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J R Soc Med. 2001 August; 94(8): 418–419.
PMCID: PMC1281641

65 years of mobile life for all?


The noble pauper is a perpetually romantic image—clean in body and soul, shining in virtue, blessed with wisdom and longevity. Little Dorrit was an angel but the world in which she lived reeked of filth, vice and illness. The attributes of modern poverty are stark: in marginalized regions hunger and exposure are preponderant; in the urban inferno, obesity, alcohol, smoking, drugs and abandonment. Whether in Bangladesh or Paris, in Bolivia or Detroit, the public health indicators are unequivocal—perinatal wastage, child mortality, disability and shortened life expectancy. Also the poor are the principal victims of homicide, war and displacement. The statistics are not improving: growth, the fetish of modern economy, does not reach the poor; to the contrary, it is often accomplished at their expense.

Some seem to be content with this state, arguing that relative poverty is merely a matter of ‘normal’ distribution and thus inevitable. However, most people and all governments declare, with varying degrees of sincerity, that absolute poverty is the result of social injustice—a societal illness that must be alleviated and eliminated.

How can this be done? The contemporary belief is in wealth creation: productivity and trade will enrich everyone, it is said. Customarily wealth is measured in units of money. Money can be imagined to be available in infinite quantities: ingenuity and work and a modicum of regulatory adjustment are believed able to create money and hand it in incremental amounts to larger and larger numbers of people. In consequence, it is hoped, wealth will eventually spread and bring health and longevity to all.

But wealth can only be created by harnessing energy. Ever since Prometheus stole the fire from the Gods, fuel was burnt. The first power-plants to be harnessed were slaves. Later water and wind were put to service; but the leap in wealth creation occurred when we learnt how to utilize fossil fuel and latterly nuclear power. Wealth can be measured in Joules—the amount of energy at the command of an individual or a nation. Whilst money can be imagined to be infinite, Joules are numbered. Joules on earth are a gift of the Sun and come in finite quantities daily. Apart from harvestable nuclear energy—a remnant of the embryonic universe—the Joules coming from the Sun are stored in water and air and in living species and in fossil residues of former life.

The exploitation of fossil energy resources has boosted wealth creation and boosted the population increase as well. 6 billion people now compete for the globe's resources. As many as half of these are likely to be short of the food, shelter and access to education and healthcare that would offer a life expectancy of 65 years without unmanageable disability. The rich represent perhaps a sixth of the total and soon can expect to live 85 and 90 years. The Alma-Ata clarion call ‘Health for all’ was never more than a slogan. ‘65 or more years of life for all’ is a proposition that has the merit of greater clarity. If one adds the qualification ‘...and the ability to move about,’ then freedom from disability is defined in the most general terms.

There are three possible ways to provide everyone with the minimum power required for 65 years of mobile life. One method would be to redistribute what we have. This is the concept of ‘The New Economic World Order’. A grand design of power sharing indeed, yet it suffers from two handicaps. First, no one ever gives up power voluntarily in any form—whether might or Joules. Second, the effects of Western technology are for everyone to see and, in the present mental state of the world, even the most deprived are convinced the way to salvation lies in adopting that technology. The mere fact that most of the things rich people possess and do are vainglorious does not persuade anyone not to covet them.

Redistribution within a national economy is possible if there is political will. Redistribution of the power, and consequently the wealth, of nations by peaceful means has never been attempted. Lately no rich nation has consistently spent on developmental aid the targeted 1% of its national income. A truly free system of world trade would considerably help poor nations; but, when the rich countries clamour for free trade, they mean free selling of their produce and not an end to protection of their wealth.

The limits of wealth creation by means of power generation are determined by the laws of thermodynamics and the tolerance of the globe's present ecosystems. If we attempted to make available energy on a scale that would lift the consumption of every person above the minimum necessary for ‘65 years of mobile life for all,’ and left, at the same time, the rich what energy they now have at their disposal, thermal pollution together with chemical pollution would overwhelm the present balance between the Sun and the biosphere of the Earth. (Such effort would also deplete the fossil energy reserves. Although the efficiency of power use could be increased, and sunshine, wind and water used to a greater extent, the possible contribution of these ‘renewable’ forms of energy is limited if for no other reason than scarcity of space.)

If the available energy is not redistributed and the total energy per head cannot be substantially increased without dire consequences for life on Earth, the third possible way to safeguard the energy required to abolish absolute poverty is to reduce the number of people. Or, put it differently: to allow the number of people to reduce itself. This is already happening. The world's poor represent a population buffer, dying in great numbers and at young ages from hunger, exposure, infection and violence.

Why, then, does the world's population continue to grow? In the wild, the number of offspring of animals is inversely related to the investment of the parents in the individual offspring. The human species modified this rule. In consequence, whilst the origins of the species were characterized by cooperation, its present condition is cursed by the fact that every child born is every other child's potential enemy. The world lacks a population policy because fertility fetishes of formerly isolated agricultural societies have been absorbed into world religions and pseudoreligious salvation creeds.

The ideological arguments concerned with reproduction are fought at the expense of the poor. The third-world poor are born to die young, either in the first decade of their life, of infection, or, if this is prevented by vaccination then, increasingly, as teenagers with gun in hand. The gun might come from the same country that made the vaccine. Health and disease, life and death are primary biological phenomena; and so too is inequality in genetic endowment and environmental circumstances. Medicine is the primeval cultural activity that tries to modify these phenomena. Until recently, the philosophy of medicine was not complemented by knowledge and technology. Now medicine has become a potent modifier of life events and population dynamics. Increase in capability demands increase in responsible actions. Doctors ought to point out that redistribution of energy is in everyone's interest, as is the arrest of population growth. It was selfishness and fear that initially prompted colonial powers to establish health services and sanitation in the large towns. The same mechanism might work again, this time on a global scale and in a more comprehensive manner. The priorities of the world are essentially medical priorities—universal sanitation, cheap air and water procurement, food security, immunization, the establishment of psychiatric services, control of sexually transmitted diseases and family planning. Wealth creation is limited by the finiteness of energy available and by the inevitability of pollution and its consequences. Better utilization and redistribution of energy and a global population policy are the realistic modalities for elimination of absolute poverty.

Man is not likely to destroy himself and he cannot destroy life on earth, for evolution is too robust. What modern man could do is to set himself back by several generations, by several centuries, lose kin and friends and goods and beauty and cultural achievements. He may well be on the verge of doing so by failing to address global income distribution and consumption of energy.

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press