Recently in health Category

By Bethany Schroeder

Introduction

To many people, health is largely a matter of perspective. In the main, we subscribe to a working definition that includes feeling physically good; able to act and react according to some semblance of a reasonable self image; remaining fit in a passable manner; and weighing in at something near the insurance industry’s norms.

Food security is another matter: some people describe food security as little more than being assured of the next meal, whereas others are unsatisfied with anything less than pantries full of canned and dried goods and well-stocked freezers. Members of disciplines as disparate as nutrition, planning and development, medicine, social justice law, and the armed services have considered the meaning and uses of the term with a view to overcoming the implied warning in its terminology.

Both health and food security are fraught with expectations at social, academic, and governmental/regulatory levels. Both are states of mind as well as physical conditions. Absent either, the human organism eventually dies. In short, health and food security are necessary to life—all life, and in the case of the present examination of the terms, most pointedly to human life. Health and food security are worth consideration because they are basic to life and because they have at all times in specific contexts existed in some imbalance. In general, when it comes to health and food security we expect much and plan all too little.

The author, in search of food security

Food security versus food insecurity

Depending on the audience, experts have defined food security in formal and informal ways. In 1996, participants at the World Food Summit identified the presence of food security as in effect “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.”[1] Participants also emphasized the combined requirements of being able to find and afford both nutritious food and food that meets an individual’s preferences.[2] According to the Bureau of Public Affairs, it is thought across the globe that, quite simply, people are food secure when they can find and pay for food. Under this rubric, families are food secure when the members neither experience hunger nor fear starvation.[3] Furthermore, people with ethnic traditions and socio-religious mandates require that food be culturally appropriate. Many will refuse foods—even when hungry, even when in the midst of a food shortage—that fail to meet their expectations.[1] At least one local source, the Community Food Security Coalition, maintains that “community food security is a condition in which all community residents obtain a safe, culturally acceptable, nutritionally adequate diet through a sustainable food system that maximizes community self-reliance and social justice.”[4]

Regarding the relationship between health status and food security, it may be sufficient to define good health as the ability to withstand the effects of exposure to illness and injury. The connection between nutritious food and health status is, from this perspective, fundamental, whether or not innate. Leaving aside the question of how to educate people to make healthy and nutritious choices, assuring access and affordability becomes a matter of public policy and the generous application of social support.

Also worth noting is the counter-intuitive notion of wide-spread hunger and food insecurity in the presence of abundance.[5] Inequalities in distribution combined with general and pervasive poverty and a lack of knowledge about food preferences and prohibitions can result in food insecurity so endemic that neither individuals nor communities can overcome barriers to supply and access adequate to mitigate the problem.

In the past couple of decades, the terms and circumstances of food insecurity have been the subjects of increasing scrutiny. Citing 1990 research findings, the USDA describes food insecurity as “. . . limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.”[5] What is more, the conditions associated with food insecurity are just those that we expect will result from declines in the availability of energy and the subsequent threats to the status of human health.

Hunger, food insecurity, and the effects on health

Until recently, the absence or presence of hunger was the primary measurement by which many experts assessed food security as it applies to an individual’s well-being. Without minimizing the significance of hunger, researchers recognized that hunger in a household might be an inconsistent problem and might apply primarily to one or more persons without being true of the entire household. Wanting to understand the role of hunger as it relates to food insecurity, researchers and policy makers began to think about food security or insecurity in the larger context of the community and the availability of food in general. Questions that routinely arose included the following:

• What are the circumstances of hunger in a household?
• Who, in a household, experiences hunger, and why?
• What are the effects of hunger in a household?
• What is required to relieve hunger, both temporarily and permanently?

Such inquiries found that hunger is typically the result of inadequate resources to obtain food but can exist when food choices are limited, too. Hunger often affects select adults who may ration food for more vulnerable members of the household. In the presence of food insecurity, hunger can affect everyone, especially the very young and the very old. Effects can include periodic hunger and the potential to develop food insecurity, if a lack of resources to acquire food or the unavailability of food is the cause of hunger. To achieve short- and long-term improvements in relieving routine or chronic hunger accompanied by food insecurity requires that planners, leaders, farmers and other food producers, just to name a few invested parties, develop a systemic understanding of the problem.

As a result of this and associated research, the USDA in particular altered its use of terms related to hunger and food insecurity, and has continued to look for refinements in ways of categorizing and addressing both phenomena. Germaine to this TCLocal article is the realization by USDA and others that the understanding of hunger deriving from food insecurity “. . . results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation [of hunger].”[5] Especially during the past two decades of discussion and investigation, policy makers and those responsible for conducting research and the instruction of the next generation of field and university researchers and educators have come to appreciate the connection between food insecurity and the conditions, manifestations, and ramifications of ill health. Among other things, the implication is that hunger, in addition to being a symptom of food insecurity, is also a part of the panoply of conditions that signal compromised health status.

Undernourishment and malnutrition are two conditions widely agreed to be the results of hunger and food insecurity. Among children, conditions that can coincide with the latter include weight loss, fatigue, stunting of growth, and frequent colds. Studies have shown that undernourished pregnant women are more likely to bear babies with low birth weight, and the babies are then more likely to experience developmental delays that can lead to learning problems.[6]

Iron deficiency anemia is also common among hungry and food insecure children on one end of the spectrum and older adults on the other. In children, the condition can cause delays in development and learning. Children with iron deficiency anemia are also more susceptible to the effects of lead poisoning. In people of every age group, iron deficiency anemia can cause fatigue, weakness, shortness of breath, and irregular heart rhythms, among other symptoms.[6]

Moreover, hunger and food insecurity worsen the effects of all diseases and can accelerate degenerative conditions, especially among the elderly. Hunger and food insecurity create psychological responses such as anxiety, hostility, and negative perceptions of self-worth.[6] In an energy- and resource-constrained world, diseases like malaria, HIV/AIDS, dengue fever, and other infectious conditions from distant places, which experts anticipate will migrate in reaction to changes in weather patterns, can be expected to become more prevalent. More frequent incidents of these and other opportunistic diseases are likely to be reported, resulting in the potential to overburden the ability of any medical or public health system that tries to address the problem(s).[7]

Local considerations in combating hunger and food insecurity

In an energy-constrained future, such as TCLocal envisions in the next 10 to 20 years[8], food insecurity and its consequences are expected to be increasingly common. The combined pressures of a larger population, climate change, reduction in the adjuvant energy required to grow food as well as the increased cost of such energy, and the potential for reduced or altered water resources could all create the environmental circumstances that lead to food insecurity. In fact, simply based on a growing population with the means to purchase choice foods, the demand for food could increase by as much as 50 percent by 2030. On the other hand, researchers speculate that increased demand and falling productivity could create widespread hunger and food insecurity, especially in the poorest communities of the world. All over the world, taking a preventive approach to food insecurity will require that we improve agricultural productivity and make access to markets easier.[9]

The outlook for our region is likely to be similar to that of the rest of the Northern Hemisphere, if not the world. The good news is that many of the residents of Tompkins County have developed an appreciation for the need to husband resources, as well as some of the skills to be effective at the practice. Locally, educators in well-established and informal venues alike have focused on the connection between promoting food security in combination with supporting good health, underscoring that each facilitates the other.

Assessing food security on a local level at this juncture with a view to predicting the potential for future changes will allow for planning and intervention. For example, according to 2009 statistics regarding the perception of hunger in Tompkins County, people across all income levels reported that the problem was widely evident. Twenty-three percent of respondents in the county’s COMPASS survey said that having enough money to buy food was a problem in their own households. The use of local food pantries increased 30 percent between 2003 and 2008. Food stamp use also increased during the same period, with 4,223 households reporting participation in this subsidized food program in 2008 versus 2,288 households participating in 2003. Between 2001 and 2007, increases in reduced-fee or free lunches were noted among school children, with a quarter or more of all students in Groton, Dryden, Ithaca, and Newfield receiving support in the purchase of their meals.[10] Thus even in Tompkins County, where the standard of living is widely thought to be above average, a notable number of households experience hunger and food insecurity.

Though more can be accomplished, much is being done to address the problems associated with declines in health and food security. The services of agencies like the Department of Social Services, Catholic Charities, TC Action, the Red Cross, FoodNet, and others directly address local problems and enjoy an overall reputation for effectiveness. At the same time, the notable array of local Community Supported Agriculture seasonal options, the variety of U-pick and share farms in our area, the small and large market gardens, and the many agencies and local programs that educate people about how to use and preserve food have increased the general awareness of the need to address food security in Tompkins County.

A short list of local access-oriented programs includes emergency food services through Loaves & Fishes and the Salvation Army; the United Way’s Food Pantry Garden in Brooktondale; the school district’s Fresh Food and Vegetable program, which serves elementary age children; and assistance to childcare providers, parents, and pregnant teens through the Child Development Council, just to name a few. The Human Services Coalition’s Information and Referral program and 2-1-1 Connect have also been helpful in directing people to much needed resources, including food resources.[10] Web-based support is available through the Community Cooperative Extension and the locally developed websites of Prepared Tompkins, IthaCan, and Harvestation. As is true in many communities across the U.S., in Tompkins County the internet has the capacity to connect people with resources by way of specific mail lists that promote local activities and community solutions to many problems, including hunger, food insecurity, and the consequences for health.

Increasing awareness of the existence of or potential for hunger among our neighbors and friends has spurred local efforts to find immediate relief. Although considered an unsanctioned method of food collection in some parts of the Western world, gleaning is not uncommon in communities across the U.S. In this region, grassroots efforts to serve and protect the poor among us have been responsible for large local gleaning projects, frequently announced on the mailing lists of Sustainable Tompkins and the Finger Lakes Permaculture Institute, among others.

Local food security is also promoted by community gardens, where area residents not only grow food for their tables but practice prevention and health promotion in the act of working outside. Many local groups, including TCLocal, the Level Green Institute, and Sustainable Tompkins, have called for the development of this readily available solution to the problem.

Local options for enhancing health and food security

At an evening meeting of farmers and others interested in issues related to local food production, one of the farmers responded to the question, “Can the farmers in Tompkins County feed the population here?” with, “No. We can probably provide just 20 percent of the needs of the local community.” Important in this anecdote is 1) the farmer’s frank assessment and 2) that the question arose just four years ago.

Others have asked whether New York State can feed itself[11]. Indeed, in a time of energy descent, when fewer resources are available to grow and transport food, the potential for growing food closer to home, as well as recruiting and supporting local growers, may be among the most important questions to ask. In addition to assessing how much food production is possible locally, planners, growers, and area residents should consider the ways in which each might contribute to the solution rather than merely being part of the problem.

For starters, every yard and container has the capacity to be a food garden of one kind or another. Today the activity might primarily focus on cultivating the skills to grow food, whereas future circumstances may require skills honed to fill the table and the larder. Spending time outside in the garden encourages bone density through the absorption of vitamins. It also helps to build muscles and to keep the body fit and healthy. While not everyone likes to work in the garden, most of us like to eat. Learning to think about food production as a civic responsibility has historical contexts all over the world, as much in Tompkins County as anywhere else.

Legislators at all levels of government could help more of us to be producers rather than only consumers of food. Suspending or discontinuing ordinances that restrict farming, gardening, and tree-crop production could encourage more participation in the food economy, most likely at the informal level. Whether considering food for sale, barter, or personal consumption, reducing the unnecessary barriers to food production that inhibit growers is the first step in ensuring that everyone has enough to eat. Rethinking area ordinances about the management of food and food systems will be necessary to enhancing health and food security in an energy-constrained world. Considerations of what constitutes agricultural land, who can hold it, and how it’s taxed should be topics of discussion at county, town, and city levels of local government.

In general, Tompkins County has an abundance of fertile, versatile land and adequate water supplies to promote the growth of every manner of food that can be produced in this climate. Increasingly significant in the study of agricultural techniques are nutritional outcomes, depending on the quality of soil and its augmentation. Despite many studies and much debate, the jury remains undecided about the relative value of organic versus conventional methods of soil management for the sake of healthy nutritional impacts.[12] Nonetheless, researchers do agree that organic methods produce less environmental stress. At the very least, the absence of additives, typically derived from natural gas, commends organic techniques to the small farmer or gardener in circumstances of energy descent. No matter which methods we use to grow food, we must thoughtfully manage the short- and long-term integrity of the soil if we want to help retain its best characteristics year after year.

So too must we be careful stewards of the region’s ponds, creeks, and lakes. At the local level, the protection of all water resources is a matter directly related to health and food security. The public health department oversees the potability of water, relying on standards set at state and federal levels. Common sense and a basic understanding of interdependencies are enough to show that poor management of our water will affect whether we can grow adequate food, not to mention whether water supplies are safe for our consumption and for consumption by livestock.

Animal husbandry includes the allocation of important food resources, but the practice is presently defined and permitted according to economic standards that we, under circumstances of reduced access to energy, cannot hope to sustain. Owning a cow or a flock of chickens, for example, may not be necessary to every family, yet the availability of milk and eggs locally sold (or shared) and produced might well come to be viewed as a necessary feature of community life.

At the same time, assuring that those who work to grow food, whether formally or informally, have access to hygienic resources makes good sense from the perspectives of safeguarding the talent and skill necessary to effective farming and gardening and to the quality of our food at its source. People need bathrooms and sinks or other hand washing options, especially options that don’t contribute more trash to already overburdened landfills or the use of supplies made from oil or natural gas. We could make facilities more widely available near gardens and farms, and we could manage them locally.

Discussions at NOFA conferences and other similar meetings are reportedly well attended, exhibiting the kind of regional knowledge and sensitivity to local issues that supports asking important questions about food issues and promotes success in approaches to planning that address those issues. In particular, food policy councils, frequently made up of interested professionals, community members, farmers, vendors, and legislators, have proven to be useful in some communities in helping to organize the selection, production, and distribution of food.[12] As noted earlier in this article, a loose coalition of food experts and community organizers in Tompkins County has lately convened to discuss the possibility of an area food council. Among others, issues explored included, first, the activities helpful to improving the local food system via a food policy council, and second, the necessary resources and commitment needed for success.

In this article, I have described just a few considerations related to health and food security. I hope that others will follow up my work with a deeper and more expert examination of the issues. In addition to adhering to the principles that guide TCLocal in its goal of understanding how residents might operate with fewer resources and more sustainable approaches to development, I recommend that we examine first principles of fair access, fair use, and fair expectations regarding health and food security. A healthy, integrated, and self-aware community must learn how to share resources, recognizing that the whole is only as strong as its weakest part.

References

[1] http://www.who.int/trade/glossary/story028/en/.

[2] Nutritional research has shown that social, religious, and personal food preferences play a significant role in maintaining appetite, ultimately influencing the quality of an individual’s diet.

[3] http://www.state.gov/s/globalfoodsecurity/129952.htm#.

[4] http://groundswell-ithaca.blogspot.com/2010/12/working-toward-food-security-in-ithaca.html.

[5] http://www.ers.usda.gov/Briefing/Food Security/measurement.htm.

[6] http://www.frac.org/html/hunger_in_the_us/health.html.

[7] Bissell, R., Bumbak, A., Levy, M., & Echebi, P. (2009). Long-term global threat assessment: challenging new roles for emergency managers. Journal of Emergency Management, Vol 7, No. 1, pp. 19-37.

[8] http://tclocal.org/2010/10/outlook_for_liquid_fuels.html.

[9] http://www.usda.gov/wps/portal/usda/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os_gAC9-wMJ8QY0MDpxBDA09nXw9DFxcXQ-cAA_2CbEdFAEUOjoE!/?navid=FOOD_SECURITY&parentnav=FOOD_NUTRITION&navtype=RT.

[10] http://uwtc.org/compass-ii-20-social-issues-key-findings.

[11] http://tclocal.org/2009/06/can_new_york_state_feed_itself.html.

[12] http://www.foodsecurity.org/FPC/council.html. One of the best Websites I found while completing the background reading for this article, the site is rich in subjects that range from agronomy to wildcrafting, from vitamin deficiencies to nutritional variances among indigenous peoples.

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.

Care facilities

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.

Care models

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.

Conclusion

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.

References

Alexander, C., Ishikawa, S., & Silverstein, M. (1977). A pattern language, p. 255. New York: Oxford University Press.

Bednarz, D. (2007). Medicine after oil. Orion Magazine. Available at http://www.orionmagazine.org/index.php/articles/article/314/.

Bednarz, D. (2008). Energy and the health sciences: a strategic management perspective. Energy Bulletin. Available at http://www.energybulletin.net/print/46146.

Bissell, R., Bumbak, A, Levy, M., & Echebi, P. (2009). Long-term global threat assessment: challenging new roles for emergency managers. Journal of Emergency Management, Vol 7, No. 1, pp. 19-37.

Chamberlain, S. (2009). The transition timeline for a local, resilient future. Vermont: Chelsea Green Publishing.

Jeffrey, S. (2008). How peak oil will affect public health. Energy Bulletin. Available at http://www.energybulletin.net/print/45750.

Vision 2020: Final Report of the Addison County Conservation Congress. Available at http://www.acornvt.org/Documents/Vision2020.pdf. Accessed September 1, 2009.

A Local Health Resource Assessment

By Bethany Schroeder

Through an ongoing application of fiscal resources, professional collaboration, and continuous assessment, the legislative, medical, and social work communities of Tompkins County have created a network of health services that largely complement one another. The degree to which the network remains integrated as peak oil and climate change influence the region will be a matter of planning, depending on the approach the community and its formal and informal leaders take.

The purpose of this overview is to describe broadly the infrastructure available in the County, so as to quantify local medical care, with a view to planning for access to services despite fewer resources. If, as anticipated, travel from one part of the County to another in the next 10 to 20 years becomes increasingly expensive, planning alternatives to present automobile-oriented patterns of care will be the best way to assure a healthy community. Similarly, the cost of producing and distributing required supplies at the end of long supply chains may become prohibitive, either because of decreasing availability of materials from which the supplies are made or because of the cost of transporting them. In short, decisions about developing, using, and husbanding local physical and human resources are necessary if we are to provide health care to residents in an energy-constrained environment.

Almost all medical supplies rely on petroleum for manufacture and transport. Plastics are actually made out of fossil fuels.

Tompkins County Medical Infrastructure and Human Resources

With a population of just over 100,000 people, Tompkins County supports myriad health services, many already integrated into a system of referral sources organized to serve the needs of local people.

The largest health service is also the County’s only hospital, Cayuga Medical Center (CMC), which is also one of the largest employers in the region. Over 250 physicians have privileges at CMC, and they work with more than 1000 staff members, including nurse practitioners (NPs), physician assistants (PAs), registered and licensed vocational nurses, physical and occupational therapists, nutritionists, radiological technicians, and other healthcare professionals and support staff, just to give a few examples. (Most of the 250 physicians noted above and many of the 75 or more NPs in the County have local private or group offices; a small number of physicians have private practices but do not maintain privileges at CMC.) The hospital is licensed for 204 beds but has square footage for many more, even by modern medical standards, and thus could accommodate more people in an emergency. CMC and its outpatient offices report serving 150,000 patients annually, many of whom sought care outside the Finger Lakes region until technological advances in diagnosis and treatment became available at CMC. At present CMC provides general and specialized care across the lifespan; through its multiple affiliations with other medical facilities and schools, CMC can claim with confidence the ability to treat a wide array of human ailments.

Clinic and urgent care services in the County are available through Guthrie Medical Group, based in Sayre, Pennsylvania; through CMC’s urgent care offices; and through the Ithaca Free Clinic (IFC).

The Guthrie Medical Group offers primary and specialty care; diagnostics, including laboratory and radiology services; and supplies, such as medical equipment and oxygen. Patients who select Guthrie can opt for inpatient, outpatient, and emergency care at Robert Packer Hospital in Pennsylvania; most Guthrie physicians are affiliated with CMC as well.

Guthrie is an important local source of home medical supplies.

CMC’s Convenient Care Center provides urgent and surgical care; radiological, laboratory, and imaging services; and sports and rehabilitation medicine. The Center also contracts to provide space to the Veterans Administration of Syracuse, which then offers outpatient services to local veterans. Many of the physicians who work at Convenient Care are affiliated with the hospital and have admitting and attending privileges at CMC. Both the Guthrie Clinic and CMC’s Convenient Care employ dozens of professional, ancillary, and support staff, including mid-level providers such as NPs and PAs.

At the other end of the technological spectrum is the Ithaca Free Clinic, where the County’s un- and under-insured residents receive care three afternoons a week. Staffed by volunteer retired physicians and the occasional NP or PA, IFC achieves its goals with the help of volunteer registered nurses, nutritionists, occupational and physical therapists, and administrative personnel. IFC is one of only two medically integrated free clinics in the United States. Alongside conventional or allopathic clinicians at IFC is a group of volunteer complementary and alternative providers, including a chiropractor, an herbalist, a licensed acupuncturist, and a massage therapist. Apart from simple urinalysis, random blood sugar analysis, and on-site electrocardiography testing, however, IFC offers no technical diagnostic services.

The Ithaca Free Clinic provides primary medical care for more than a thousand uninsured local residents.

Additional resources are available through an array of complementary and alternative medical (CAM) practitioners in the County. Complementary care is designed to complete or to enhance a person’s state of well-being, especially from a holistic point of view that considers the prevention of illness, the promotion of healthy behaviors, and the use of alternative products, such as herbs and oils. Local CAM practitioners include more than 35 chiropractors and 15 acupuncturists. The services of several herbalists are available to the community; others have been trained, may practice informally, and continue to reside in the area. Reflexologists, naturopaths, homeopaths, massage therapists, and other CAM providers practice in various settings in the area, although their numbers are difficult to quantify. Many of these care givers support themselves by way of other skills in order to make a living.

In addition to therapy services available in institutional settings, occupational, physical, and speech therapists work in private local offices. The services of audiologists and social workers are available in the larger institutions and through private offices as well. Similarly, several psychologists and psychiatrists practice locally, some in collaboration with other area programs, some in their own or shared offices. Nutritional services are available privately, through the schools, and through a variety of area programs, including Cornell Cooperative Extension, which sponsors programs that provide counseling, nutritional awareness, and basic education in food safety and preparation.

Cornell University and Ithaca College have student health centers, where students can receive specific levels of care, depending on the school’s resources. Gannett Health Center at Cornell offers medical care, including a full range of diagnostic services, as well as physical and psycho-social therapy services. The Hammond Health Center at Ithaca College provides a similar level of primary care to students, including laboratory and radiology services. Both health centers refer students to CMC for inpatient care, and both have extensive collaborative relationships with care providers in the larger community.

Several skilled nursing facilities (SNFs) give medical and nursing care and shelter to more than 600 area senior residents: Beechtree Care Center, Groton Nursing Facility, Kendal at Ithaca, Lakeside Nursing and Rehabilitation Center, Longview, and Oak Hill Manor. A number of houses for people, mostly seniors, who have conditions that require specialized care include Bridges Cornell Heights, Sterling House, and Claire Bridge. These facilities offer assisted living to residents who have functional limitations up to a specific level, at which time patients might be transferred to other facilities with the capacity to provide higher levels of care. Additional assisted living services are available in Dryden, Newfield, and Trumansburg. SNFs typically maintain most of the equipment needed for basic care, including respiratory, intravenous, and pharmaceutical supplies, whereas assisted living homes are licensed to provide occasional help rather than full support to residents. Housing primarily youngsters and adults with chronic developmental conditions, at least nine Franziska Racker Centers operate in Tomkins County. Limited unlicensed care is available 24 hours a day in these residential settings.

Two free-standing home health programs exist in Tompkins County. The Tompkins County Public Health Department (TCPHD) has programs in health promotion, communicable diseases, immunization clinics, obstetrical and maternal services (MOMS), home health care, and nutritional aid to woman and infants (WIC). Several programs for children with special care needs are available at TCPHD, along with bioterrorism preparedness, a flu hotline, and departments of environmental health, health and safety, and vital records. In total, the staff—registered nurses, physical and occupational therapists, nutritionists, and others—serve hundreds of patients in the community each year. The second local licensed home health agency, Visiting Nurse Services, also provides a range of intermittent services to homebound patients; in addition, this agency has social workers available to its patients. The county has one free-standing licensed hospice, Hospicare. This agency offers home visits and 24-hour care in its six-bed residential unit.

More than 60 dentists practice in the County, including generalists, periodontists, orthodontists, and oral surgeons. Dental hygienists and dental assistants are typically employed in dental offices as well, and most dental practices have most if not all of the equipment required for diagnosis and treatment of dental conditions. Ithaca is also regularly visited by American Mobile Dental, a dental van completely outfitted for every manner of oral care. The service is particularly helpful to people with Medicaid, since few area dentists take state insurance reimbursements.

Several optometrists and ophthalmologists have offices in the County. Such services are also featured in some of the larger retail stores—especially the “big box” stores. At least one area optometrist offers complementary services in his office, and he is recognized among CAM practitioners for his work in alternative therapies.

Dozens of human service organizations operate in the County. As a rule, non-profit organizations are represented by the Human Services Coalition (HSC), are listed in the local 211 directory, and use the HSC mail list to remain current on area social services trends and issues. Referrals to the non-profit social services come by way of service providers or the Information and Referral network housed within HSC.

The development of the HSC has resulted in a highly collaborative model of care within the psycho-social and public-resource oriented community, where the needs of the area’s most vulnerable residents are overseen and addressed. Food insecurity; gaps in healthcare access; conditions challenging to treat, such as addictions, traumatic stress, mental illness, abuse, sexually transmitted diseases, unplanned pregnancies, and AIDS are some of the problems these organizations work to resolve. The agencies that serve the public at this level rely on case management and care management skills to connect people with resources, analyze systems to solve problems, and consider problems and needs in the context of social settings. Many of the organizations mentioned in this assessment are members of the HSC.

Assessment Implications

Unlike some counties in upstate New York, Tompkins County currently offers a wide array of health-related resources and has the infrastructure and personnel to connect most people with the services they need. Nonetheless, according to recent census data, up to 12,000 Tompkins County residents have no insurance, an increase of 2,000 residents over the number just five years ago. Some number beyond these have inadequate insurance, but at the very least a safety net of state programs and a local initiative in the form of the Ithaca Free Clinic are available to them. Funding considerations at the state and federal levels may impact the availability and delivery of care in the near term. As the effects of peak oil and climate change unfold, transportation from home to healthcare facility, as well as the equipment and products available to support the treatment of diseases and injuries, will likely become more difficult and expensive of access. Speculation about the methods by which local health providers and County leaders could address the need to integrate preventive and treatment approaches to care and to consider changes in the allocation of infrastructure and human resources will be the subject of Part II in this series of articles.

References

Bednarz, G. (2005). Public health in a post-petroleum world. Energy Bulletin. http://www.energybulletin.net/node/12158. Accessed March, 2008.

Bednarz, G. (2008). Rising costs and the future of hospital work. Energy Bulletin. http://www.energybulletin.net/43514.html. Accessed May, 2008.

Community health assessment. (2005 & 2007). Tompkins County Health Department. http://www.co.tompkins.ny.us/health/cha05/index.htm. Accessed May, 2008.

McClure, L., & Kaufman, M. (2006). Just health care. 2^nd Ed. Coalition for Democracy of Central New York Health Care Committee.

Tompkins county health department annual report (2007). http://www.co.tompkins.ny.us/health/annual.htm. Accessed March, 2008.