Village Medicine

[The Four Questions have drawn an incredible number of responses, both as blog comments and as much longer emails. They are still coming in, and will take me some time to process.]

The e-book edition of Communities that Abide includes a chapter by Peter Gray, which didn't make it into the paper edition. Peter is a family physician in Canada (as is James, who contributed another chapter on medicine; it is nice that Canadian medics are stepping up to helping people deal with the medical madness that reigns south of the border). He set out to explain “how a village healer in a post-collapse community of a few hundred people, with some basic knowledge and simple tools, might make a positive difference to health, illness and suffering in that community. Peter is not any sort of alternative practitioner: “The tools and techniques described in this essay are only to be used in scenarios where conventional Western medicine is unavailable.” But unlike the vast majority of his colleagues, Peter has spent a great deal of time thinking forward to the time when the tools Western medicine takes for granted are unavailable, and finding out which alternatives are effective, which medical interventions should still be attempted, and which are pointless to try.

The topic of the future of medicine hits a nerve with a great many people. We all know people whose ability to function depends on an uninterrupted flow of “regimen” drugs. Even those who are healthy (in the sense of not having to take anything except air, water, food and a bit of sunshine) still worry about having access to medical care for emergencies, for giving birth, and for palliative care in our final months and days. It is good to know that there can be recourse (with a bit of preparation); it is also good to know what to expect and what not to expect.

Western medicine starts with the promise of eternal life but ends with hospital hallways filled with the dying while the rest of the population avoids them like the plague, for fear of getting sick. Somewhere in between, if the conditions are right, it goes through a phase of financial gluttony: how much should Americans spend on health care (whether they are healthy or not)? 20%? 30%? The sky is the limit. But the end result will be the same.

The alternative does exist. Peter picks up where James left off, responding to questions that my readers have asked me, and that we will all find ourselves trying to answer as we search for alternatives to the “radical cashectomy”—a non-elective surgery with a poor survival rate that is currently on offer at most of our contemporary medical establishments. The areas he addresses are:

• Keeping healthy
• Stockpiling medications
• Insulin-dependent diabetics
• Immunization
• Psychological medicine
• Herbal medicines (legal and illegal)
• Surgery
• Making difficult choices

At the outset, Peter debunks the thesis that regular check-ups are somehow useful or necessary: “From my personal observations as a family physician, the patients who show up at my office regularly tend to be the least healthy, while the patients who remain healthy well into their 80s and 90s are seen rarely, if at all, and are usually on minimal or no medication. ... The main problem with the ‘doctor knows best’ narrative is that it places the responsibility for staying healthy on the physician rather than the patient. This type of health care is a luxury we can barely afford even in today’s affluent, technologically advanced society, and it will not be available in a post-peak village community. Maintaining your health in the future will probably come down to just this: ‘Look in the mirror. Are you obese? Are you undernourished? Do you smoke? Do you drink to excess? Do you engage in risky behavior?’ People know these things for themselves without needing a physician or expensive tests to tell them.”

Of course, people do get sick, and if certain life-saving drugs have been stockpiled beforehand, then their chances of recovery can be much better. Peter goes into some detail about the Shelf Life Extension Program (SLEP), “a secretive US Government program which was set up to conduct research into whether pharmaceuticals which have passed their expiration date are safe and/or effective to use.” Don't ask your government, because the pharmaceutical companies have forbidden it from telling you, but the conclusion is this: “Overall, the available evidence suggests ... that most solid pharmaceuticals (capsules and tablets) are safe and effective to use long after their official expiration date provided they have been stored in cool, dark and dry conditions. The same cannot necessarily be said of liquids or of pharmaceuticals which have been stored in sub-optimal conditions. The maximum length of time for which pharmaceuticals can be kept is uncertain, but I understand that some pharmaceuticals which have been kept from the start of the SLEP program in 1986 may still be effective.” Another key point: over time, pharmaceuticals generally do not become dangerous; they just become less effective. Thus, a stockpile of the right drugs in the right form makes it much easier to handle a variety of medical emergencies, while supplies last.

When the supplies start running out, the remaining recourse is to start using herbal medicines. Peter separates them into three groups:

1. Herbal medicines which probably work
2. Herbal medicines which probably don’t work
3. Herbal medicines which definitely work but are illegal to produce without a government license

The “probably work” list is rather long and deserves plenty of study. The “definitely work” list is quite short and, in some ways, more important: you wouldn't want to perform most kinds of surgery without having a bit of opium on hand, by which point having a government license to produce it will be rather beside the point, because, you see, government officials sometimes require surgery too.

Speaking of surgery, Peter singles out the single most common surgical procedure village practitioners will be called upon to perform: lower limb amputation: “Diabetes is the most common reason for lower limb amputation today. One third of all foot amputations are performed on diabetics with foot wounds or ulcers. The reason why so many diabetics need amputations is because high circulating blood sugar levels over many years cause damage to the interior of blood vessels, making them them narrower and less efficient at delivering blood and oxygen to where they are needed. As the condition progresses, the flow of blood and oxygen drops below critical levels, at which point the tissue dies. ...  If modern pharmaceuticals become unavailable, we will have a large number of untreated diabetics developing complications much faster than they would have previously. The numbers are difficult to estimate, but let's say that the number of amputations needed may increase five-fold. Then, instead of looking at just four amputations in a working lifetime, [a village doctor] may now be looking at 20 amputations—one every couple of years. Whatever the exact numbers may turn out to be, there will be a significant number of these procedures needed.” How will you handle these? Peter walks you through the steps. Yeah, the patient might die. But if gangrene is allowed to run its course, the patient will die. It's the patient's decision.

And this is perhaps the most important point of all: we will all be forced to make life-or-death decisions. Currently, our decisions are a matter of consumer choice—hamburger or cheeseburger? In the future, it will be “Should I allow an untrained person to amputate my gangrenous leg without a general anesthetic, or should I succumb to gangrene? ... The era we are entering into has been called “the Age of Limits.” It might as well also be called “the Age of Difficult Choices.” Good luck.