In the South the grave nature of the demographic trap should be widely publicised. Time for manoeuvre is critical; for populations entering the trap there is insufficient time before disaster for the ordinary processes of development, assuming they occur, to lower the birth rate. Family planning programmes must be promoted with renewed vigour, and the objective of sustainability used as the impetus to drive them. Sadly, there is much unfulfilled demand for family planning, especially in sub-Saharan Africa. 17 An ecological view of the world must be shared by as many of the world’s people as possible. Each community must decide what immediate consumption should be forgone, and by whom, in the interests of future generations. Reduced childhood mortality must no longer be promoted as a necessary and sufficient condition for reduced fertility. The demographic and ecological implications of public health measures must be understood at all levels, especially by the community. If these are desustaining (sustainability means
reducing),
more
complementary
ecologically
sustaining
measures, especially family planning and ecological support, must
be introduced with them. If no
complementary
measures are
adequately sustaining possible, such desustaining
oral rehydration should not be introduced on a health scale, since they increase the man-years of public human misery, ultimately from starvation. However, the individual doctor must rehydrate his patient. Surprisingly, health services may not be a priority for these communities (J. Seaman, personal communication). Mother Theresa has
measures as
667
that the world’s poorest need our love and compassion-tragically, such programmes may not necessarily be part of that love.
reminded
us
TowardsHSE2100 These are disturbing reflections, setting, as they do, levels of mortality control. What should our personal response include when we are faced with the consequences of unsustainability, and especially with famine, for which we can do almost nothing?l8 We should: (a) resolve to live a sustainable lifestyle; (b) promote the sustainability of our own community with the utmost determination; and (c) refrain from advocating public health policies for other communities which, unappreciated by them, worsen their sustainability so that they ultimately starve. Such a strategy needs a name. Why not call it HSE 2100-Health in a sustainable ecosystem for the year 2100? WHO has been exclusively concerned with the health of the people of the world. The recognition that their health is dependent on the health of the planet means that WHO now has a shared concern for the health of the planet as a whole. Only in this way will it properly care for them, and will it truly become The World Health Organisation.
I thank the following for their many contributions: Dr Jane Adam, Dr Atsung Aier, Dr John Blacker, Prof David Bradley, Dr Leslie and Mrs Ann Burgess, Rev Charles Elliott, Dr Andrew Green, Prof Adrian Hastings, Dr Alan Hill, Mrs Dorothy Hobson, Dr Gunnar Holmgren, Dr Jennifer Jackson, Prof Ulrich Loening, Prof David Morley, Prof Philip Payne, Dr Peter Poore, Dr John Seaman, Dr Rudi Sloof, and Dr George Ross.
This paper is based on the 1990 Swellengrebel Lecture Netherlands Society of Tropical Medicine.
given by MK to the
REFERENCES 1. World Health Organisation. From Alma Ata to the year 2000: reflections at the midpoint. Geneva: WHO, 1988. 2. Worldwatch Institute. The state of the world 1988. New York: WW Norton, 1988. 3. Dyson T, Murphy M. The onset of fertility transition. Popul Rev 1985; 11: 399. 4. Notestein FW. Population-the long view. In: Schultz TW, ed. Food for the world. Chicago: University of Chicago Press, 1945: 36-57. 5. Brown L. Analysing the demographic trap. In: The Worldwatch Institute. The state of the world 1987. New York: WW Norton, 1987. 6. Malthus T. Essay on population, 1798. Reprinted, London: Macmillan, 1926. 7. Newcombe K, An economic justification for rural afforestation: the case of Ethiopia. Energy Department paper no 16. Washington, DC : World
Bank, 1984. 8. UNICEF. The state of the world’s children 1987: 91. 9. Brown L. The future of urbanisation: facing the ecological constraints. Worldwatch paper no 9, May, 1978. 10. UNICEF. The state of the world’s children 1986: 78. 11. Preston S. The effects of infant and child mortality on fertility. Population Division, United Nations New York. New York: Academic Press, 1978. 12. UNICEF. The state of the world’s children 1985: 22. 13. United Nations Population Fund. The state of world population 1990. New York: United Nations Population Fund, 1990: 1. 14. Hill AV. Presidential address to the British Association for the Advancement of Science, Belfast, 1952. Reprinted in: The ethical dilemma of science and other writings New York: Rockefeller Institute Press in association with Oxford University Press, 1960: 78-82. 15. Macintyre A. After virtue. London: Duckworth, 1987. 16. World Commission on Environment and Development. Our common future. Oxford: Oxford University Press, 1987. 17. World Bank. Sub-Saharan Africa: from crisis to sustainable growth. Washington, DC: World Bank, 1989: 70. 18. IPCC United Nations Intergovernmental Panel on Climatic Change, reported in the Guardian, May 22, 1990.
CLINICAL PRACTICE Psychiatric findings in Wolfram syndrome homozygotes
Diabetes mellitus and bilateral optic atrophy are the defining characteristics of the autosomal recessive Wolfram syndrome. Diabetes insipidus, neurogenic bladder, deafness, and other neurological manifestations are frequent. A review was made of the medical records of 68 Wolfram syndrome patients, aged between 8 and 43 years, identified by casefinding throughout the USA. 41 of the patients (60%) had episodes of severe depression, psychosis, or organic brain syndrome, as well as impulsive verbal and physical aggression. These symptoms were very severe in 17 patients (25%), of whom 12 required admission to a psychiatric hospital and 11 attempted suicide. We conclude that the Wolfram syndrome gene
predisposes homozygotes to psychiatric illness.
Introduction When a genetic syndrome is inherited in a definite mendelian pattern-autosomal or X-linked, dominant or recessive--clinical findings result from the metabolic aberration determined by a single mutant gene. Syndromes of this type (eg, autosomal dominant Huntington disease! or autosomal recessive Wilson disease2), in which psychiatric findings are a frequent or invariable component, provide useful insight into genetic and biochemical mechanisms in mental illness by illustrating how a single metabolic abnormality produces specific behavioural manifestations. ADDRESSES
Biological
Sciences
Research
Center
and
Departments of Psychiatry and Medicine, University of North Carolina, Chapel Hill, North Carolina, USA (R.G. Swift, MD, D B Sadler, BA, M Swift, MD) Correspondence to Dr Michael Swift, Biological Sciences Research Center, University of North Carolina, Chapel Hill, North Carolina 27599, USA
VIEWPOINT
Health is
a
sustainable state
MAURICE KING
"If in this world misery must exist, so be it: but let some little loophole, some glimpse of possibility at least, be left, which may serve the noble portion of humanity to hope and struggle unceasingly for its alleviation Fate has allowed humanity such a pitifully meagre coverlet, that in pulling it over one part of the world, another has to be left ...
bare."—RABINDRANATH TAGORE, 1893
The World Health Organisation opens its report From Alma Ata to the Year 20001 with Tagore’s words. In it WHO acknowledges for the first time the terrifying spectre of human communities destroying their ecological support systems as the result of population growth. However, the report neglects the health of the planet itself, and the contribution to planetary ill health made by the industrial one-fifth of the world,2 which makes greater demands on the global ecosystem than do the remaining four-fifths.
The
demographic trap
The high rates of population growth in the developing world are the result of falling death rates, and of birth rates which have risen, and in some cases are still rising.3 Notestein’s’ model of the demographic transition from high birth and death rates to low birth and death rates was largely built on the experience of the industrial world. He described a first stage, when both birth and death rates are high and the population grows only slowly. During the second stage living and health conditions improve and death rates fall, but birth rates remain high and the population grows rapidly. In the third stage economic and social gains combine to reduce poverty and lower the birth rate, so that birth and death rates are in equilibrium again, but at a much lower level. Populations with rapid and sustained growth in the second stage are in danger of exceeding the capacity of their local ecosystems, especially if these are fragile, as in much of the tropics. They face a three-phase ecological transition, which contrasts with their demographic transition in having a disastrous third phase. In the first phase expanding human demands are well within the sustainable yield or carrying capacity of their ecosystem; in the second phase human demands exceed the sustainable yield, but are still
expanding as the biological reserves are consumed; and in the third phase human consumption is forcibly reduced as the ecosystem collapses. An essential feature of a demographic transition is that it is a transition. The unstable second stage must be completed quickly, otherwise the population will enter the demographic trap-if the birth rate does not fall, the death rate will ultimately rise again, so the population is stuck in the trap and finds itself in an unsustainable state with a high birth rate and death rate, with ever increasing pressure on its resources, and with a rapidly deteriorating environment. Whether a population gets trapped depends on its rate of growth, and on the ability of the local environment to support that growth. The possible outcomes are limited: the population can: (a) die from starvation and disease, (b) flee as ecological refugees; (c) be destroyed by war or genocide; or (d) be supported by food and other resources from elsewhere, first as emergency relief and then perhaps indefinitely. The demographic trapS is a new term and a good one, although the idea is old. Malthus6 did not foresee the demographic transition, or the need to pass through its second stage quickly; nor did he foresee that negative feedback could destroy the biological support system and cause ecological collapse. Such a collapse and ecological refugees have already occurred in parts of Ethiopia, until limited scale.7 How far are the earlier stages of the process operating on a wider scale elsewhere? Early signs would be a slowing of the expected fall in the child death rate followed by a rise. Ominously, UNICEF report that, after decades of decline, the infant mortality rate has stopped falling in at least 21 developing countries, and is rising in others.8 Incipient ecological collapse is one of the
now on a
same
possible causes. The huge and rapidly growing cities of the developing world are in an ecological predicament which is no less grave. Unlike rural areas, cities are normally fed, watered, ADDRESS. Department of Public Health Medicine, University of Leeds, Leeds LS2 9LN (Dr M. King, FRCP)
665
and
supplied
with energy and materials from elsewhere.
Many are fed from the grain surpluses of North America. Many of these cities are even now barely viable,9 and the human condition of most of their citizens defies adequate description and promises to deteriorate. How is the birth rate to be reduced? There is a widespread assumption that the necessary and sufficient condition for reducing the birth rate is to reduce the child death rate. The reasoning is that if families see that their children no longer die, they will have fewer of them. 10 Prestonll has already questioned this notion. He found "... hopeful policy declarations resting on a thin research base", and wondered how much mortality decline can be expected to translate into fertility decline, and the strength of this relation in "setting levels of mortality control". He also found that an additional child death in a family leads to far less than one additional birth, especially in pretransitional high-fertility societies, and concluded that: "The picture is not attractive for those who look to mortality reduction as a means of reducing fertility through familial effects, let alone those who advocate such measures as a means to reduce growth rates. Nor does it lend much support to models of fertility decision-making that view couples as proceeding deliberately ... towards some target number of surviving children". The association between declines in child death and birth rates is complex. The view that, if the child death rate declines sufficiently, the birth rate must decline also, and that there is a causal relation between them, is untenable. Such association as there is, is best explained if both rates respond to other common factors. In particular, the birth rate is unlikely to be lowered by measures designed to reduce the child death rate that are imposed on people by vertical programmes-eg, those for mass immunisation and for oral rehydration for diarrhoea-and that do not simultaneously change people’s behaviour, lifestyle, and standard of living. A fall in the birth rate leading to a demographic transition seems to require the harnessing of social and economic gains to the reduction of poverty and the promotion of socioeconomic development. Unfortunately, serious constraints prevent such development happening and the birth rate falling as fast and as widely as is necessary to escape the demographic trap. These factors include lack of agricultural land and its poor quality, poor supplies of energy and other raw materials, limited access to education, and lack of political representation. There is also the economic stranglehold exerted by the rich over the poor, and by the industrial over the developing world; the time needed for structural and cultural change must also be taken into account. For many countries these constraints appear to be so great that a demographic transition is unlikely to occur before excessive pressure is exerted on the ecological support system. Thus, to the argument that the most effective way to bring down the birth rate is to lower the child death rate, the tragic reply has to be that, even if this were true, there is no certainty that a community will not destroy its ecosystem first. It has been argued that, even if this were not true, the effect would "not be very great", and that a halving of the child death rate overnight would add only 10% to the expected 10.5 billion people in 2110.12 As if to confirm this prediction, the United Nations Population Fund now report that mainly due to slower than expected
fertility "... the world has overshot the marker points of the 1984 ’most likely’ medium-term projection and declines in
is now on course for an eventual total that is closer to 11 billion than 10 billion" .13 This extra billion will be mainly added to the world’s most tragically trapped. I believe this outcome is due not only to declining efforts in family planning, but also to declining child mortality not having its alleged effects on fertility. During the next century world population will probably double and could triple. 13 It is difficult to escape the conclusion that there are going to be population crashes as the result of diseases old or new (eg, human immunodeficiency virus infection [HIV] in parts of Africa), or of famine. The African famine in the mid-1980s is expected to have been the first of a modern series which will strike Africa again, and also India, in the 1990s and beyond (J. Seaman, Save the Children Fund, personal communication). 10% of India’s starving will soon be a 100 million people.
Ethical dilemmas The reduction of human death rates has always been seen as an absolute good in public health, and unease about population increase has never been an accepted constraint on any public health measure. Will visions of the ultimate effects of population expansion alter this view? Hill called it "the most solemn problem in the world" and wrote: "If ethical principles deny our right to do evil in order that good may come, are we justified in doing good when the foreseeable consequence is evil?1’ Are there some
which, although they are technically feasible, be initiated because of their long-term population-increasing consequences? In Preston’s words, should one deliberately "set levels of mortality control"? Is what is done corporately in public health ethically different from what is done individually? How far is it necessary to
programmes
should
not
look into the future to decide between immediate and distant goals? How much should ecological sustainability influence health programmes? The ultimate in unhappy choices is to be faced on the one hand with not doing all that is possible in public health, and on the other with increasing ecological deterioration, leading eventually to starvation and to the destruction of the very population it is intended to benefit. Are ecology and compassion incommensurate? To say that the ecological state is never simple, that prediction is uncertain (HIV was not predicted), and that no single public health programme will have any significant demographic effect, does not provide an escape from the dilemma. Belated recognition of the need for global sustainability is destroying one of the deepest convictions of Western civilisation-that our ability to control the natural world will ultimately allow all communities to develop indefinitely in an endless progression. It is also destroying the illusion that if the problem of equity can be postponed for a while, in the hope that if all peoples get richer and technology gets better, sustainability will be easier to deal with. Unfortunately, irreversible changes in the environment will make equity even more difficult to achieve in future. Although Tagore’s meagre coverlet is keeping the early achievers warmer, they are mostly responsibility for wearing it out. At the root of our difficulties lies the fact that, on one hand we share with all other animals a dependence on the same
666
ecological constraints of territory, food, and population as they do, and yet on the other hand we have a unique ethical view of ourselves as people. In humanist terms this is the absolute value of each single human being, and in theist, or at least Christian, ones it is the value of each one of us in the eyes of the Creator. This brings the argument into metaphysical dimensions-what is the purpose of man? What do philosophy and particularly ethics contribute to all this? Logic can monitor the arguments as to how a man should act, but cannot show that one set of premises from which these arguments are developed is better than another, hence the interminable nature of much ethical debate.15 The choice of initial premises is influenced by the social and metaphysical position of the contestants. Hitherto, living man has been the measure of all things; now many people are beginning to wonder if this measure should not be the integrity of the ecosystem or the welfare of future communities. Unfortunately, these premises conflict. Adherence to them also seems to be changing.
The way ahead
Broadening concepts of health Health was originally an individual concern, then a concern of the family (family health), and then of society (social medicine). More recently WHO has introduced the concept of Primary Health Care. All current concepts of health focus on the present, in that they take no account of either future individual health, or of the health of future communities. In effect, concepts of both individual and public health end with the death of the patient. In most parts of the world, the ecological threat to health is a problem for the future not the present. It can be argued that any concern with the future must be the luxury of those who are healthy today, and cannot be a concern of the world’s present sick and starving. Surely the response to this is that, of all the criteria of human achievement, none more universally commands respect than the transcendence of self to care for what is not oneself; care for what happens in future is merely an extension of concern for what is not
"ourselves". Health is
a
sustainable state
According to the Brundtland Commission16 concern for the future is a concern for "sustainability-the ability to maintain the desirable elements of the status quo into the future". If the concept of health is to include the health, and even the existence, offuture populations, WHO’s celebrated definition should become "Health is a sustainable state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity". It is sustainable for the individual in that it enables him to live out his normal lifespan; more importantly, the means of achieving it must be consistent with the health and existence of future communities. However, the Brundtland definition is incomplete. Since social and economic change is inevitable, sustainability should be "The maintenance of the capacity of the ecosystem to support life in quantity and variety". Although health has many established ecological relationships, such as those between man and his parasites, his food, and his water, the concept of sustainability extends these and takes proper account of the ecological foundations
of health. Sustainability is also the theoretical basis for necessary action, with important implications for lifestyle. A healthy lifestyle must now encompass a sustainable lifestyle, in that to live healthily one must also live in a sustainable relationship to one’s environment. Unfortunately, the modest demands of a healthy lifestyle are trivial for those who live in the industrial world compared with the demands of a sustainable one.
A
new
global strategy
The strategies of WHO and UNICEF for Primary Health Care and for Health for All by the Year 2000 are majestic "political directions" in which "the global health machinery" is being mobilised. From Alma Ata reviews them, and they have accomplished much. However, they do not address the new threats and the new dilemmas. Somehow, we must courageously enter the era of measured and managed sustainability. Some of the challenges, especially massive famine and huge numbers of refugees, are so unmanageable that it will have to be a long-term goal. There needs to be a major change in the structural relations between North and South, as well as within each of them. Most difficult for those in the industrial North, with its unsustainable economy, a sustainable lifestyle means consumption control-intensive energy conservation, fewer ...
unnecessary
journeys,
smaller, slower cars, also
more
warmer
much
public transport; fewer,
clothes, and colder rooms. It
recycling and a more diet with more joules to the environmentally friendly hectare. The deliberate quest of poverty (for the privileged North the reduction of luxurious resource consumption) has an honoured history. Sustainability supports this, and means that any further increase in living standards must be achieved in a way that does not increase resource consumption, and may require that consumption be reduced. In the South the grave nature of the demographic trap should be widely publicised. Time for manoeuvre is critical; for populations entering the trap there is insufficient time before disaster for the ordinary processes of development, assuming they occur, to lower the birth rate. Family planning programmes must be promoted with renewed vigour, and the objective of sustainability used as the impetus to drive them. Sadly, there is much unfulfilled demand for family planning, especially in sub-Saharan Africa. 17 An ecological view of the world must be shared by as many of the world’s people as possible. Each community must decide what immediate consumption should be forgone, and by whom, in the interests of future generations. Reduced childhood mortality must no longer be promoted as a necessary and sufficient condition for reduced fertility. The demographic and ecological implications of public health measures must be understood at all levels, especially by the community. If these are desustaining (sustainability means
reducing),
more
complementary
ecologically
sustaining
measures, especially family planning and ecological support, must
be introduced with them. If no
complementary
measures are
adequately sustaining possible, such desustaining
oral rehydration should not be introduced on a health scale, since they increase the man-years of public human misery, ultimately from starvation. However, the individual doctor must rehydrate his patient. Surprisingly, health services may not be a priority for these communities (J. Seaman, personal communication). Mother Theresa has
measures as
667
that the world’s poorest need our love and compassion-tragically, such programmes may not necessarily be part of that love.
reminded
us
TowardsHSE2100 These are disturbing reflections, setting, as they do, levels of mortality control. What should our personal response include when we are faced with the consequences of unsustainability, and especially with famine, for which we can do almost nothing?l8 We should: (a) resolve to live a sustainable lifestyle; (b) promote the sustainability of our own community with the utmost determination; and (c) refrain from advocating public health policies for other communities which, unappreciated by them, worsen their sustainability so that they ultimately starve. Such a strategy needs a name. Why not call it HSE 2100-Health in a sustainable ecosystem for the year 2100? WHO has been exclusively concerned with the health of the people of the world. The recognition that their health is dependent on the health of the planet means that WHO now has a shared concern for the health of the planet as a whole. Only in this way will it properly care for them, and will it truly become The World Health Organisation.
I thank the following for their many contributions: Dr Jane Adam, Dr Atsung Aier, Dr John Blacker, Prof David Bradley, Dr Leslie and Mrs Ann Burgess, Rev Charles Elliott, Dr Andrew Green, Prof Adrian Hastings, Dr Alan Hill, Mrs Dorothy Hobson, Dr Gunnar Holmgren, Dr Jennifer Jackson, Prof Ulrich Loening, Prof David Morley, Prof Philip Payne, Dr Peter Poore, Dr John Seaman, Dr Rudi Sloof, and Dr George Ross.
This paper is based on the 1990 Swellengrebel Lecture Netherlands Society of Tropical Medicine.
given by MK to the
REFERENCES 1. World Health Organisation. From Alma Ata to the year 2000: reflections at the midpoint. Geneva: WHO, 1988. 2. Worldwatch Institute. The state of the world 1988. New York: WW Norton, 1988. 3. Dyson T, Murphy M. The onset of fertility transition. Popul Rev 1985; 11: 399. 4. Notestein FW. Population-the long view. In: Schultz TW, ed. Food for the world. Chicago: University of Chicago Press, 1945: 36-57. 5. Brown L. Analysing the demographic trap. In: The Worldwatch Institute. The state of the world 1987. New York: WW Norton, 1987. 6. Malthus T. Essay on population, 1798. Reprinted, London: Macmillan, 1926. 7. Newcombe K, An economic justification for rural afforestation: the case of Ethiopia. Energy Department paper no 16. Washington, DC : World
Bank, 1984. 8. UNICEF. The state of the world’s children 1987: 91. 9. Brown L. The future of urbanisation: facing the ecological constraints. Worldwatch paper no 9, May, 1978. 10. UNICEF. The state of the world’s children 1986: 78. 11. Preston S. The effects of infant and child mortality on fertility. Population Division, United Nations New York. New York: Academic Press, 1978. 12. UNICEF. The state of the world’s children 1985: 22. 13. United Nations Population Fund. The state of world population 1990. New York: United Nations Population Fund, 1990: 1. 14. Hill AV. Presidential address to the British Association for the Advancement of Science, Belfast, 1952. Reprinted in: The ethical dilemma of science and other writings New York: Rockefeller Institute Press in association with Oxford University Press, 1960: 78-82. 15. Macintyre A. After virtue. London: Duckworth, 1987. 16. World Commission on Environment and Development. Our common future. Oxford: Oxford University Press, 1987. 17. World Bank. Sub-Saharan Africa: from crisis to sustainable growth. Washington, DC: World Bank, 1989: 70. 18. IPCC United Nations Intergovernmental Panel on Climatic Change, reported in the Guardian, May 22, 1990.
CLINICAL PRACTICE Psychiatric findings in Wolfram syndrome homozygotes
Diabetes mellitus and bilateral optic atrophy are the defining characteristics of the autosomal recessive Wolfram syndrome. Diabetes insipidus, neurogenic bladder, deafness, and other neurological manifestations are frequent. A review was made of the medical records of 68 Wolfram syndrome patients, aged between 8 and 43 years, identified by casefinding throughout the USA. 41 of the patients (60%) had episodes of severe depression, psychosis, or organic brain syndrome, as well as impulsive verbal and physical aggression. These symptoms were very severe in 17 patients (25%), of whom 12 required admission to a psychiatric hospital and 11 attempted suicide. We conclude that the Wolfram syndrome gene
predisposes homozygotes to psychiatric illness.
Introduction When a genetic syndrome is inherited in a definite mendelian pattern-autosomal or X-linked, dominant or recessive--clinical findings result from the metabolic aberration determined by a single mutant gene. Syndromes of this type (eg, autosomal dominant Huntington disease! or autosomal recessive Wilson disease2), in which psychiatric findings are a frequent or invariable component, provide useful insight into genetic and biochemical mechanisms in mental illness by illustrating how a single metabolic abnormality produces specific behavioural manifestations. ADDRESSES
Biological
Sciences
Research
Center
and
Departments of Psychiatry and Medicine, University of North Carolina, Chapel Hill, North Carolina, USA (R.G. Swift, MD, D B Sadler, BA, M Swift, MD) Correspondence to Dr Michael Swift, Biological Sciences Research Center, University of North Carolina, Chapel Hill, North Carolina 27599, USA
