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Having heard all of this you may choose to look the other way… But you can never say again you did not know– William Wilberforce, British Parliamentarian, 1789
The present article is about the potential impact of the environment on the health of children and youth in the 21st century and where the paediatrician might fit in. You might expect the words ‘child’ and ‘paediatrician’ to show up again fairly soon, but such will not be the case. There is a reason. An expectation of recent generations has been one of gradual improvement; thus, our standard of living is better than our parents and theirs of their parents. However, this expectation is about to change. Every child, everywhere, all three billion of them over the next 50 years, will have to confront unprecedented and generally adverse change within their societies during their lifetime. Just as our economy is undergoing incredible change, so is the environment. Just as today’s economic changes are distressing to most, so will be tomorrow’s environmental changes. Just as we precipitated these economic changes because of our arrogance, greed and hubris, so have we caused many of the environmental changes. Just as we must adapt to tighter times, so must we adapt to living within stringent environmental limits. By exploring how man’s perception and treatment of his environment has altered it so much that its ability to sustain humanity is threatened, and how that may affect our descendents, the present paper will help you understand this change and will prompt you to act, each in your own way, to prepare yourselves, your families and the doctors of the future, for what is to come. We must do this so our descendents will be able to enjoy flourishing human cultures.
Pogo, We have met the enemy, and he is us– Walt Kelly
The word ‘environment’ evokes images of pristine oceans, lakes and forests populated by diverse varieties of fish, animals and plants, but it also reminds us of polluted air, dirty water, dead fish, fossil-fuelled agriculture, parking lots, highways and slums. John Last’s, A Dictionary of Public Health (1), defines the environment as “the setting and conditions in which events occur. The total of all influences on life and health apart from genes, comprising the physical world and the economic, social, behavioural, cultural, as well as physical conditions and factors that are determinants of health and well-being.” This definition implies the presence of an ecosystem, “the comprehensive web of interrelations that exist between the components of the environment, particularly the plants and animals, and the checks and balances that govern their existence” (2), which provides those services to nature that keeps it healthy for all life.
The prevailing attitude of humanity is that while we might give lip service to the biological and physical environment, human existence really only relies on those facets made by man – the cultures, philosophies and religions, our economies and governments, and the physical infrastructure that lets us live in comfort and safety. In our quest for growth and progress, we have set the natural world apart and used it primarily for exploitation, extraction, food production and waste management (2). While we value those resources we can use, we rarely consider nature’s services – the autonomic nervous system of the earth, working critically in the background. Analogous to ensuring that nutrients are delivered to and wastes removed from our body tissues, natural ecosystems purify our air and waters, generate and preserve soils, disperse seeds, dispose of the dead, maintain biodiversity, and create places of beauty and inspiration. We largely discount these ecosystem services and seem to have forgotten that human survival depends on their healthy functioning. In fact, we have difficulty in accepting that we are just another species among many and are subject to the laws of physics and biology that govern nature.
We have attributes that let us exploit the earth far more than any other species and have used them in many ways. Some human groups view their environment as a resource to use gently (eg, the ‘seventh generation’ concept of many Aboriginal tribes); others view the environment as something to overcome. We have taken too literally the biblical command “be fruitful and multiply, and…have dominion… over every living thing….” (Genesis 1.28; King James version). We have used this directive to create theologies, theories and ideologies to justify our actions. And we have succeeded! We ‘conquered’ nature, or so we thought.
We have created artificial environments that let us live anywhere on earth, developed civilizations and ventured into space. Our ingenuity has let us increase our population exponentially, and we will add another three billion people within 50 years. In doing so, we inevitably will use nature’s resources, and when they become scarce locally, we will conquer new lands and peoples. Today, we outsource our needs to whoever can provide, with little concern over the effects of these demands on their resources or their environment. Nature’s resources seem limitless. Concluding that we are ‘above’ nature is inevitable. But, nature has limits and we are facing them today, and our descendents will face them even more.
In 1990, Wackernagel and Rees (3) conceived the ‘ecological footprint’ to quantify our demand on nature. In 2008, our ecological footprint was 31% more than earth’s capacity to meet our needs (4). In terms of nature’s services, humanity is drawing down both principal and interest, and just like living off our savings, this ultimately leaves us with nothing. As individuals, when we live beyond our means, we tap our savings, borrow if necessary and reduce our consumption, fairly confident that we can pay our debt. As societies, we also do this, borrowing or stealing from other nations to meet our needs, but as a world, we cannot do it. This is it. There is no other earth to borrow from.
And if we could borrow, we surely would, because if we continue our pattern of living, by 2050, we will need 2.5 earths to meet our needs (4), and many more earths than that if everyone on earth lived like us. This is especially true for energy, for here we face life-changing problems. Soon, likely within five years, we will face ‘peak oil’ – the time when world oil production is maximal and then starts a permanent decline, eventually resulting in an absolute lack of readily accessible petroleum (5); natural gas will peak somewhat later (6), and then coal (7). All will functionally be gone by 2100. These fossil fuels undergird our way of life (8), and because most of our economic growth and industrial development, plus the spinoffs from that, such as stable governments, education, food, health, transportation and employment depend on cheap and abundant energy, this loss of fossil fuels will lead to the greatest social challenge and change that humanity has ever seen on a global scale. This loss will be associated with increasing oil and gas costs, economic and social disruption, food insecurity, poorer health, uncertain health care delivery and general hardship (8–10). Renewable solar, tide and wind energy will help soften the blow, but will not negate it, and for the most part, will not replace the fuels essential for cheap transport.
We also will want to borrow from another earth, just to eat, because food security will be a common problem. Oceans will lack fish and their ecosystem services will be impaired (11). We will lack petroleum and natural gas for fuel and fertilizer production, so our ability to produce adequate food for everyone will diminish (8). Agriculture also uses 75% of the world’s fresh water, and water is becoming increasingly scarce. By 2025, 1.8 billion people will face absolute water scarcity, and 4.5 billion will live under conditions of water stress (12).
To this must be added the effects of climate change (climate instability, higher temperatures, drought, desertification, rising sea levels, biodiversity loss, changing local ecologies and changing growing conditions) (13). The muted emphasis on climate change in the present article does not reflect its real importance to humans because it will affect all of us, most likely adversely, and for centuries. But even if there was no climate change, our assault on nature’s capacity to sustain our way of life poses near-fatal dangers to our environment and to our societies.
The decades ahead will be times of reckoning, of dealing with the problems of diminished biocapacity, resource depletion, climate change and overpopulation; all driven by our need to dominate. If we do not soon change how we live, nature will force a new way on us. But what do we do? Do we acknowledge these problems, do we deny their existence or do we leave them for our children to deal with? You must discover for yourself and become knowledgeable because these changes are so profound and the life ahead so different that as you continue to practice medicine, patients and parents will look to you to help them understand, to help them decide what to tell their children and how to help them.
We are happy in proportion to the things we can do without– HD Thoreau
It is traumatic to accept that instead of being governed by power, economic growth and the bottom line, we must live within the limits of the natural world and replace our growth economy with a steady state economy – a system that permits qualitative development but not overall quantitative growth (14). We still want sport utility vehicles and Mcmansions, weedless gardens, iPods (Apple Inc, USA), kiwi fruits and trips to Bali. We may think ‘nature can handle my bit of garbage,’ or ‘it is not my problem.’ But, it cannot and it is your problem; it is everyone’s problem. Just as our society now faces crippling financial debt, humanity will soon face the debt owed to nature. Politics, philosophy and economics undergird cultural development, and they have taken us from living only in nature to living in an advanced civilization, but they cannot trump biological and physical reality (2). Everyday, as health professionals, in clinics, intensive care units and emergency rooms, we face this reality. The science of medicine is based on it. But we seem unable to transfer that reality to our own way of life. Yet, for our descendents to survive with a culture, rather than just as a species scrambling for existence, it requires that we accept this reality and learn to live sustainably. This does not mean the oxymoron ‘sustainable growth’; it means that we recognize that we are a part of – not apart from – nature, and must live within nature’s limits. It means a radical new paradigm of living, not just fine-tuning our current way of life. The first and hardest step is to face reality; to learn, acknowledge and act. This is our most important task.
But where do tomorrow’s children fit in? It is by how we raise our children and grandchildren, and how we affect the environment within which they live that much of their future life and health are determined. The philosopher John Hoyt wrote, “people are often heard to say they are concerned about the kind of world we will leave to our grandchildren, but equally critical is the kind of grandchildren we shall leave to the earth. The values and attitudes imparted to the children and youth of today are crucial in building the political will for sustainable societies in the next century” (15). The children one generation from now will grow up living in a world of constraint and conservation, and may adapt to this constrained world much more easily than the child born today. Today’s child, unless we are very careful, will learn the paradigm of living that has directed our own activities, and they will tell their children what life was like ‘in the olden days.’ This is a recipe for frustration and anger. We have to prepare them for a new life.
Tomorrow’s problems require perspectives of creativity, constraint, conservation and consideration, not growth and consumption. How do we give our children those perspectives? Because predictions can only be nonspecific, the prescription can only be general. We need to teach them to live gently on this earth, to value it, to assiduously conserve its resources and take care of it because it is all they have, and it has to last forever. Their world view should promote an ethic of conservation, sustainability, and respect for nature and for their neighbours because support systems will be essential. Travel will probably be less common, so life will be more local. Our children will need to learn how to get fulfillment in life from their families and community, from work, from education, not only in science and mathematics, but also from art, literature and music, and not so much from computers and consumption. We have to prepare them to face change with the confidence that they can solve the problems of tomorrow, whatever they are, with the methods of tomorrow. This requires a conscious and arduous effort on our part – not just parents but everyone, especially those influential in society – to model these roles and needs, and not to continue ‘life as usual’.
To be an effective model for our children means we must be knowledgeable about the world, not the world of entertainment and excess, but about the environment and how it is changing. We need to learn about things we can do to reduce our impact on the earth and then act on our learning. Without education, we lose the drive to change our own lifestyles, to go from consumption to conservation and to teach others. Without education we cannot rebut the denier, convince the skeptic or effectively prompt governments to change. Of course, education is only part of action. The other part is motivation – a much tougher step than education. We often say ‘I would do anything for my child.’ Now is your chance.
And what of paediatricians, indeed all doctors. Medicine in 2050 may well differ from today, but the basics will not change. The problems and concerns of parents and children will still be there, but the solutions may be different. We must seriously consider how and what we teach our students and residents because their practice of medicine may be based on simpler technology, fewer drugs and expert clinical skills. The opportunity will remain of ensuring that children recover from their illnesses, and that they will have the best chance to live a full and useful life. The requirement to advocate for the needs of all children will persist. Paediatricians will be doctors, teachers, psychologists, advocates, advisors, mentors and friends; just like always.
Predictions often ridicule the predictor, but I am sure that the challenges all the children of the 21st century will face will be greater than those faced by any other generation in the history of humankind. In many children’s stories, the ending is “…and they lived happily ever after.” Let us work to ensure that this ending ultimately persists. It is up to us as parents, teachers, physicians and responsible adults to make it so.