The Onion and the Satellite - Lucas Gonzalez

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This is an entry in The Future We Deserve - a collaborative book project about the future. See all the entries or talk about this entry.

Many health-care systems, where they exist at all, are being assessed as "unsustainable", with expensive and sometimes even harmful interventions, waiting lists so long they look like rationing, and exclusion from care for a number of people (sometimes many). If these systems are indeed unsustainable then it follows, with unbelievable logic, that they will fail, crack, morph into something different.

So, what’s next? If there's time, maybe some or all health-care systems can be dynamically redesigned from the core, making use of what’s available in other systems, and thinking in layers?

We must redesign from the core. Health-care systems' core is the bi-cellular seed deep inside the system: someone who has a health issue (a broken bone or a future disease that's preventable) and someone who can help. (You take both roles if you prevent or treat yourself.) Everything beyond that core - from the assistants who bring the drug or the knife, to the folks who plan world-wide vaccine production - is like the tail in modern warfare: layer upon layer of complexity, helpfulness and failure: the onion. Sometimes the tail is long and fat, but it's just the tail, intended to help those two people who are at the heart of the onion.

The core and all the layers have basic, and sometimes conflicting, missions. Classically, we deal with death, function and pain (or pain and function), and aesthetics. If aesthetics is “social function” or “social pain”, then it's only death and pain/function, and how we deal with that.

Regarding death, let's face it: we all die at the end of our life. (Big news, I know.) So health-care systems can't really reduce death. All they do is delay it, making room for more life, if we live it.

We start at the center. We look at the age pyramid of the living and the smaller age pyramid of those who die. Then, we look at the causes of death for each age group, and delay death there. This is the business of contained or containable mortality, which we might define as the mortality that would emerge or reemerge if rich countries' healthcare systems collapse. In poor countries, such mortality is simply uncontained or, if you feel optimistic, "yet to be contained".

(Sometimes we're too good at delaying death, if population growth kills the ecosystem, if generations fight each other for resources, or if demographic shift makes the pyramid grow old so that either it shrinks and collapses or younger neighbours feel invited to migrate. It seems there's no failure like success, but that's another story.)

Dealing with death is felt to be most important regarding kid’s lives, whose "potential life-years lost" indicator is greater than their grandparents’. But, of course, if and when I become a grandparent, my remaining life-years will be 100% of what I have at that point, so I will want my hip-bone replaced so I can learn to play golf at age 97. See, that's pain and function.

Infrastructure stands between us and the universe, delaying our death from the basic six ways to die: too hot, too cold, thirst, hunger, disease and injury. In health-care systems, it's buildings and energy, staff and stuff, knowledge and procedures ... much of which is paid for with money, which in turn is chronically short for the poor, and may become acutely short for the now-rich.

If money is short, how do we get the services we need? Do we look into scalable high technology? Should we look into permaculture as a design methodology that stresses "relative location for mutual service"? Could we use and improve the devices and methodologies that are currently being developed for (and by) the poor, thus helping everyone?

We want prevention, so maybe we can wash our hands with tippy tap. For diagnostic devices, we can look at what out-of-the-box designers are doing with, say, stamp-sized tests. For communications that don't scale, but spread, use medic frontlinesms. For learning and information, build learning systems like Khan Academy, perhaps using books like Where There Is No Doctor and inserting them into wikireader-like devices. For communities of mutual help, time banks are being used. For better thinking and less stress, look into the role of meditation (with as much or as little spirituality as you like). And, of course, in general, contribute to open sources like appropedia.

Some of the above technologies look very, erm, local, don’t they? What about expensive factories that make inexpensive antibiotics and pain-killers for millions? Even if you dislike Big Pharma, don’t they have an essential role in health-care systems?

Well, of course they are part of the big picture, which includes all the layers, from "self", sitting at the center of my world, to "mom" to "neighbour" to "satellite". Simply because I can't make vaccines for my family, and WHO directors can't wash my hands.

So we need to look at how layers define themselves, and how they interact. Maybe use a variation of Simple Critical Infrastructure Maps SCIM with the specifics for healthcare systems? What would that look like? How can we use both, the onion and the satellite, and everything in between? Work in progress!