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 .

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!

Discussion[View | Edit]

Coments and links for version 2.0[edit source]

The main page for this is but now I consider it a bit weak because I didn't include "risk": not just death, pain and function, but also risk of those outcomes. I'll leave the piece as I wrote it, but clearly there's room for further thinking.

After that, we did some thinking over at EdgeRyders:

Today, 20130125, I've read "Standardised patients" made me recall "The $10/per year health insurance system" with more details at

I wonder what a useful next step would be:

  • Open data with census and The Lancet recent global burden of disease to build the database?
  • Link to Appropedia pages on health-care gadgets, and other solid sources on simple no-harm treatments?
  • What would @paulpolak, @frontlineSMS and others think of this? Who are those others?
  • ... ?

Other links we had collected:

Previous draft in Spanish[edit source]

The following is a previous draft in Spanish. I'll make sure all the concepts are ported to the main piece, then delete this. LucasG 11:05, 24 October 2010 (UTC)

La salud en tiempos de catástrofe[edit source]

En Canarias, con una población de dos millones de personas, sabemos que fallecen unas doce mil personas al año. Si entramos en detalles, conocemos la mortalidad bruta por grupos de edad, por causas genéricas, y por grupos de edad para algunas de las causas.

Lo que resulta más difícil es estimar la mortalidad potencial en un escenario de fallo sistémico. Dicha mortalidad se debería a los efectos secundarios del propio descalabro sistémico (fallos en los servicios vitales básicos), y también a una "descontención" de la mortalidad actualmente contenida por los servicios sanitarios (insulina para los diabéticos insulin-dependientes, tratamiento de fracturas accidentales graves, etc).

¿Qué parte de la mortalidad "descontenida" sería evitable con una preparación y una respuesta adecuadas y realistas? ¿Cómo serían esa preparación y esa respuesta para distintos escenarios?

En los países y poblaciones sin recursos, ¿qué proporción de la mortalidad es "contenible" con poco dinero, mucha inteligencia y algunos esfuerzos bien enfocados?

Dos escenarios posibles y uno más[edit source]

Se ha planteado, y el tiempo ha amortiguado la preocupación de muchos, la posibilidad de una pandemia gripal de alta letalidad, o cuando menos de letalidad suficiente para provocar un intenso descalabro sanitario y sistémico de manera más o menos simultánea en todo el planeta. O, al menos, en los países que disponen de un sistema sanitario digno de tal nombre.

Dejando a un lado esa posibilidad "hiperaguda", el escenario más obvio es el deterioro del sistema asistencial en los próximos años, de forma posiblemente "crónica con reagudizaciones". No es absolutamente seguro que se produzca, si la energía solar barata y las nuevas generaciones de sistemas informáticos y de comunicaciones "nos salvan". Pero entra dentro de lo posible que la actual insuficiencia presupuestaria, la complejidad que hace que el sistema se ahogue bajo su propio peso, y factores externos, puedan romper la espalda del camello sanitario. ¿Qué sería esencial salvar, y cómo? ¿Qué se podría sustituir por alternativas más ligeras, y cómo? ¿De qué nos tendríamos que olvidar, y cómo aceptar eso?

Por otro lado, hay que recordar activamente que hay una enorme cantidad de personas en el mundo que ya están en la situación que nosotros podríamos temer. Son personas que tienen partos sucios, falta de corrección de su agudeza visual, y muelas que se les pudren sin antibióticos ni analgesia. Lo que nosotros tememos se llama "pobreza", y en nuestro caso sería una falta de parte de los recursos a los que estamos acostumbrados, que ocurriría en forma de pérdida más o menos brusca, como "pobreza sobrevenida". Tal vez aprendiendo cómo resolver los problemas de quienes viven desde hace mucho tiempo en situación de "pobreza crónica" resolvamos parte de los nuestros, incluso si no sentimos compasión alguna (ni miedo a que emigren).

La infraestructura sanitaria[edit source]

Si contemplamos el sistema sanitario en sus componentes esenciales, lo que vemos son edificios, personas, suministros, conocimientos y procedimientos. Una catástrofe sistémica no rompería los edificios, podría desactivar (por enfermedad, desmotivación u otros motivos) a parte de las personas, podría sin duda afectar a los suministros, y obligaría a olvidar algunos conocimientos por inaplicables, al tiempo que se reutilizan los aplicables de forma flexible para reconstruir los procedimientos.

Si se mantiene el suministro de fármacos y de electricidad, la mayoría de las cosas pueden funcionar de forma razonable. Si lo que se rompe es la economía, seguirán existiendo las dos mitades del corazón de la cebolla: personas que necesitan ayuda y personas que pueden prestarla, aunque puede que revincular de forma creativa a los proveedores de servicios con quienes los necesitan.

Áreas de interés[edit source]

  • Suministros: medicamentos y otros materiales, electricidad, información
  • Sistemas: cómo unir a clientes y proveedores
  • Procedimientos: cómo "operar" tras el colapso del sistema, y mientras se está colapsando

Ideas concretas[edit source]

  • Wikipedia sanitaria con "cuándo/dónde no hay doctor" (incluyendo "rehabilitación"), youtube, khan academy sanitaria (por ejemplo, liberar apuntes de especialidades y lugares e idiomas), ver qué hay en appropedia (el sitio natural para todo esto, creo)
  • Medicina preventiva por un tubo: tabaco, accidentes, lavado de manos, mosquitos, etc
  • Fabricación local de medicamentos: antibióticos, analgesia, anestesia ...
  • Ideas tomadas de lo que se hace en/para los países pobres: gafas baratas, incubadoras, etc (ver outofpoverty y los demás de esa constelación de emprendedores), redes telefónicas (frontlineSMS-medic etc), microscopios
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