Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is at www.thevirtualpediatrician.com.

"The future is here. It's just not widely distributed yet" Bruce Toganizzi

There have been two dominant memes of the 20th and now early 21st centuries, and they fundamentally oppose each other. On one hand, we have a global techno-euphoria, very pervasive, spurred on by post Second World War optimism, found in Star Trek, the Jetsons, and nearly everything Disney. On the other hand, we have the stubborn persistence of Thomas Robert Malthus, who in the late 18th and early 19th centuries formulated a fundamental rule of socio-economic behaviour that still applies today. Malthus stated that the growth of population, if unfettered, is always faster than the growth of the resources which sustain it. Global appetite, in other words, always exceeds global supply.

Techno-euphoria is about finding better living through technology. Malthus is about limits. In my world, it is clear that how this tension plays out will fundamentally change health care.

While change is an intrinsic part of our society, there are some forces that stand out as dominant. Demographic shift is one; our patient population is getting older, and therefore medically more needy, and so are our caregivers, who are retiring in record numbers. Those that are left don't like working 80-plus hours per week anymore; we are therefore less productive as well. The numbers of doctors in Canada hit a peak in the 1990s, the number of nurses is peaking now, and there is no new baby boom in the pipe to supply our future needs.

Peak oil is another; health care is entirely dependent upon cheap readily available oil not just to move patients to care, but in the production of supplies and drugs, to light and heat our buildings, cook our food, autoclave our instruments, launder our linens, and to support the society in which health care is embedded.

Many respected mainstream researchers and even senior members of the financial community agree that the end of cheap, readily available oil is at hand, probably before the end of the next decade. Health care, as it exists now, cannot function without cheap oil. As one submission to an Australian senate committee states: "Rather than looking forward breathlessly to … how stem cells will be curing all sorts of ailments … we should really be asking … How will we be able maintain … childhood immunization in 2030 …"

A bit apocalyptic, but even the rosiest of forecasters do not have a ready rebuttal.

The World Health Organization (WHO) anticipates that climate change will in turn change patterns of infectious disease, increase the incidence of weather-related disasters (like New Orleans) and increase, perhaps dramatically, human migration. Effects on industry (farming, transportation, insurance) will result in substantial economic costs for governments. Further, any positive impact we can have may take decades to show results.

Look at these three challenges and you can see three separate categories of impact.

The demographic shift increases patient load, and decreases caregiver supply. Peak oil and other resource shortages compromise patient mobility, day-to-day operations and has significant financial consequences. Global warming has other long-term impacts on government finances, and hence health-care budgets.

Each of the pressures is independent of the others. This isn't a domino effect, where removing one chip stops the process. This is a perfect storm, where, even in the absence of one or two of these factors, it is going to get pretty darned windy.

Dealing with change

So without abandoning advocacy and our passion to change the world, we should begin to visualize the changes implied by these powerful socio-economic forces.

Currently, physician services start locally, in primary care centres and smaller communities, and are usually provided by family doctors. Larger health-care centres, because of increasing population, have more technology (labs, radiology, etc.), and increasing diversity of physician expertise, with the largest having significant access to educational and governmental administration.

Consequently, physician services in Canada are enclosed within a rigid knowledge hierarchy. Patients are distributed, while the health-care system is centralized. Patients are mobile (they have to be to access care) while the system is immobile, and waits for the patient to come to it. We foster a rigid view of the "medical expert," while underutilizing and under appreciating the local generalist.

Information transfer is weak, and generally involves only physicians who end up in the same room as the patient.

