Health Care in an Energy-Constrained Environment (Part II)
Options for Re-evaluating Care Resources
By Bethany Schroeder
In Part One of this two-part series on healthcare resources in Tompkins County, I pointed out that today we have a variety of options and a well-developed infrastructure to meet the health needs of many local people. Noted exceptions include un- and underinsured residents, now estimated at 13,000. Some of these people are treated outside the County at regional medical centers and some receive care at the Ithaca Free Clinic (IFC). Many do without regular care at all, visiting a facility on an emergency basis only. As an unstable economy and reduced resources persist and worsen, more and more people will experience the exigencies of decline. In terms of health care, much can be done to mitigate the effects through evolved expectations and planning for the change. Recognizing health care as a right rather than a privilege goes some distance toward effective planning. Understanding that the illness or injury of anyone in our community is a hazard to all of us and one we should address by providing support also demonstrates our humanity and our solidarity.
Overcoming Barriers to Care
In the future, barriers to care will include transportation challenges, lack of available facilities, and alterations in care models.
Transportation to care
Whether one is a healthcare worker or resident in need of services, a chief barrier to care delivery in the future will be transportation. Because most large health resources such as Cayuga Medical Center (CMC) and the Convenient Care Center are located at the outer limits of the city of Ithaca, people presently rely on private cars, taxis, bicycles, or public vehicles, such as busses and Gadabout shuttles, to get to and from appointments. CMC also operates a Convenient Care Center located in the adjacent county of Cortland, where some residents of Tompkins County living nearer to Cortland than to Ithaca access care. Similarly, most of the residential facilities, including assisted living homes and skilled nursing facilities (SNF), have private shuttle services specifically for transporting residents to and from healthcare appointments. As clinic and office spaces are developed in Ithaca, more and more physicians are presently located at the periphery of the city's boundaries. Nonetheless, already established physicians and nurse practitioners in smaller offices, as well as the offices of many complementary and alternative providers, are located within the city and within some of the villages and towns, making it possible for residents who live nearby to walk to appointments. Both options of locale have pros and cons, and these will change over time.
An obvious way of managing challenges to transportation, both from the perspective of caregivers and people needing care, is to encourage healthcare workers to live near worksites and for residents to establish relationships with providers near their own homes or worksites. The present centralization of healthcare facilities makes this difficult to achieve, whereas planning for a future change now could make the concept more acceptable. Specific transportation options are outside the scope of this article and will be addressed by other TCLocal contributors. Nonetheless, an obvious consideration includes developing employment and social structures that routinely allow workers to seek care during work hours, especially important to workers in settings located near care settings. At the same time, healthcare providers could consider holding flexible hours, in order to facilitate access through available transportation options.
Another option for arranging transportation is to reverse the process, especially in clusters of dense dwellings. Teams of caregivers in any number of configurations could easily walk through neighborhoods delivering service—either in the form of direct care or education or both. Physicians have largely discontinued making house calls in the U.S., but visiting nurses still do travel to homes, and this practice may prove efficient in some circumstances and settings. For example, a team composed of a registered nurse, a dietician, and an herbalist could offer nutritional and medicinal education. A chiropractor, an acupuncturist, and a massage therapist could provide alternative pain management. If the teams worked together, they could help one another in the process of finding the right method of fulfilling the needs presented to them.
Tompkins County could also learn a lesson from the Cubans, who assign physicians, nurses, and others to live and work in specific neighborhoods, inspiring, according to reports, a deep commitment to the neighborhood and its residents. Care providers in the immediate vicinity of those needing care are naturally able to see and to know their prospective patients in a different way than when both reside apart.
If things get as bad as some of us think they might, another potential consideration is the option of taking care into the community, such as the former rural district nursing practice. At the beginning of the last century, nurses cared for patients in rural settings using horses to get to and from settlements. In many parts of the U.S., this would be an untenable scenario, whereas Tompkins County-indeed, the entire Finger Lakes region-already supports many horses, horse farms, and local routines that include horses in daily life. Under circumstances of energy descent, many more people may be occupied in agricultural pursuits, in which case we might expect more farming injuries and other agriculturally-related healthcare needs. Visiting nurses or even visiting physicians could well be a necessary part of daily life.
Part One of this series provided an overview of care facilities in Tompkins County. Apart from the Public Health offices, owned and operated by local government, most local facilities are privately owned. City and town planning boards review and approve the construction or re-fabrication of care facilities, and some degree of oversight of the development of facilities occurs through the work of the Health Planning Council and its advisory board. Projects that may rely on public money, such as Medicaid dollars used to house residents in assisted living homes or SNFs, are scrutinized for the need of services in a particular area. Nonetheless, there is no master plan based on realistic census projections and estimates of available resources necessary to ensure care for all residents.
In an era of adaptation, the leadership of Tompkins County can rethink the requirements of a care facility, as well as the number of facilities in any part of the county. If care can be delivered in less formalized and standardized settings, then almost any storefront or main floor of a house or other common building is adequate so long as it has bathrooms and a hand-washing sink in a common space, as well as space for reception and discharge activities, a waiting room, and a private room where primary providers can interview, examine, and treat people.
In Alexander's 1977 Pattern Language, the architect and writer advises: “Gradually develop a network of small health centers, perhaps one per community of 7000, across the city; each equipped to treat everyday disease.” Identifying small or modest buildings or parts of buildings with multi-use features, such as several doors for entrance and exit, ground floor access, and a variety of plumbing options, could help to realize the image of “a network of small health centers.”
Before the advent of cheap oil, providers living in neighborhoods delivered care in their homes, and the very sick or those who could not be transported received house calls from physicians and nurses. Hospital care was reserved for the gravely ill and was often an option of last resort, because families were loath to be separated from one another and hospital care was for many people prohibitively expensive. Organizing care within a matrix of walkable locations and within easy distance of one's home or work may even have the potential for making the idea of care less forbidding. Reserving the hospital for the most extensive and demanding care and, once energy descent is fully and inexorably underway, possibly reshaping the hospital for a variety of community roles, may be the most responsible use of resources.
Alexander has also suggested organizing health centers with recreational and educational activities related to good health in mind. Some of our local resources have exactly this level of functionality. Island Fitness, owned in part by CMC, includes fitness training equipment, offers a broad range of fitness and stress reduction exercise classes, operates a spa with massage services, all the while providing physical therapy and rehabilitation to people who are strong enough to use an out-patient facility. Similarly, the Integrative Medicine offices in downtown Ithaca are within easy walking distance of the City Health Club, and a number of chiropractic offices in downtown Ithaca are located near pilates and yoga studios. Viewing these opportunities as part of our local resource and planning in a way that supports groups of services in clustered arrangements is good for the people who need the help and for the people giving it.
Most employers either provide or require a certain amount of on-the-job or continuing educational effort so that the knowledge within the workforce remains current. At this time, healthcare coverage in work settings of a certain size is mandated, and some progressive employers understand and appreciate that employees knowledgeable about matters of health and wellness have made an investment in their own longevity by demonstrating responsibility for their choices. By the same token, most schools offer classes in healthy living, sports and exercise, nutrition, and lifestyle. The person who has learned about his or her health needs and is willing to take steps to maintain a healthy status is an asset to the workplace, to the school, and to the community. Such an individual is also an example of the lessons of prevention taken seriously.
Many people already know much about their bodies. A by-product of our modern lives and the leisure we have includes aspects of self awareness that can lead to healthier states of being. Yoga, t'ai chi, qui gong, and many other martial and meditative arts support health and healthy living. Similarly, recreational and competitive sports have the potential for promoting self-discipline and long-term vigor. Prevention will necessarily be a big feature of healthcare delivery in a post-peak environment. The residents of Tompkins County are already better prepared than many people in the U.S. for the choices related to prevention: primary care, complementary and alternative medicine, regular exercise, sound nutrition, and a holistic perspective on the relationship between the mind and the body inform the lives of local residents.
On the other hand, most of the treatments, therapies, and surgeries we presently rely on as interventions to maintain or improve health require products made largely from petroleum. Under our current system, we take for granted the disposal of used equipment, if only because it's impossible to thoroughly sanitize or sterilize plastic containers and fixtures. In times past, most of the implements of care were made of glass and metal and could be refurbished and reused. Preparing to live with fewer of these adjuncts requires that we re-think our throw-away healthcare culture and take better care of the health we have now.
Much as energy descent will change aspects of care delivery, we can expect climate change to influence the illnesses we are exposed to. For example, as temperatures increase in presently cold climates, microbes and vectors that were previously unable to survive lower temperatures will begin to survive and then thrive. Treating diseases with which we have no experience and no immunities will require flexible and creative approaches, good diagnostic abilities, and an educated response not only from caregivers but also from community members. As is true with many of the illnesses we now confront, new illnesses from other environments often diminish in the face of prevention. In addition, we will need to learn to use netting to protect sleeping and resting spaces, effectively manage snakes and other animal interlopers, and contend with the effects of poisonous or otherwise noxious plants and insects. We can expect a benefit from such accommodations to be the return of better and more regularly used porches protected, of course, against the predations of new pests of one sort or another.
Two specialties in health care are especially well-suited to the delivery of services in a post-peak environment in which unknown illnesses and strained resources prevail. Emergency medical administrators and providers as well as public health officials and providers will be in much demand as energy descent and climate change reshape our world. Emergency medical professionals are already accustomed to the concepts of triage and developing priorities required to confront disasters and the shortages disasters incur. Public health professionals are also continually advised about the changing landscape within the regions that shelter their communities. Both specialties promote interdisciplinary models of care and encourage broad areas of expertise, and both could be called on to organize local efforts to safeguard populations and teach individuals how to respond to the threat of disease. These professionals invariably know how to think about dealing with shortages of supplies and personnel. In making the observations here, I cannot recommend anything more forcefully than maintaining and even adding to our local emergency medical and public health expertise.
While no one wants a diminished level of health care compared to what we enjoy now, most pundits agree that expecting interventions to solve our health problems rather than preventing them at the outset is prudent and less trouble. We can't always outfox our genetic heritage or stop an accident that causes broken bones or some other injury, but there is much we can do to prevent other kinds of injury and illness.
The coupling of preventive and primary care may be the best use of medical resources in the coming age. Promoting the synergies between the two models acknowledges the strength of each while encouraging their interdependence. Hierarchies in any social structure are to be expected, but the hierarchies of medicine have been bad for health care. We will surely need more cooperation and collaboration when we have fewer natural resources; preventive care and primary care are ready allies, even now. In Tompkins County several well-respected primary care physicians and family nurse practitioners seek out collegial relationships with complementary and alternative providers, thereby producing on a local level the integrative medical model increasingly, albeit quietly, under construction all over the world.
Some current technologies may be adapted to energy descent or saved outright due to their utility. One such technology could add to the models of care available in a remote place like Tompkins County. Telemedicine, the use of telecommunications devices to transmit medical information, complete examinations, and conduct surgeries, among other things, has been used successfully in a wide range of care settings. Some teaching hospitals use the technology to extend teaching and learning opportunities to distant sites; some use it to make surgical and other procedures more widely available. For more than 15 years, a few home care and hospice agencies across the U.S. have used telemedicine to make more efficient use of nursing and ancillary services and to allow patients, nurses, and other providers to see one another and to communicate complicated situations without taking on the burden of extra home visits. As the internet becomes more robust and ubiquitous, it is easy to imagine that the current monitor and phone line set-up typically required for telemedicine will be transformed by greater adaptability without much more of an investment in or expectation of increased technology. As energy descent ensues, maintaining the infrastructure required to power the internet will be a multi-faceted asset.
Today residents rely on local specialists or specialists in Syracuse, Rochester, New York City, and out-of-state medical centers for some of the more arcane problems related to health status. Both energy descent and climate change will make travel to far-flung destinations difficult, costly, dangerous, and often impossible. Access via a screen may be the most we can expect when our local medical resources are not enough.
Finally, self care is the model health professionals of all stripes promote at the foundational level. Few “patients” can achieve self care, because once people become patients they're also sick and in some jeopardy of ever resuming a state of wellness. If as a community we aspire to knowing, protecting, and grooming our bodies and minds, we can be full partners in our tenancy here, which will make us all the more capable of managing other aspects of energy descent and climate change. For the purposes of realistic management in an energy-constrained world, self care includes knowing how to evaluate one's needs, adhering to a plan for achieving those needs, and being aware and capable of administering basic first aid, at a minimum.
Health care in the 21st century is a complex service requiring a complex set of skills. We can anticipate that aspects of the discipline will become more basic as energy descent and climate change progress. Residents can do much to prepare for altered expectations by learning concepts of basic care and by participating in planning for healthcare delivery in an energy-constrained environment. Supporting primary care and methods that lead to the prevention of illness, as well as the interdisciplinary model of integrative medicine, are helpful, proactive actions. Similarly, residents can provide oversight by insisting on the security of emergency and public health resources and by taking responsibility for the self care of their families.
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