Category Archives: Health Futures

Ageing Genes: Planning for Discontinuous Futures (2000)

Posted on by

By Sohail Inayatullah

Even amidst the “future shock” of the last fifty years, the future has been stable. It has been an image of the future defined by Continued Economic Growth: a suburban home, escape from manual work, a better life for one’s children, a nuclear family along with traditional notions of retirement (birth, student, work and retirement near the ocean/golf course) and working patterns (5 days a week, 9 to 5).

Financial futures – planning for long term security – is quite an easy task when change is similar to the immediate past. In such a climate, irrespective of when one invests in the share markets as long as one keeps on investing, in the long term, things work out. Of course, say the planners, investing should be balanced (some in value stocks, some in growth stocks, some in a house, some in cash) and the sooner you start, the better. Life, critical illness, and income insurance are useful as protection in case the tragedy that usually happens to someone else happens to you.

But in the year 2000, can we confidently assert that the long term trend of this century – of upwardly rising markets, of the move from industrial to post-industrial, of increasing wealth for the top and for the middle class in OECD nations – will continue?

How we saw the future a generation ago

Going back a generation, researchers in a ten nation survey asked 9000 people 200 questions focused on the year 2000. They were asked to predict and prescribe the future (Images of the World in the Year 2000 by Johan Galtung and Robert Jungk). What they saw was the dark side of the “Continued Growth” future. Says editor Galtung: “More sexual freedom, less attachment to families, more divorce, more mental illness, more narcotics and more criminality, a future of highly materialistic, egocentric individuals striving for personal pleasure and benefit.”  What people have experienced is a gap between the image of the future – an endless array of new technologies leading to progress – and the reality of their own, increasingly meaningless lives. They have seen the postmodern future, for Australians, youth suicide is the best indicator of this.

It is this anomie that has historically characterized a time between eras. And this is the big question – not are we between new eras – but what will the new era we have entered look like? Can we plan for such an era? Do we desire a different future than the future we are unconsciously living?

The new era

Will the new era be a rejection of progress and a return to a slower life that is far less complex, far less global, far less dependent on technological solutions to social problems? In visioning workshops conducted in four nations – Taiwan, New Zealand, Thailand and Australia – two futures emerged (Inayatullah, Managing the Future: A workbook). The first is the continued growth scenario and the second is an organic, green future. In this alternative future, technology is still central but relationship with nature, god and neighbors is far more important than getting the new yacht. Capitalism might still be around but it would be, as writer Jeff Gates argues, a shared capitalism with far more economic democracy, with workers owning companies and thus working harder and smarter since they would receive a greater share of the profits.

But the future may be dramatically different than the organic Green or the Continued Growth future. It is not just the sense that something is wrong with the Continued Growth image but the growing prominence of three trends that challenge its unabated continuation.

Ageing. First, an ageing population means retirement pensions are difficult to sustain (the ratio of worker to retiree will dip from the current 3.1 to 1.5 to 1); second, who will purchase stocks when baby-boomers sell for their retirements; third, whose hard work will drive the economy? Immigrants, perhaps, but only if they are let in. Fourth, can we imagine a world with the average age  of 40 instead of the historical 20, where will innovation come from? Another equally crucial question is: will the elderly be happy or miserable?

The facts are not good with depression, ageing related health costs and disability the likely future. In Queensland, Australia the porportion of those over 60 years will increase from 15% in 1995 to 23% in 2031. Already 25% of those over 65 demonstrate functional psychiatric disorders.

Genetics. The discoveries are daily and may mitigate the decline in elderly health. The creation of synthetic DNA, computers that use DNA instead of chips to store information, cloning, designer babies, the delinking of sex and reproduction have occurred or are on the horizon.

And it is not just the science but our own desires that will carry us into an unrecognizable world. Few would object to gene therapy for curing illnesses or preventive gene therapy for fetuses. But the slippery slope will be quick from genetic prevention and genetic health to genetic enhancement, the creation of smarter and taller children. Already Wall Street genetic companies are starting the quick rise upwards, not yet like .com companies but that is the next likely wave. The question is: what type of world are we creating? Can stupid workers be created for housework (with slightly modified brains)? Will it be Gattaca or Mad Max that will result? How different will the double-helix generation be from the .com generation and or the today’s generation x?

To assume that the genetic future is a far away is a huge mistake. With the mapping of human genome soon to be concluded, social engineering on a massive scale is next. Who among your friends has the criminal genes and who the entrepreneurial gene? Will insurance companies give life and critical illness insurance to those with inappropriate genes? Should they? How will prisons be transformed? Are there any industries that will not be dramatically changed by genetic manipulation? And what of sex? Some people will make children the old fashioned way, most will not.  And with germ line engineering, the genetic structure of future generations will be forever modified (eliminating diseases and “undesirable traits) (http://research.mednet.ucla.edu/pmts/germline).

Jobs and work

The jobs that result as well are impossible to forecast. Already, a multitude of job categories are being created that did not exist a few years ago. Profits for companies such as Intel are being created in products that did not exist even a year ago, 80% in one year reports Intel co-founder Gordon Moore.

While certainly genetic counseling will be a boom career, the deeper question is: will there be jobs in the future? Again not a question with a simple answer.  There are three scenarios. The first is: 10% work and 90% don’t. The big issue is: will the 90% get a universal agreed income, a global poverty dole or will they be in technology heaven, the consumers of the endless products created by nano-technology? The second scenario is: 30% work full time, 40% work in contract work and 30% remain unemployed. The last scenario is: full employment. This remains the dream of all liberal  governments but with women working and technology eliminating work it is the least likely, the unrealizable fantasy. With the internet eliminating the middleman  resulting in massive lay-offs of middle managers, the future of work is not bright if you are a typical MBA.

And what will the financial planner do? With highly interactive artificial intelligence (AI) web based programs that work with you, defining and helping achieve your financial goals, why go to a financial planner? Already, many prefer AI psychotherapy plans. AI financial planners – webbots – will be able to instantly and continuously search through the globe for appropriate shares and mutual funds – and other financial instruments- and they will always be on top of the latest tax strategies. The human financial planner will have to have a dramatic value-added edge to compete with the AI planners.

The big question remains: Can a future that is about to be foundationally transformed by ageing, genetics and the internet be stable and secure? Can it be planned for? Or instead of planning for the future is it better to ensure swift responsiveness to a changing future and the development of personal and institutional confidence to do so?

When your financial planner gives you high-growth, medium-growth and slow-growth scenarios for your investments, ask him: what if the world dramatically changes, transforming the assumptions that have made the Continued Growth world, changing how we work, how we age and the very basis of life?

Trends Transforming the Futures of General Practice and Practitioners: Or is there a doctor in your future(s)? (2000)

Posted on by

Presentation to the Queensland Divisions of General Practice, Brisbane, February 11, 2000

By Sohail Inayatullah

 

FUTURES

To begin with, the purpose of futures thinking is only marginally prediction. More important is opening up the future to alternative interpretations. This allows a discussion, a debate, of alternative presents. Basic assumptions of what we believe is most significant, what we think is the true state of affairs, and how best we desire to change the world can thus be questioned.

To understand the future, futurists tend to use a range of methods. These include:

  • Trend analysis – a quantitative approach to the shape of change
  • Emerging issue analysis– the search for issues that have the promise to foundationally society. These issues are often irrelevant to immediate strategic concerns but crucial to map as they can sidetrack any strategy.
  • Scenarios – stories or pictures, considered an easy and elegant way to map the future. Scenarios can be global, operational, convergent or divergent.
  • Visioning – determining the future one desires
  • Anticipatory Action learning – quite the opposite of strategic planning consisting of creating the future through experiments, and then following a cycle of reflection, action, reflection, always questioning and improving the process.

This said what are the likely futures of general practice in the next ten to fifteen years? Which trends are opening up the future and which are constricting what is possible? To understand the future we must find a balance between our personal and collective desires as well as with structure -real economic, political, technological, cultural drivers and forces that are already creating the future. Indeed, while many claim the future five to ten years hence requires a crystal ball, the opposite is true. The short-term future is the known future, forces, giant waves of change, are already underway. While we can ride these forces, little can be changed.

Merely desiring other futures in the short run, while important in setting up alternative action steps, generally can change very little. Thus the need for an expanded time horizon in which real change is possible.

TRENDS TRANSFORMING GP FUTURES

Five trends are crucial: Globalisation, the internet revolution, the genetics revolution, the multicultural swing and ageing. The first two are full blown trends while the latter three are emerging, and will, I believe, create futures that we are unrecognizable to us today.

Globalisation

For the general practitioner what is relevant is that Globalisation leads to:

  1. More and quicker access to news and technological breakthroughs elsewhere. This is true for doctors as well as patients. Moreover, under the pressure of Globalisation, universal definitions of health are far more difficult to hold on to. [1]
  2. The corporatisation of businesses, partly the buying out of national business to global players, but as well the adoption of the corporate business model for all service providers. For small practices, corporatisation usually means vertical integration. At the national and global level, it means the merger of giant pharmaceutical companies. Doctors will have to develop strategies to fend off vertical integration (through strategic alliances) or through setting up of their own national corporation or at the very least ensure that corporatisation occurs on their terms.
  3. Globalisation is also a direct challenge to the welfare state model, in the health field to the idea of universal cover.[2] Whether for ideological reasons (privatization or market forces are more efficient and better meet customers’ needs) or cost reasons (ageing of population, medicalisation of illnesses) universal health care, as achieved in advanced OECD nations, is under threat.
  4. While the debate between cradle to grave versus a mix of private/public or totally private goes back and forth, Australia’s generous model of Medicare is unlikely to continue.
  5. Globalisation also changes the governance context of health futures. It makes national boundaries far more porous. While not eliminating the nation-state, it certainly makes action at the very local level (the shire council), the associative (with local and transnational non-governmental organisations) and at the very global (the entire host of UN families, WHO), far more potent. However the de-evolution of responsibility has generally not come with concomitant funds, thus changing the local-federal power relations and expectations. However, this loss of local funding has been partly solved by an expanding civil society, the gamut of local and international nongovernmental organisations, from Medicine sans Frontiers to Amnesty International.

The Internet Revolution (IR)

Working in tandem with globalisation, indeed, accelerating this process is the .com revolution. While currently this is web-based, very soon this will expand to higher levels of virtualisation. This will lead to the always on, wearable computers, or web-bots. These emergent health bots may take a robotic form or a more virtual form – either a robodoc or an always- present doctors.com.[3]

In a rudimentary form, telemedicine is already current underway in Australia (2000 hours of consultations are conducted monthly)[4] and consists of:

  • tele-assistance, consulting with doctors using email and videoconferencing
  • using nurses to preform simple procedures supervised by video-linked doctors (remote supervision)
  • Access to research data bases as well as potentially a medical records database

The justification and goal of telemedicine is to use technology wisely so that the institutional care costs (21billion dollars of the 46$billion Australian dollar budget) are reduced.[5]

However, we should not be lulled into thinking this is a win-win technology. The internet revolution will take away business for certain GPs. Individuals are already going to doctors.com sites for general informational purposes. Overtime this will lead to therapeutic assistance. Already webmd/Healtheon, the .com business, is a huge business in the US, currently capitalised at 8.5 billion. Moreover, while at a superficial level it appears that the information era means that economies now enter win-win relations (passing on information to another does not diminish one’s own information in contrast to passing on raw materials to others), in reality those who enter the new economy first create infrastructure monopolies or lock-ins. The smart get smarter and instead of diminishing returns there are increasing returns. Earlier entrants into the internet – digital doctor space – will be able to capture attention, visual space, one of the most important characteristics of success in the new economy. They will grow and have an advantage over traditional practices as well as later cyber med entrants.

Moreover, our understanding of cyberspace should not be limited by its current function. For example, in the near term future, sensors will be developed that detect health problems through the smell of breath and alert doctors for early diagnosis.[6]

As the web develops, we can anticipate health-bots or health coaches, that is, always-on wearable computers. They will provide individualized immediate feedback to our behavior, for example, letting us know caloric intake, the amount of exercise needed to burn off the pizza we just ate. They will also let us know the make-up of each product we are considering purchasing, helping us to identify allergies, for example. [7]These intelligence computer systems would be reflexive knowledge systems, learning about us and our preferred and not so preferred external environment.

Writes health futurist Clement Bezold:

Future approaches to heart problems reflect ongoing changes in health care and biomedical knowledge. In 2010, our DNA profile will be part of our electronic medical record, and our genetically based proclivity to major diseases, including heart disease, will be known. There will be sophisticated, low-cost, noninvasive or minimally invasive biomonitoring devices; for example, a wristwatch device will provide very accurate, ongoing information on your health status.

You will likely have powerful in-home expert systems, probably supplied by your health-care provider, which will not only aid diagnosis but also reinforce pursuit of your chosen health goals. These expert systems, or electronic personal guides, will tailor the information to your own knowledge level, interest level, and learning style, as well as those of your family members, each of whom would have a personal electronic “health coach.” If you are genetically or otherwise inclined to heart disease, your coach will encourage specific preventive measures[8]

The assumption here is that 50% of the variance of the causes of preventable premature death is due to behavior (20% genes, 20% environment and 10% is related to medical care).[9] It is this 50% that that the health-bot – the health professional on a wrist – will help us manage. [10]We can always take it off unless insurance companies step in and require their continuous use for cheaper premiums. Of course, geneticists argue that genes play a much bigger role than 20% and it is genomics and germ-line engineering that will have a far more profound impact on our health.

The questions for gps is: will doctors.com and health-bots squeeze traditional practitioners or give them a new way to meet patient’s needs? Can GPs help design the content of these new health tools or will they be passive recipients?

In the long run, this means that there will be smarter consumers who will check on research studies and be able to maneuver in a world of conflicting data and conflicting paradigms. Smarter and more empowered consumers should make the jobs of GPs easier. However, as smart cards and health-bots continue to evolve, their intelligence will certainly reduce doctor’s visits, saving money to the health system but as well forcing GPs to reconsider their role in the health system. GPs, however, will need to quickly become net-savvy, seeing it as a way to communicate with patients especially younger patients raised on the net – the .com generation. [11]

We know that every year 85% of Australians visit a GP – over 100 million GP consultations. Every year these consultations cost 2.5billion aud.[12] And every year other costs resulting from visits to GPs, such as drug prescriptions, tests and investigations, and specialists visits, add up to more than 7billion aud$. The question is: might doctors.com reduce these costs?

Or will health-bots become the new gatekeepers, that is, will the technology in itself become the new middle-man? And if so, will they be able to ensure patients rights, one of the key dimensions of the GPs work. The other dimensions being: business, profession, part of the health bureaucracy, and community centre.

Indeed, we can well see how globalisation and the internet revolution further individualize medicine reducing the probability of the community health paradigm.

A question for GPs is: should they have their own websites or should the Practice have a web kiosk there so that patients can go to doctors.com and get basic information. Should they recommend particular websites? Is it ethical to do so? How can they best use the new technologies and ensure they are not used by them? They will need to use them, already estimates of e-business are to go from 61 million in 1997 to 1.3 billion aud in 2001.[13]

The third revolution is genetics

The first step in the genetics revolution is identifying what diseases one is predisposed to. Next is gene therapy (replacing a defective gene and therefore a disease causing gene with a healthy one). Further sophisticated and quite likely is body part cloning (growing replica parts to replace faulty ones). Combined with the information and technology revolution, we will have hospitals on our wrists, actually, within our bodies.

Genomics thus will identify what genes and what physical of behavioral characteristics (genotypes and phenotypes) are most relevant for determining how to treat a given condition. This allows for customization (the claim interestingly of alternative/complimentary whole person therapies as well).

Will the GP need to become the genetic counselor as well? Or will the GP need to ensure that a genetic counselor is on board?

Leroy Hood, William Gates Professor of Biomedical Sciences and the founding Chair of the Department of Molecular Biology at the University of Washington, believes that overtime we will be able to determine what genes or combination of genes cause certain types of behavior.[14] However, the genetics revolution’s full potential lies with germ line engineering, which modified or manipulates the human DNA, for example by altering the DNA of an unborn child in order to eliminate or decrease a predisposition towards a given disease. Germ line engineering can as well pre-select ideal sperm and eggs for fertilization, thus affecting the germ lines of generations to come.[15]

The mapping of human genome also transforms the nature of science, making it global and discovery-based instead of hypothesis-based. It also changes biology from its historical machine metaphor to an informational metaphor. There appear at this stage few limits with science fiction even too timid. Already the first synthetic DNA was created by scientists at the University of Texas. Researchers are “planning to create a series of designer bugs, with super efficient mechanisms for infecting target tissues such as cancer tumors, and then killing them[16]

And if nano-technology delivers what it promises than our entire bodies will become a pharmaceutical factory, reading to detect, diagnose and react to imbalances, says Bezold.[17]

The claims of the Foresight Institute headed by Eric Drexler are equally grand[18]

  • A mouthwash full of smart nanomachines could do all that brushing and flossing do and more, and with far less effort—making it more likely to be used. This mouthwash would identify and destroy pathogenic bacteria while allowing the harmless flora of the mouth to flourish in a healthy ecosystem
  • Medical nanodevices could augment the immune system by finding and disabling unwanted bacteria and viruses.
  • Medical nanodevices will be able to stimulate and guide the body’s own construction and repair mechanisms to restore healthy tissue
  • Viruses can be eliminated by molecular-level cellular surgery. The required devices could be small enough to fit entirely within the cell, if need be. Greg Fahy, who heads the Organ Cryopreservation Project at the American Red Cross’s Jerome Holland Transplantation Laboratory, writes, “Calculations imply that molecular sensors, molecular computers, and molecular effectors can be combined into a device small enough to fit easily inside a single cell and powerful enough to repair molecular and structural defects (or to degrade foreign structures such as viruses and bacteria) as rapidly as they accumulate. . . .There is no reason such systems cannot be built and function as designed.”[19]

Multiculturalism

The fourth trend can be termed loosely the multicultural trend. By this I mean (1) the social construction of medicine movement, for example, mapping how diseases are named, called and treated variously in different nations. (2) The move toward alternative medicine or complimentary medicine, primarily drawing on Chinese and Indian traditions of meditation and acupuncture but as well less accepted alternatives such as homeopathy (from Germany).

The data is stunning. In the US, a Harvard Medical School Study reports that 64% of medical schools offered elective courses in complementary medicine.[20] The study also reports that one in every three American adults uses such alternative treatments such as chiropractic, acupuncture and homeopathy. They assert that: “patients see conventional medicine as ineffectual, too expensive or too centered on curing disease rather than maintaining good health.”[21]

In Australia, the estimate in a 1993 study is 621million aud for alternative medicine and 309 million for alternative therapists. [22]This compares with 360 million aud for all classes of pharmaceutical drugs purchased in Australia in 1992/93.[23]

Users tended to be female and better educated. But what accounts for this? Is it the deficiencies in conventional care? And what accounts for this when one can question the paucity of sound safety and efficacy data, ask many GPs.

An article in the Medical Journal of Australia finds that Victoria over 80% of general practitioners have referred patients to alternative therapies. 34% are trained in meditation, 23% acupuncture and 20% herbal medicine. Of particular interest is that nearly all GPs agreed that acupuncture should be funded and 91% believe hypnosis should and 77% believe meditation should and 69% for chiropractic. 93% believe that it should be part of the undergraduate core curriculum.[24]

Doctors worry about the professionalism of alternative practitioners as well as scientific studies supporting them. It is likely that the therapies supported by doctors are those with strong empirical evidence, for example, Dean Ornish’s focus on life style changes (diet, stress management, personal growth, reducing social isolation and exercise) has shown that heart disease can be reversed. A major insurance company pays for individuals to attend his program.[25] Data around the world shows interest among GP increasing as well as by users.

However, what may account for the interest and use in alternative therapies is that they empower individuals as alternative therapists tend to spend greater amounts of time with users and attempt to customize therapy. This is the suggested by George T Lewith, Honorary Senior Research Fellow and Honorary Consultant Physician, School of Medicine, University of Southampton, United Kingdom, in his review of the literature on complementary medicine.

He writes: [26]

Disenchantment with conventional medicine is not necessarily the reason why patients turn to CAM. One suggestion is that patients are increasingly knowledgeable about CAM and seek a more egalitarian process within the consultation. It has been confirmed that patients seek CAM because of an intuitive feeling that it could offer them a more appropriate medical model for their illness. Patients may therefore not be seeking proof of efficacy of particular treatments, but meaning and context for their illness, thus allowing them the freedom to benefit from therapeutic consultations within their chosen milieu. Why should we impose our medical model on patients? Their use of CAM may be their process of empowerment, which in turn allows them to contain and manage their chronic illness. It is perhaps difficult for those of us educated within the conventional medical system to allow our patients the freedom to make such journeys in a truly egalitarian manner.

Support for a model more in tune with the Australian population may also come from the changing demographics of medical students in Australia. There will be more students from a rural background, more from an Asian background, but most significantly admissions policies are now being expanded to include the qualities of communication, tolerance, insight into others’ worldviews, and commitment to patients and their interests as a priority.[27]

Ageing

There is a fifth trend that is ageing, suffice to say it will be dramatic. While genomics, health-bots and alternative therapies may make us healthier, the data generally does not look good for the aged.

The average person is sick or disabled for nearly 80 percent of the extra years of life he or she gains as life expectancy rises. [28] Health expenditure for Australians over 65 is already four times higher than for the rest of the population. The World Health Organization estimates that by 2020 depression will be the leading cause of “disability adjusted life years“ dramatically increasing the demands for psychiatric health services for young and old. [29] The aged, particularly those removed from family and community, will be especially prone to mental illnesses. In Queensland, Australia the proportion of those over 60 years will increase from 15% in 1995 to 23% in 2031. Already 25% of those over 65 demonstrate functional psychiatric disorders.[30]

The financial implications will be tremendous as well – the retiree to worker ratio will go from the 3 to 1 to 1.5 to 1. Who will buy the stocks when baby boomers sell for retirement as there is no age cohort of that size and income level to follow? [31]How will society react to the average age going from 20 to 40?[32] Where will innovation come from?

Moreover the WHO reports that while ageing is dramatic problem so the global teenager. By 2025 the teenager cohort will have grown by 252 million from two thousand million in 2001.[33]

THE CHOICES AHEAD

Given these futures what should the GP do. There are a few distinct options:

  1. Multi-door health community centre which has a high tech component, a genetic counselor and complimentary medicine. While GPs might remain the gatekeepers, they will have to augment their understanding of the Net, becoming knowledge navigators. However, GPs will have to focus as well as on what technology cannot give – warmth, human understanding and empathy – as well as what some alternative therapies cannot give either, tough, rigorous analysis. It is this multiple function in the context of respect and authority that will GPs ahead of the curve.

The challenge will be to find the value added, to anticipate the changing health needs of citizens instead of assuming that patients will be like yesterday’s patients. We already know that generation x is more aspiration driven concerned about the environment and the community than previous generations.[34] Indeed, what shows up consistently in research around the world on preferred visions of the future is that individuals, especially in the West, have a great need and desire for community, for interconnection. [35]Individuals want to believe and feel that the GP is not far away but part of their community. GPs that can best develop the multi-door health center in the context of community medicine will prosper.

  1. Become or remain a mass provider, the bulkbilling scenario. This in the short run might be the way to go but health-bots and the internet are likely to reduce the profits on the mass market health business. The mass market health care dollars might go to the new technologies. Especially as the patient-in, patient-out system appears to be what users do not want. However, it is cheap. The question is: will it retain its value for money? The answer to this question is partly based on what type of economy and health system Australia will have? Will it manage to retain universal care? In any case, for the medicare system to survive, there will have to be some level of internet technology as well, clicks and mortar, and the rapidly ageing and not necessarily healthy (but possibly with genomics and nano-technology around the corner) age-cohort.
  1. Find specific niches not being met by doctors.com, the alternative system or genomics. Or excel at one of these niche areas, that is, become the best possible GP knowledge navigator, It might also mean finding new partners, expanding beyond the federal or state levels to international non-governmental health organizations – the global third sector. Or focus on specific demographic groups – the global teenager and the aged who will need extra care and find out what their specific needs are. This also means designing waiting rooms in practices to reflect their ideals.

The question is: will these trends impact the three most common reasons for people going to their GPs (prescriptions, coughs and cardiac check-ups) Yes or no. What new reasons might they go to GPs for, new diseases?

What this means is that GPs will have to reinvent themselves, discerning what role they desire for themselves in the future. They will need to ask what level of technology are they familiar with, can they adapt to? Can they become knowledge navigators? Can they use the new technologies to increase their own quality of life, using the Net for seamless administration, so that their hours can be more flexible? Can they enter into dialogue with complementary medicine or at least begin to listen carefully to patient’s concerns about their treatment, that is, about their body-mind-spirit-environment-community needs?

If GPs are unable to reinvent themselves and meet the changing needs of their patients then one future is clear: general practitioners will come to be considered as quaint alternative medicine practitioners – the definition of general practice will have changed.

CONCLUSION

If we go back a century or even 30 years, we know that changes in science and technology have been tremendous. There is no let up in sight. In such an environment, trying to forecast the future accurately is a mistake. Determining alternative futures is a step forward as worst case and best case scenarios can be developed. Scenarios based on different drivers – technology, values, economics – can be explored. But more important than scenario planning is developing institutional foresight, the capacity to respond to changing needs, to create a multicultural learning and growing organization, community. GP organizations, state divisions will need to swiftly embark on creating health learning organizations that exemplify the type of future they want.

[1] See, Which-doctors diagnose us: Medicine still tribal in our high-tech era. The Sunday Star-Bulletin and Advertiser (Honolulu, March 12, 1989), d-2. Noteworthy is: Lynn Payer, Medicine and Culture.

[2] See, Roy Moynihan, Professor warns of Medicare’s ultimate demolition, The Australian Financial Review (February 17, 2000), 5.

[3] For more on this, see bochemist and medical journalist Alexandra Wyke’s 21st Century Miracle Medicine: RoboSurgery, Wonder Cures, and the Quest for Immortality (Plenum, 1997). Writes Wyke: Surgey will depend not on the steady hand and experience of the doctor but on devices such as the recently invented ROBODOC, combined with new imagery technology and computers that essentially make flesh and bone transparent in 3-D images, allowing machines to make cuts or dissolve tumors and blockages in exactly the right place.

[4] See, Call the doctor online, The Sunday Mail (January 2, 2000), 7. Smartcards are already used by the USA army where soldiers carry their medical history on a comuterized dogtag. See: www.coh.uq.edu.au at www.health.qld.gov.au/qtn

[5] ibid.

[6] Sausage Part of World Forum, The AustralianIT, (February 8, 2000) 55.

[7] See, for example, Sohail Inayatullah, Eco-bots in you future, The Age (forthcoming, 2000).

[8] See Clement Bezold, Will heart disease be eliminated in your lifetime? The best of health futures, Futures Research Quarterly (Summer 1995) and The Future of Complementary and Alternative approaches in US Health Care. Institute for Alternative Futures, 1998.

[9] Ibid, Clement Bezold, Will heart disease be eliminated in your lifetime?, 30.

[10] See, for example, Mike Hollinshead, Alternative Futures for Health Care in 2018. Available from Facing the Future. 150003, 56 Avenue, Edmonton, AB, T6H 5B2.

[11] See Heather Gilmore, Younger shoppers opt for the Net. The Courier-Mail (February 21, 2000), 6. Gilmore reports that the number of young people on the Net has tripled in the past year in Australia.

[12] See, press releases and reports from, Australian Institute of Health and Welfare. http://www.aihw.gov.au/

[13] NOIE, E-commerce Beyond 2000. See, Mark Hollands, Internet dreaing drives dot.com fury, The Australian IT (8 February 2000), 51. Also see www.economist.com for the latest data on the new economy.

[14]See: Celebrated biotechnologist Dr. Leroy Hood addresses attendees, Humanity 3000 News (vol. 2, No. 2, 1999), 1 and 7.

[15] See: http://health.upenn.edu/~bioethic/webget/archives.html

[16] The Sunday Times in the Australian, January 25, 2000, pg. 1.

[17] Bezold, Will heart disease be eliminated in your life time, 38.

[18] See the website: Unbounding the Future: the Nanotechnology Revolution – www.forsight.org see, Robert A. Freitas: Respirocytes – A Mechanical Artificial Red Cell: Exploratory Design in Medical Nanotechnology at http://www.foresight.org/Nanomedicine/Respirocytes.html

[19] Ibid, www.forsight.org

[20] Yahoo News, Harvard Medical School Study, September 1, 1998.

[21] Ibid.

[22] Maclenan AH, Wilson, DH, Taylor, AW, Prevalence and cost of alternative medicine in Australia, Lancet, 1996, March 2: 347(9001): 569-73

[23] ibid. Also see, Health Harmony, The Sunday Mail (January 2, 2000), 7.

[24] Marie V. Pirotta, March M Cohen, Vicki Kotsirilos and Sstephen J Farish, Complementary therapies: have they become accepted in general practice? MJA 2000; 172: 105-109.

[25] Clement Bezold, Health Care Faces a Dose of Change, The Futurist (April 1999), 30-33.

[26] See: Complementary and alternative medicine: an educational, attitudinal and research

challenge: We need to understand more about these treatments, why they are being used, and what makes them effective. MJA 2000; 172: 102-103

[27] New breed of doctors on the way – www.aihw.gove.au/releases/1998/csams89-96.html. Accessed January 2000.

[28] Beth J. Soldo and Emily M. Agree quoted from the USA Population Reference Bureau’s bulletin, American’s Elderly in Cheryl Russell, American Demographics, March 1989 v11 n3 p2(1).

[29] www.who.org, See, World Health Organization, The Global Burden of Disease, 1996. http://www.who.int/.   See, Caring for Mental Health in the Future. Seminar report commissioned by the Steering Committee on Future Health Scenarios. Kluver Academic Publishers, Dordrecht, 1992, 315. See as well: The Global Movement for Active Ageing. http://www.who.org/ageing/global_movement/index.html.

[30] “To a Queensland Disability Policy and Strategy,” DFFCC, 1997, 12 (Discussion Paper) quoted in Ivana Milojevic, Home and Community Care Services: Generic or Discriminatory, HACC Action Research Project. Report to Catholic Social Response, Auspicing Body, 1999, 35.

[31] See Peter Peterson, Gray Dawn. New York, Random House, 1999.

[32] See Sohail Inayatullah, Ageing Futures: From Overpopulation to World Underpopulation, ” The Australian Business Network Report (Vol. 7, No. 8, October, 1999), 6-10.

[33] www.who.org/hpr/expo/futures11.html. Accessed January 2000. WHO Health Futures – Major trends shaping health.

[34] See www.pophouse.com.au – the work of Rosemary Herceg. See, Future News, GenXers: Quiet Revolutionaries (August, 1999).

[35] See, Sohail Inayatullah,Youth Futures, in Jennifer Gidley and Sohail Inayatullah, Youth Futures. Manuscript in preparation.

Aging Populations – From Overpopulation to Underpopulation (1999)

Posted on by

By Sohail Inayatullah

As the world welcomes passenger number six billion – symbolically chosen by Kofi Annan to be a baby Bosnian from Sarajevo – the debate on overpopulation heats up. Concern over the carrying capacity of the Earth, resource use of the rich, and fear of billions of “others” at immigration gates consistently make population a high ranking world problem.[1]

Delivering contraceptives to the teeming masses is the solution most often raised. Others point to poverty, seeing population as a development problem, not as a trait of “impulsive races.” Still others go deeper, examining women’s power, their control over the future, their bodies. It is concern for the future, that is, one’s social security, of who will take care of oneself in one’s older years, that is seen as a decisive variable. While most states in India have high birth rates, Kerala does not, largely because feudalism has been overthrown and a stable social security system, a stable view of the future, created.[2]

But, there is evidence that instead of overpopulation it will be underpopulation that will be the world’s biggest world problem, first in the West, and then most likely throughout the world. Only nations that have high immigration in-takes and can make the switch from a youth economy to an old person’s economy will survive. This will mean among the biggest changes in human history – pensions, growth economies, 9-5 work schedules, student/work/retirement life pattern and male domination – all will have to end if we are to succesfully navigate the agequake ahead.

Writes Paul Wallace, author of Agequake, historically “we have been remarkably young. Our average age has been around 20 or less. But in the current generation’s lifetime, the average age of the world will nearly double from 22 in 1975 to 38 in 2050, according to the UN’s latest projections issued at the end of 1998. Under another projection, it could reach over 40 as early as 2040. Many countries will reach average ages of 50 or more.”[3]

Not only is the population pyramid about to flip but populations in Europe are generally poised to plunge on a scale not seen since the Black Death in 1348. “An extraordinary crossover is already starting to occur as older people outnumber younger people for the first time in human history. In the early twenty-fist century, this tilt from young to old will take on a new dimension. It will go hand in hand with the onset of population decline in many developed nations as they experience the first sustained demographic reverse in centuries.”[4]

But this is not just a Western trend, indeed, because of the speed of the demographic slowdown in the developing world, it means that “they will age much more quickly than the West,” says Wallace. In twenty years’ time, China will be one of the most rapidly ageing societies.[5]

The worker to retiree ratio

While many of these changes will be obviously positive, longer life (by mid-century there will be over two million centenarians compared with 150,000 today)[6], healthier life styles, less childhood deaths, and falling number of young people (which means falling crime rates), others are not so positive. Who will pay for the retirement benefits of the older population? This is especially important after 2010 when the ratio of the working age population to old dependents will decrease. And over the next thirty years the ratio of workers to retirees on pension in industralised nations will fall from the current 3-1 to 1.5 to 1. How will societies stay rejuvenated with new ideas? Would we have had a personal computer revolution if youngsters like Steve Jobs were not there to challenge authority and create new products? And what of the Internet.com revolution and the associated changes in corporate culture and organizational culture? Of course, the definition of ageing will change, and older people may become much healthier than they are now, but this does not solve the problem of dependence on the young for economic growth. And what will happen when those purchasing stocks in the 1980’s and 1990’s begin to sell them 20 years later to pay for their retirement? There will be no age-cohort to purchase them as the baby boomers have currently. Will we enter a long term bear market and thus possibly a long term economic depression? Will the demand problem be worsened by the continued delinking of the finance economy from the real world economy of goods and services, of cyberspace from manufacturing and investment space?

But what is the cause of the ageing of society? Two factors. First, we are living longer and second, birth rates are falling. “In the late 1990’s fertility rates are already at or below replacement level – 2.1 children per woman – in 61 countries with almost half the world’s population,“ writes Wallace.[7] And so on, even nations like India and Indonesia are likely to fall below this level.

Along with ageing, there will be a genderquake. In the West, children are being postponed as women focus on their careers, this brings down fertility as there is a strong link between a woman’s age at first birth and the average size of her family. Also many more women are not having children at all. In contrast, leaders in the developed world are urging women to produce more children, Japan is even trying to convince the salaryman to spend more time at home, play with the children, make his wife’s life easier, so she will have more children. While this does not mean patriarchy in Japan is under any threat – structural changes are unlikely – it does mean women’s value will be enhanced.

Iceberg ahead

The population pyramid is reversing. Populations are declining, especially in rich nations. Populations are like supertankers, it takes forever to turn them around, but when they do, the changes are dramatic. Europeans have not noticed the population decline because of immigration, high fertility in the past and declines in mortality, but in reality birth rates are plunging in reverse. Pete Peterson in his book, Gray Dawn, describes global ageing as an iceberg. While it is easy to sea above the waterline, it is far more difficult to prepare for the wrenching costs … that promise to bankrupt even the greatest powers … making today’s crisis look like child’s play.”[8] One solution for the West is immigration. Already California is set to become a majority minority state. The USA will become the second largest spanish speaking nation in 2020. But there are danger signs as generally older Californians will be caucasian and rich, while younger one’s will be hispanic and poorer. The question is not will California secede but which California will secede? Writes, Pete Pederson:

“Perhaps the most predictable consequence of the gap in fertility and population growth rates between developed and developing countries will be the rising demand for immigrant workers in older and wealthier societies facing labor shortages. Immigrants are typically young and tend to bring with them the family practices of their native culture – including higher fertility rates. In many European countries, non-European foreigners already make up roughly 10 percent of the population. This includes 10 million to 13 million Muslims, nearly all of whom are working-age or younger. In Germany, foreigners will make up 30 percent of the total population by 2030, and over half the population of major cities like Munich and Frankfurt. Global aging and attendant labor shortages will therefore ensure that immigration remains a major issue in developed countries for decades to come. Culture wars could erupt over the balkanization of language and religion … electorates could divide along ethnic lines.”[9]

Higher Productivity

A second solution is increasing productivity, working smarter. While the convergence of computing and telecommunications have not shown immediate gains, it is early days yet. The problem of fewer young people working will not be a problem since they will be able to produce more wealth. And even if the Internet revolution does not lead to higher productivity, the real explosion may come from the convergence of genetics research and computing/telecommunications. Productivity could be enhanced through first, genetic prevention, second, genetic enhancement (of “intelligence” “typing speed” “language ability”) and finally, genetic recreation. It is the latter that is is the bet for the right wing in developed nations as this guarantees the survival of a shrinking “white” population (not caucasian since south asians are counted as caucasians in Western statistics), keeps their place as dominant caste. Genetics with nano-technology could go a step further, ending scarcity, and at the same time, ending economic advantage and one of the primary reasons immigrants leave their home nations in any case.

The agequake is predictable since projecting the future age structure of a population can be done with a great deal of certainty (barring asteroids, pandemics, etc). Demographics also can predict changes in behavior since one is more likely to migrate in one’s 20s, one is more likely to vote conservative in one’s 50s (when one has property to conserve, and when one is concerned more with crime and order and less with freedom and social justice). Wallace also points out that membership in one’s generation is significant in determining one’s life chances, but not in the ways one thinks. For example, if you are born in a baby boom year there will be more competition throughout your life, while if you are born in a baby-bust year there will be less competition for work, marriage partners and houses.

Surviving the agequake

How can one personally survive the agequake? Firs, it is crucial to think in the long term, the very long term. Second, it is important to buy and sell in products and services that are based on ageing. Equally crucial is to think in terms of products which baby boomers will be eager to purchase so as to remember their youth – the nostalgia factor .Third, the future will be multicultural, rainbow societies with diverse identities. Already the buying power of latinos in the US is larger than Mexico’s economy.[10] Just as internet stocks took off, in the not too distant future, ageing-related stocks might as well. Retirement homes for retiring babyboomers in developing countries will probably also do well as they will want to move to places where their strong currencies buy more, and where the idea of community still flourishes. It is unlikely that virtual communities will provide the feeling of belonging that elders will need.

Which countries will be the winners and which the losers? Because of immigration the US will retain its power as will England. Because of its relatively young population, Ireland will also do well. However, Gemany and Japan will be losers because of “falling working-age populations.” Indeed, the crisis that Japan is emersed in is partly a crisis of ageing, it no longer has a favorable demographic structure for economic growth.[11]

All this – coupled with advances in genetics, life extension – may lead to a new age. However, not all see ageing as so rosy. Once they make it to old age, currently few people escape long-term health problems. Beth J. Soldo and Emily M. Agree of the American Population Reference Bureau argue that in developed nations such as Canada and the US, as the elderly population grows due to life expectancy gains and the ageing of the huge baby-boom generation, there will be many more sick and disabled old people.[12] The average person is sick or disabled for nearly 80 percent of the extra years of life he or she gains as life expectancy rises. Health expenditure for Australians over 65 is already four times higher than for the rest of the population.

The World Health Organization estimates that by 2020 depression will be the leading cause of “disability adjusted life years“ dramatically increasing the demands for psychiatric health services for young and old.[13] The aged, particularly those removed from family and community, will be especially prone to mental illnesses. In Queensland, Australia the porportion of those over 60 years will increase from 15% in 1995 to 23% in 2031. Already 25% of those over 65 demonstrate functional psychiatric disorders.[14] For ageing to be a bright future not only will society’s economic and social structure have to change but medical developments in life extension will have to materialise, otherwise we will live in a future where the elderly will be sick and marginalized, used on television ads to raise money for charities, just as Third World children are today.

At a macroeconomic level, immigration will solve some of the West’s problems but in-take will have to increase by ten times the current amount and be sustained for the West to survive the the burden of taking care of an older population. In the long run, India, Brazil and other slow-ageing societies will do the best. Worse off will be Russia – and others parts of the former USSR – which is in the midst of a demographic crisis as Russian men are dying in middle age. Russia does not have generations of prosperity to soften the shock of the agequake. However, Russia could take advantage of the new modern information technologies especially as the current generation is being born without the mental blocks of the Soviet era. But for this to happen, mafia-ecomomics will have to end, and a predictable future for investment and shared distribution created.

As the developing world becomes more important, international organizations will, to survive, have to include memberships from these nations There will thus be a new world order, in which an “ageing, sluggish West is ringed by more youthful and economically buoyant countries,“ says Wallace.[15] The UN security council, international finance agencies, security alliances are all likely to see their memberships change. Alternatively Western nations and institutions could decide to go it on their own creating a Fortress/Castle West with “high gates and big dogs.“

Asians will have to change as well, becoming more multicultural. As the age pyramid bulges at the top, filial piety will be one of the first values to go. Young people will want their due since they will be scarce, and there will be too many of the elderly to take care of. The elderly will probably use religion or the state – gerontocracies – to maintain power, while the young will search for new symbols (the Net) and new social movements (alternative modernities, neither West nor East) to lay their claim on the future.

Old versus young

Generational wars is the likely future especially in those nations where pension schemes have not been reformed. In the West, writes Wallace, “The old will use their voting power to insist that younger workers fork out to pay for their pensions. But the young will resist with their economic power by pushing up real wages for services that the old have to pay and evading contributions wherever possible, so that the gap between the legitimate and the black economy grows even wider.”[16] Medicare will continue to be severely challenged. Non-essential medical services will be shifted away from the https://j-galt.com/klonopin-1mg/ State. In the long run, there might be a return to childrearing as patriotic duty, of course.

Reforms will be needed. Reforms will have to tackle the fundamental mismatch between people’s desired mix of work and leisure and what is actually on offer in the workplace. The present system crams work into people’s middle years, making children even more of a burden – so helping to create the agequake – while creating a surfeit of leisure in later years. Women are heavily penalized if they want to work part-time to enable them to look after their children, while older workers are not usually offered a reduction of working hours in their fifties and sixties. For their part, older workers are not generally prepared to accept lower earnings, even if this reflects the reality of their declining productivity.[17] We are accustomed to the elderly increasing in stature, in wisdom, since historically so few have survived, but with this about to turn over, wealth and wisdom is unlike to correlate with ageing.

While some policymakers are beginning to consider the future needs of the aged – housing, transport (the aged like youth tend to have more accidents), healthcare – recognizing that most likely these systems will be severely taxed, few have begun to understand that the entire current economic and cultural system has been based on young people working, on a normal population pyramid, on a growth-oriented economic system. We have never seen a society where the pyramid is flipped. Will immigration save the day, or will technology, the Net, Genetics or Nano (making labour far less important)?

To survive the agequake, our basic structures of work/leisure/family structures will have to change. The old pattern of student, work, retirement, death will have to transform, more flexible patterns will have to be set up to combine work and play, and the rearing of children, that is with taking care of society’s demographic future. While this will be one aspect of the needed change, in fact, the entire (endless growth) capitalist system will have transform, nothing less will be able to adequately resolve the tensions ahead.

We have historically lived in a world where the average population was young. This is about to reverse itself. The entire industrial and postindustrial system has been built on certain demographic assumptions of when we work, when we reproduce, when we retire; this is all changing, and we are not prepared.

____________________

Sohail Inayatullah recently turned 42 He is a political scientist/futurist, co-editor of the Journal of Futures Studies and New Renaissance and author/co-editor of ten or so books. In 1999, he is professor, International Management Centres, Unesco Chair, University of Trier, and Tamkang Chair, Tamkang University. He is currently editing a book titled Youth Futures – s.inayatullah@qut.edu.au.

[1] See, for example, www.overpopulation.com or
[2] For a review of some ageing scenarios, see: Edward Schneider, “Aging in the Third Millennium,” Science, (Feb 5, 1999 v283, 5403), 796.
[3] Paul Wallace, Agequake, Riding the Demographic Rollercoaster Shaking Business, Finance and Our World. London, Nicholas Brealey, 1999. From the preface.
[4] Ibid., 3.
[5] Ibid., 4.
[6] Ibid., 20.
[7] Ibid., 5.
[8] Peter Peterson, Gray Dawn. New York, Random House, 1999. Also see: http://webhome.idirect.com/~carcare/thoughts/aging.htm. Peterson writes: A little understood global hazard – the greying of the developed world’s population – may actually do more to reshape our collective future than deadly superviruses, extreme climate change or the proliferation of nuclear, biological and chemical weapons.
[9] Peter Peterson, “Gray Dawn: The Global Aging Crisis,” Foreign Affairs, January/February 1999, 42-55.
[10] Wallace, Agequake, 10. Also see, The Economist, America’s Latinos. 25 April 1998.
[11] Ibid., 172-180.
[12] Beth J. Soldo and Emily M. Agree quoted from the USA Population Reference Bureau’s bulletin, American’s Elderly in Cheryl Russell, American Demographics, March 1989 v11 n3 p2(1).
[13] See, WHO, See as well: The Global Movement for Active Ageing. http://www.who.org/ageing/global_movement/index.html
[14] See Ivana Milojevic,
[15] Ibid., 204
[16] Ibid., 211.

[17] Ibid., 218.