I’ve been recording and publishing some of the chapters from my 2016 book The Ecology of Care for free here on Substack. I’m skipping ahead this week to Chapter 7—on the effects of oil crises on health care systems—as this topic is so relevant right now. I’m also hosting a workshop to discuss this on Thursday, April 9th. Learn more and sign up here.
(If you are reading this on email, you might want to switch to reading it online, as I will be updating links in the online version.)
When the first oil crisis hit in 1973, I was ten years old. My brother and I sat in the backseat of our unheated station wagon getting bored and teasing each other while our single mother waited in line behind other frustrated drivers to buy gas. OPEC (a group of oil-exporting Middle Eastern countries) had put an embargo on the United States and several other countries for supplying arms to Israel. The price of oil quadrupled. Gas was rationed, with most stations closing (at President Nixon’s request) from Saturday night until Monday morning.
The era of “service stations” was over: gas stations stopped giving away steak knives and green stamps to try to entice customers to buy gas. Attendants stopped washing windows and waving at me and my brother, and they stopped offering to refill the oil or check the pressure in the tires as they pumped the gas. Instead, attendants rushed around with their heads down trying to stay out of the way of angry customers.
Hospitals, which were required to keep their thermostats at a minimum of 75 degrees, were hit hard by that oil crisis, as well as by the second oil crisis in 1979, when oil production dramatically dropped in Iran and Iraq due first to revolution and then to war. When, as a teenager, I went to work for my neurosurgeon grandfather, I didn’t know that Hartford Hospital was struggling to pay its bills—spending $10 a minute just on heating the building on the coldest winter days. Fuel costs were $1.7 million for the year.
When the hospital was designed in the 1960s, oil prices were a mere five cents a gallon, but by 1981 heating oil prices were a whopping $1.00 a gallon, twenty times higher than what they had planned for.1 That second oil crisis during the Iranian Revolution affected hospitals in other ways, as well. Plastic medical supplies like syringes were hard to obtain,2 delayed in production because of shortages of petroleum—which is used as a raw material to make plastics, and as fuel to transport medical supplies from factories around the world to hospitals in places like Hartford, Connecticut.
Today’s hospitals are far more dependent on fossil fuels than they were back then.
“ Strengthening health systems to enable them to deal with both gradual changes and sudden shocks is a fundamental priority in terms of addressing the direct and indirect effects of climate change for health.”—World Health Organization, “Climate Change and Health”
In the fall of 2007, the US went through a third oil crisis, but this time I wasn’t sitting in the backseat punching my brother. This time I was the single mother driving the car, and I was the owner of the health-care facility, paying the bills.
The economic crisis unfolding around me was the first of several events that woke me up to the reality of the need to simplify and re-localize the way we care for each other during uncertain times.
By moving from my house into my clinic, I resolved some of my own dependency on fossil fuels, and by changing to a more communal business model, I solved some of my patients’—and my own—financial struggles. But every time I went to visit a patient in the hospital, and started to think on a larger scale, I felt uneasy again. It was one thing to convert my clinic into a more sustainable model. How in the world would a hospital do it, or an entire country’s health-care system? It seemed that in an era of increasing conflicts over oil rights, and increasing pressure to reduce our dependency on fossil fuels, hospital care could be dramatically impacted if there were a sudden price hike, another embargo, or simply a shortage of oil, as some people were predicting.
I had been to Cuba to research the amazingly successful way their health-care system responded to sudden oil shortages, but in the US we did not have the public-health infrastructure in place to make the transition as smoothly as they did. I wrote short articles about my concerns about the sustainability of our larger health-care system and posted them online.
One day a stranger named Dan Bednarz emailed me, saying, “We should talk.”
Dan was a public-health professor who had recently gotten fired from his job at the University of Pittsburgh for insisting on talking about the end of cheap oil, and its impact on hospitals—an unpopular subject.
Dan combines an academician’s love of statistics with a pessimist’s view of the future. I can understand why people didn’t really want to listen to him until after the economy fell apart and hurricanes Katrina, Irene, and Sandy hit. It’s easy to discount wisdom that comes from the margins—where the people who have been pushed aside are often able to get a clearer view of the whole. Dan has a somber tone to his voice, perhaps from growing up in Detroit, where his father worked on an assembly line. But he was one of those truly astute people who, from his outpost, saw what was happening, and how it was happening—ahead of time—and was brave enough to talk about it, even if it meant losing his job.
He started a website called “Health after Oil” and then found mine (www.sustainablemedicine.org)—one of the only other websites discussing the same issues at that time. And he had learned, like I had, that it helps to make friends, especially when you’ve made a career out of proclaiming that the emperor has no clothes. Dan pointed me to the Post-Carbon Institute and the Oil Drum, where other people were writing about climate change and the impact of rising oil prices on industrial agriculture, housing, and transportation, but very little about health care.
I suggested that we interview each other about our current thinking and concerns and then post the interviews online. Our interviews (part one and part two) were like a perfect yin and yang outlook on the future of health care—he tackled gloomy looming problems, and I held out hopeful, idealistic solutions. Together we painted a relatively full picture of the conundrums and opportunities of transitioning to a health-care system that was more localized and less dependent on fossil fuels.
Those two interviews brought in emails from concerned medical students, people building clinics in Africa and India, radio hosts, and newspaper reporters. Soon I was appearing on panels discussing the future of health care, giving talks around the state, testifying at the statehouse, and meeting with hospitals. And Dan’s online articles began getting millions of hits.
A Small New England Hospital’s Relationship to Oil
During a meeting with the “Green Team” of a small, independent New England hospital to discuss their fuel use, I asked them to calculate how much the cost of oil would have to rise before they would no longer be a viable business.
Sitting around the table with upper management, a few providers, and the facilities manager, we calculated that if oil prices doubled, the cost of merely heating the building would eat up close to the entire amount that the hospital was currently clearing as profit. In other words, the hospital would just about break even—barely. Then I showed them a list I had compiled of all of the items in a hospital that are made of petroleum, and we started figuring in the costs of all the petroleum-based hospital supplies that would also double in price because they rely on oil for raw materials, production, and shipping.
It appeared likely that the hospital could go out of business in very short order if there were another embargo, or if oil prices suddenly rose. Being dependent on a single resource creates incredible instability in a system: if something goes wrong, it goes wrong in a very big way.
Our medical system is completely dependent on fossil fuels from side to side and from top to bottom, with the exception of a few wilderness first responders, herbalists, and hands-on healers who have never forgotten the basics. Our offices, our record keeping, our supplies, our tools, our diagnostic machines, our medicines, and our ambulances are all dependent on petroleum and other fossil fuels.
I showed the Green Team an article from the Journal of the American Medical Association that concurred: if there is an oil shortage due to another embargo, or if we successfully shift away from fossil fuels for the climate’s sake, much of our current health-care system will need to be redesigned.3
The world’s population is expected to increase from seven billion to eight billion between 2015 and 2030, and the US Department of Energy expects that unless we find entirely new sources of fuels by 2030, we will have about half the amount of oil and other liquid fuels that we had in 2011.4 So that’s all of us, plus one billion more people, to share half as much oil and other liquid fuels. [Note that when this chapter was originally published, the “Shale revolution” was underway in the United States, vastly expanding the use of fracking in the U.S., and thus expanding access to fuels—but of course we now have new reasons for fuel shortages. And…yes, in 2026, world population is now well above 8 billion.]
See “A Partial List of Health Care Items Made out of Petroleum”
The upshot is this: by choice or by circumstance, we are going to have to find ways of providing health care that are not dependent on cheap oil.
As I started telling this hospital’s Green Team about very practical ways of creating resiliency in the workplace and lessening dependence on fossil fuels, I suddenly realized I had lost them.
Their eyes were glazed over. Their concern about a bleak future made it hard for them to pay attention to the alternatives I was about to propose. (That was when I understood how Dan Bednarz had lost his job: trying to explain these same issues to his colleagues.)
One of the biggest leadership challenges of this era is this: how do we communicate urgency and relaxed confidence at the same time? Clearly, in that meeting I did not succeed. As I try to get neighbors and colleagues to think about planning for the future, I’ve learned that I need to be able to hold up solutions at the same time that I explain the problems.
The small independent hospital I met with could have made changes that would have benefitted them and the community they served. If, like Muscogee Community Hospital in Oklahoma, they had invested in a geothermal heat pump, which uses the constant 55-degree temperature below the earth to draw in heat in the winter and cool in the summer, they could have recouped their investment relatively quickly through savings on heating oil and they would have been protected from one major aspect of fluctuating oil prices for decades to come (while reducing their carbon footprint at the same time).
Instead, they waited and were bought out by a larger hospital a few years later. This merger merely postpones the hospital’s problem, because as we have learned, “too large to fail” is not an accurate assessment of any institution.
Technological Complexity Versus Natural Complexity: Which One Do We Want to Depend On?
Cheap oil has allowed us to create an extremely complex society and an extremely complex medical system, with a huge amount of specialization, and innovation. Many good things have come out of this. But in order to maintain our medical system at this level of complexity we have to find ways of providing services that are unlikely to be affected by political upheavals, embargos, or the increasing pressure to reduce our impact on the climate. The technological complexity that fossil fuels have afforded us is too vulnerable, and too costly to our atmosphere, to continue to depend on for our entire health-care system.
I’d suggest that the complex systems we rely on for our health care from here on out should increasingly be the complexity of natural systems. We should be putting our time and money into the restoration of functionality of our soils, human relationships, microbiomes, and ecosystems.
The problem is not that we can’t live without fossil fuels. The problem is that we have forgotten how. We have dismantled the landscapes that used to provide us with local food, fiber, and power. We live and work in skyscrapers that become useless during extended power outages, and in suburban neighborhoods that are hard to reach without vehicles. Most of us have forgotten how to travel without fossil fuels, how to build without them, and how to grow food without them. We have also forgotten how to take care of each other without them.
Like most people, I love many aspects of modern technology. I love being able to take photographs of my walks in the woods and send them instantly to my friends. I love being able to read obscure medical research online while sitting in front of the woodstove. I love the fact that a radiologist can show me exactly where my son Alden’s collarbone has fractured (from doing stunts while sledding down the driveway), and predict how long it will take to heal.
Yet in today’s high-speed, competitive, petroleum-based world, vulnerability is not limited to the slender bones around our necks. As we do our daily stunts with our computers and cell phones and medical imaging machines, we are constantly sliding down the slippery slope of increasing dependence on modern technology in an era of increasing power outages, political upheavals, and supply-chain failures. And it is precisely our insistence on holding on to everything that creates the situation that threatens us with the very real possibility of losing everything.
Think about your mobile phone.
In a report by David Korowicz, called “Trade-Off: Financial System Supply-Chain Cross-Contagion, A Study in Global Systemic Collapse,” he writes:
Mobile devices, now ubiquitous, represent the culmination of twentieth-century physics, chemistry, and engineering. They signify thousands of direct—and billions of indirect—businesses and people who work to provide the parts for the phone, and the inputs needed for those parts, and the production lines that build them, the mining equipment for antimony in China, platinum from South Africa, and zinc from Peru, and the makers of that equipment.
The mobile device [also] encompasses the critical infrastructures that those businesses require just to operate and trade—transport networks, electric grids and power-plants, refineries and pipelines, telecommunications and water networks—across the world. [The production of the mobile device] requires banks and stable money and the people and systems behind them. It requires a vast range of specialist skills and knowledge and the education systems behind them.5
If this is what is required to produce a cell phone, imagine then, what it takes to design, produce, and transport all the high-tech equipment used in a hospital. And imagine, then, how many things could go wrong in a war, a long-term power outage, or a natural disaster that prevents some part of the supply chain from operating smoothly.
A surgeon in a high-tech hospital—relying on machines with parts made around the globe, and disposable supplies—has a very high risk of being affected by events on the other side of the world. The risk lowers somewhat with each step toward simpler or more local technologies. A field surgeon trained to work in a tent with little equipment and few supplies is less likely to be affected than the surgeon who only has experience in a high-tech setting. An acupuncturist who uses needles, cotton balls, and alcohol has a small but still real risk of being affected. (In the 2010s I had to deal with needle shortages almost every time I placed an order, but needles are a relatively simple technology that could be made locally if necessary, and can easily be resterilized using an autoclave.)
An herbalist in South America who works with local herbs is very unlikely to be affected by a riot in Europe, a flood in China, or rising oil prices in the Middle East, because the supplies she needs grow right around her. Likewise, a lay midwife or massage therapist doesn’t need much of anything except her own two hands. As we’ll see in the upcoming chapters, a health-care system that figures out how to use public-health measures to support the creation of a healthy, resilient population can also maintain relative health and safety during emergencies.
As much as we might feel comforted by having the most advanced medical technology in the world, at times when natural and human-made disasters knock out power, topple factories, and disrupt supply chains both here and abroad, we may well find ourselves wishing for communities that are good at taking care of each other, and practitioners who are highly skilled in low-tech ways of preventing, diagnosing, and treating illness. It is time to start creating those communities and educating ourselves in those low-tech skills.
Sudden shortages of certain medications and medical supplies have already started. Eighty-one percent of Canadian pharmacies reported that they were affected by drug shortages in 2010, partly due to a diminished supply of raw materials from China and India.6 In the US, more than 90 percent of hematology/oncology pharmacists reported shortages in chemotherapy drugs in 2011. These shortages led to delays in chemotherapy, last-minute changes in the choice of therapies, complications in conducting clinical research, increases in the risks of medication errors and adverse outcomes, and increased medication costs for patients.7
In 2013, the Centers for Disease Control put out an emergency advisory that the United States was going through a shortage of doxycycline—used not just for many respiratory and sexually transmitted diseases, but also the antibiotic of choice for treating Lyme disease and other insect-borne illnesses such as malaria, which are spreading northward due to climate change.8 Tetracycline, used for similar bacterial infections, was completely unavailable at the same time.910 The FDA also reported shortages in life-saving drugs, such as thyroid medication and epinephrine injections (epi-pens) for severe allergic reactions, as well as simple replacement minerals for IV bags, like sodium phosphate and sodium chloride.11
An article in the Washington Post detailed shortages in intravenous nutrition for premature babies that affected the health and survival of babies in the United States far more than anywhere else. Sometimes, even though the supplies are available, in a for-profit system, once a company’s patent has ended there is little motivation to continue manufacturing.12 In six years, from 2006 to 2012, drug shortages in the United States skyrocketed from 70 drugs to 299 drugs, so much so that the FDA started a task force to look for solutions.13
Just-in-Time Inventories Might Be Too Late
According to Al Cook, a member of the Medical Materials Coordinating Group that advises the US Department of Health and Human Resources on emergency preparedness, many hospitals and manufacturers of hospital goods have switched to a “just-in-time” inventory system, meaning that they don’t order new supplies, such as syringes, catheters, manufacturing materials, and food, until the supplies are depleted.14
They do this with confidence, knowing that under normal circumstances, deliveries can happen within hours. This inventory system is considered essential for corporate competitiveness in a for-profit health-care system like ours. But it leaves hospitals, nursing homes, and pharmacies very vulnerable. If deliveries are stopped in an area due to a natural disaster or sudden fuel shortage, patient care is jeopardized.
Cook notes that there are not enough supplies in any local area to support the care necessary during a large-scale emergency.15 This became painfully evident after Hurricane Katrina, when trucks loaded with emergency goods were rerouted, creating lengthy delays in deliveries of food and medical supplies to hospitals and residents in New Orleans.16
Richard Holcomb created a timeline outlining the potential consequences of restricting or halting truck traffic in response to a national or regional emergency in the United States.17 The timeline illustrated that within twenty-four hours:
Delivery of medical supplies to affected areas ceases.
Hospitals run out of basic supplies, such as syringes and catheters, within hours.
Radiopharmaceuticals for cancer treatment and diagnostics, which have an effective life of only a few hours, deteriorate and become unusable.
Gas stations begin to run out of fuel.
Medical and pharmaceutical manufacturers using “just-in-time” manufacturing develop shortages of raw materials and other components.
US mail and other package delivery ceases.
Food shortages begin to develop in hospitals, nursing homes, and supermarkets.
All this in just the first day. Within a week of the same scenario, hospitals will begin to exhaust oxygen supplies. Within two weeks the nation’s clean water will begin to run dry, lacking the chemicals needed for water purification at water treatment facilities.
This report only deals with the effects of restricted trucking. Supply chains are also dependent on shipping by air, sea, and rail. The daily operations of our medical system are entirely dependent on availability of fuels, stable transport routes, and fair weather, both political and environmental.
Rethinking Disposability
When I went to acupuncture school in the early 1990s, we were still sterilizing needles and reusing them. By the time I graduated, four years later, nearly everyone was using needles that were chemically sterilized and packaged in plastic (i.e., petroleum), and we disposed of them after a single use. Awareness of AIDS, hepatitis C, and other blood-borne illnesses made a booming business out of disposable medical products in the 1990s, and I arrived on the scene just at that turning point. In all of health care, disposable plastics—for syringes, bags, tubing, surgical supplies, pill bottles, and bandages—have replaced reusable metal and glass, and in many areas disposable (petroleum-based) “paper” has replaced cloth items for gowns and pads. Meanwhile we have forgotten we have other options, and most manufacturers have stopped making them.
Climate change, flooding, drought, fires, fuel shortages, and conflicts over water and other resources all act as destabilizing influences on political systems and economies. Local and national economies are increasingly intertwined with those of other countries. We rely on each other, around the world, for the technology, food, and other products we have become accustomed to. When one part of the world is affected, we are all affected.
The question is, do we respond to shortages with mutual aid, cooperation, and collaboration, or with conflict? Can we learn to take care of each other in ways that rely on local supplies, natural processes, and simpler technologies? Should we invest in local manufacturing of essential drugs and medical supplies and ask our hospitals to return to using older methods of resterilizing supplies?
Perhaps we can learn to hold on to technology lightly: “It’s really nice to have disposable plastic syringes and tubing, but I don’t want the hospital to be entirely dependent on them because if the supply truck can’t get through, they won’t have any other way to treat patients. So let’s figure out what else might work, and then only use plastic when absolutely necessary.”
Or, “We should invest in this company making biomarker tests for cancer, but also invest in a medical diagnostics dog training centers so that if manufacturing supplies run low, patients will have other options.” [See the sub-chapter on the incredible accuracy of dogs as diagnosticians.]
Or, “It’s been great having the option of taking pain medication, but I would rather not be dependent on it, because if the manufacturer goes out of business, or there is a flood and the road washes out on the day I was supposed to pick up my prescription, I want to have other tools at my disposal that I can access no matter where I am. So I’m going to take this pain management course, eat foods that reduce inflammation, and go to a support group instead.”
…and here we are. It is April of 2026 (fifteen years after I first researched and wrote this chapter).
We have been through the social disruption and supply-chain failures of COVID-19. We are currently in the middle of multiple wars; disruptions from fires, floods, droughts, and storms; and now are in the early stages of yet another fuel crisis, set off by recent decisions to bomb Iran and oil infrastructure across the Middle East. Health care systems and our public health around the world are being affected by all of this, and it is likely to get worse.
Most governments are highly unlikely to change their current health care systems. The private, for-profit health sector is unlikely to pivot quickly enough. So it’s up to us as citizens and neighbors to figure this out together, and learn to care for ourselves and each other in new ways. Want to discuss this? I’m hosting a workshop on this topic this Thursday, April 9th. Click here for more details, and to sign up to join us live or get access to the recording, chat, and transcript.
Coming soon: How Cuba’s innovative health care and agricultural systems survived a fuel crisis in the 1990s.
Matthew L. Wald, “Hospitals Struggling to Contain Soaring Fuel Costs,” New York Times, March 4, 1981.
Gary B. Clark and Burt Kline, “Impact of Oil Shortage on Plastic Medical Supplies,” Public Health Rep. 96, no. 2 (1981):111–15.
Howard Frumkin, Jeremy Hess, and Stephen Vidigni, “Peak Petroleum and Public Health,” JAMA 298, no. 14 (2007):1688–90.
In April 2009, the United States Department of Energy held a round-table entitled “Meeting the Growing Demand for Liquid (fuels).” A graph in their presentation document shows that the Department of Energy expects a sharp decline of all known sources of liquid fuel supplies, starting in 2011. The graph, entitled “World Liquid Fuels Supply,” drops from approximately 85 million barrels per day in 2011 to about half that by 2030. The graph contains a mysterious black line labeled “unidentified”—which represents as-of-yet-unknown sources of fuel that will be needed to fill the gap between rising demand and the decline of known supplies. (The already “identified” supplies include places where drilling has been put on hold due to environmental concerns). “Meeting the World’s Demand: Liquid Fuels, A Roundtable Discussion,” U.S Energy Information Administration, http://www.eia.gov/conference/2009/session3/Sweetnam.pdf.
David Korowicz, “Trade-Off: Financial System Supply-Chain Cross-Contagion: A Study in Global Systemic Collapse,” research paper prepared for Metis Risk Consulting & Feasta, June 17, 2012, http://www.feasta.org/2012/06/17/trade-off-financial-system-supply-chain-cross-contagion-a-study-in-global-systemic-collapse/.
Canadian Pharmacists Association, Canadian Drug Shortages Survey Final Report, December 2010, http://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/DrugShortagesReport.pdf.
Ali McBride, et al., “National Survey on the Effect of Oncology Drug Shortages on Cancer Care,” American Journal of Health-System Pharmacy 70, no. 7 (2013): 609–17.
“Nationwide Shortage of Doxycycline: Resources for Providers and Recommendations for Patient Care,” Centers for Disease Control and Prevention, last updated June 12, 2013, accessed June 9, 2015, http://emergency.cdc.gov/HAN/han00349.asp.
Centers for Disease Control and Prevention, Doxycycline Shortage, last updated July, 31, 2014, accessed June 9, 2015, http://www.cdc.gov/std/treatment/doxycyclineShortage.htm.
http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm314743.htm#tetracycline.
http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm314743.htm#sodiumchloride.
Alexandra Robbins, “Children Are Dying,” Washingtonian, May 2, 2013, accessed June 9, 2015, http://www.washingtonian.com/articles/people/children-are-dying/index.php.
American Society of Health System Pharmacists, letter to FDA regarding FDA-2013-N-0124; Food and Drug Administration Drug Shortages Task Force and Strategic Plan, March 14, 2013.
Richard D. Holcomb, “When Trucks Stop, America Stops,” American Trucking Association (paper prepared for the American Trucking Association, July 14, 2006). accessed September 27, 2012, http://www.trucking.org/Newsroom/Trucks%20Are/When%20Trucks%20Stop%20America%20Stops.pdf.
Ibid.
Sheri Fink, Five Days at Memorial: Life and Death in a Storm Ravaged Hospital (London: Atlantic, 2013).
Richard D. Holcomb, “When Trucks Stop, America Stops,” American Trucking Association (paper prepared for the American Trucking Association, July 14, 2006).
