Lean Health

Seen from the point of view of the affluent market economy, the task for Lean Health is impossible. It is to provide for the medical needs of local communities at a time when there is no money—neither taxation revenues nor private funding—available for large-scale medical services.

It could be argued that it will not be necessary to rely entirely on local resources for medical services in the future, but the task of Lean Logic is to ask that “what if?” question: if communities did have to provide their own entirely localised medical services, what would they look like?

To begin, we need to think about the effect that the climacteric might be expected to have on the health of the population in a developed country. It is reasonable to expect that the shock will have several direct consequences for health:

First of all, there will be the impact of the food famine that will follow the energy-famine.

Secondly, the pharmaceutical industry may not survive the shock on a significant scale, and this would remove the central resource of modern medicine. The supply of vaccines and antibiotics could break down, along with the drugs for the treatment and stabilisation of chronic diseases and mental conditions.

The third threat to health comes from new epidemics such as bird flu, which could be transmitted by the migration of people and their animals.

These three considerations represent more than a threat to health. The implication is of a rise in the death rate (see also “The Unwanted Inheritance” sidebar). But how, in this context, might the stabilised Lean Economy be able to care for its people, despite the lack of money?

Industrial pollutants and the threat to health in the Lean Economy

The Lean Economy will inherit a threat to health in the form of industrial pollutants. The subject is in need of further research, but the evidence to date is as follows.

One key industrial pollutant is the endocrine disruptors. Notable among these chemicals are DDT (and its degradation products), lindane, polychlorinated biphenyls (PCBs), herbicides and many of the styrenes present in plastic.L119 These chemicals damage the endocrine system of humans and other animals by mimicking the effects of natural hormones: they interact with hormone receptors which do not recognise them as intruders, and interfere with processes such as those by which the foetus and the breastfeeding infant build the structures of body and mind. Research has associated this with depleted neurological, sexual and endocrine development, and the precipitous decline in the fertility of men, reproductive problems in women, and changes in cognition and behaviour have been linked all too consistently with the exposure of embryos, infants and children to endocrine disruptors.L120

There is an overriding priority to stop further releases of these chemicals into the environment, and to research and reduce their impacts. As Theo Colborn and her colleagues write,

At levels typically found in the environment, hormone-disrupting chemicals do not kill cells nor do they attack DNA. Their target is hormones, the chemical messengers that move about constantly within the body’s communications network. Hormonally-active synthetic chemicals are thugs on the biological information highway that sabotage vital communication. They mug the messengers or impersonate them. They jam signals. They scramble messages. They sow disinformation. They wreak all manner of havoc. . . . Chemicals that disrupt hormone messages have the power to rob us of rich possibilities that have been the legacy of our species and, indeed, the essence of our humanity. There may be worse fates than extinction.L121

Another key form of industrial pollutant may be the Lean Economy’s inheritance of untreated, and leaking, nuclear waste. Some of this will catch fire if the electricity supply that powers its cooling systems breaks down, and/or when the needed round-the-clock management structures are no longer available. The only way to mitigate this is to deal with nuclear wastes as an overriding priority now.L122



For the post-market society which, in whatever form and in whatever numbers, has survived the failure of the market, the priority of medicine will be prevention. Even in the affluent market, preventing disease has become the priority, not least because of the cost of failing to do so.L118 Only one person in six survives his sixties without one or more of the major degenerative diseases: diabetes, arthritis, cancer, osteoporosis or heart disease; one third of the total healthcare budget is spent on mental health. And the antibiotics themselves, the central treatment resources for half a century, are losing their infallibility, as the superbugs fight back.L123

There are four main prevention strategies:

1. Nutrition. The contribution that good nutrition can make to preventing disease came into prominence in the modern era with the work of Dr. Robert McCarrison, writing in 1927,

When physicians, medical officers of health and the lay public learn to apply the principles which the newer knowledge of nutrition has to impart, when they know what malnutrition means, when they look upon it as they now look upon sepsis and learn to avoid the one as much as they now avoid the other, then will this knowledge do for medicine what asepsis has done for surgery. I know of no disease-producing agency which reaps so rich a harvest of ill health as [faulty nutrition].L124

And the frustration among family doctors with the treadmill of treating degenerative diseases which good nutrition could have prevented was famously summarised in the “Medical Testament”, a manifesto signed by sixty Cheshire doctors in March 1939:

We are called upon to cure sickness. We conceive it to be our duty in the present state of knowledge to point out that much, perhaps most, of this sickness is preventable and would be prevented by the right feeding of our people.L125

Advice on “right feeding” and right cooking was duly provided during the 1939–45 war by Robert McCance, Elsie Widdowson and others, producing the healthiest national diet of modern times.L126 After 1945, the work of this generation of food scientists was overshadowed by antibiotics, which reinforced confidence in clinical treatment, while rising incomes made it harder to sustain a sense of responsibility for the diet of consumers who could now afford to eat almost anything they wanted. But progress in the science of healthy eating was sustained, for instance, by Ancel Keys, a biologist at the University of Minnesota, who demonstrated a link between cholesterol in the body and the fat composition of the diet. And T.L. Cleave, Denis Burkitt and John Yudkin’s work on the damage due to the lack of fibre and excess of sugar led in due course to one of the century’s most successful books on diet, Audrey Eyton’s The F-Plan.L127 Since the 1980s, the World Health Organisation and governments have consistently argued the case for eating less fat and more fresh fruit and vegetables: the phrase, “five helpings a day” is widely recognised.L128

In a settled Lean Economy, localities will grow their own food. It will be eaten fresh, with little or no addition of the chemicals used for colour, preservation, enhanced taste and enhanced appetite, or the fat, salt and sugar which develop food’s potential as an addiction. In a sense, the unfolding energy-famine will narrow the options: high-fat, high-sugar junk food is made possible by the availability of cheap oil and gas to fertilise, cultivate, process and transport it. As sugar gets scarcer, mental health, for instance, is likely to improve, especially for children. And following the collapse of the market economy’s import-based food processing and distribution systems (Food Prospects, Climacteric) and the establishment of the central role of the household as a provider, food will tend to be eaten at mealtimes round a table.

All this is widely recognised to be a recipe for healthy eating. Would it be even healthier if it were organic? For a discussion of that question, see Lean Food. But in some senses, the question is disconnected from the reality of future food. Self-reliant local lean economies will not generally be able to get hold of pesticides and fertilisers even if they want to. Local systems-literate, fertility-building, closed-loop food production—organic cultivation—will be their lifeline. The impact on diet, then, will range between the ideal of varied, organic food, produced in a low-energy system, requiring minimal transport—and the shock of no food at all. Either way, the obesity problem will be solved.

2. Exercise. Inactivity is as great a risk factor for heart disease as a 20-a-day cigarette habit; people with risk factors such as smoking, hypertension or high cholesterol can (according to some research findings) reduce their risk of early cardiac death by as much as five-fold if they take enough exercise.L129

3. Behaviour. Smoking in the Lean Economy is likely to be limited by the cost and scarcity of imported tobacco; heavy addiction to alcohol may be inhibited by an awakened social and cultural order, and reduced by the collapse of incomes, though if the poor want to get it, or make it, they often can. The imported drugs like heroin are likely to be scarce, but localities will be free to experiment with anything that can be locally grown. Working practices will be changed by the scarcity of industrial and agricultural chemicals and by the nature of lean production. Health-promoting behaviour such as breastfeeding and childhood play in immunity-building dirt will sit comfortably with the gross earthy mixture of life in the Lean Economy.

4. Social capital. Belonging to a living community is as important to physical and mental health as taking exercise, avoiding smoking, obesity and high blood pressure. As Robert Putnam reports, the more integrated we are into our community, the less likely we are to experience colds, heart attacks, strokes, cancer, depression and premature death of all sorts.L130 The protective effects of social capital for mental and physical health have been confirmed for close family ties, for friendship networks, for participation in social events, and even for simple affiliation with religious and other civic associations. Putnam summarises,

People who are socially disconnected are between two and five times more likely to die from all causes, compared with matched individuals who have close ties with family, friends and the community.L131

In fact, if the Lean Economy can support the rich social capital of community—and it will need to do so if it is to work at all—then (holding other factors constant) it could reduce life-threatening illness by some fifty percent. Putnam cites studies which link lower death rates to . . .

. . . membership in voluntary groups and engagement in cultural activities, church attendance, phone calls and visits with friends and relatives, and general sociability such as holding parties at home, attending union meetings, visiting friends, participating in organised sports, or being members of highly cohesive military units.L132

The conclusion can be left to a statistic from Putnam:

The bottom line from this multitude of studies: As a rule of thumb, if you belong to no groups but decide to join one, you cut your risk of dying over the next year in half.L133



In the cash- and resource-depleted post-market economy, medical treatment will be organised mainly as a decentralised, informal, reciprocal service. It will be based on the principle of lean thinking, with decision-making pulled along by the detail in decluttered, small-scale organisations. The effectiveness of health care will be transformed, leaving today’s costly elaborations behind as a nightmare, straining belief. Herbal medicine, which has been under attack since the persecution of women herbalists as witches in the fifteenth and sixteenth century, will be accepted and respected. Health care in the Lean Economy, no longer trapped in the fallacy that things for which we so far have no explanation cannot be true, will recognise the value of homeopathy.

Local hospitals will not be able to afford the grief—the muda—of a regulatory bureaucracy and of excluding citizens from voluntary participation in the making and sustaining of their own hospitals and health services. Small local hospitals are limited in the treatment they can provide in a profession which consists almost entirely of specialisms, but much of the work of local hospital care can be done using informal reciprocities.L134 In the Lean Economy, the needed local labour will be on hand, along with (as far as possible) a core of medical professionals. The availability of the resources of (for instance) dentistry and surgery will depend on the depth of the post-market collapse but, over the long term, intensely effective surgery, dentistry and even pharmaceuticals could make some recovery, notably for the production of vaccines and antibiotics. Nonetheless, some treatments, such as surgical procedures which stretch the resources even of the pre-climacteric economy, will be abandoned, and the long-term care of the profoundly and chronically dependent comes at a cost which no society other than one enjoying the exceptional wealth of the market economy could sustain.


In summary, the collapse of the vast medical establishment is to be expected, but its lightweight replacement is in many ways attractive, as well as resilient. The transition from treatment to prevention will require some understanding of diet, of ways of avoiding the grief and expense of being ill, of how to be happy without drugs. And local hospitals and care homes will make use of the local potential for lean thinking, for voluntary work—for the talent and care that is available to institutions when they are recognised as part of the community.


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David Fleming
Dr David Fleming (2 January 1940 – 29 November 2010) was a cultural historian and economist, based in London, England. He was among the first to reveal the possibility of peak oil's approach and invented the influential TEQs scheme, designed to address this and climate change. He was also a pioneer of post-growth economics, and a significant figure in the development of the UK Green Party, the Transition Towns movement and the New Economics Foundation, as well as a Chairman of the Soil Association. His wide-ranging independent analysis culminated in two critically acclaimed books, 'Lean Logic' and 'Surviving the Future', published posthumously in 2016. These in turn inspired the 2020 launches of both BAFTA-winning director Peter Armstrong's feature film about Fleming's perspective and legacy - 'The Sequel: What Will Follow Our Troubled Civilisation?' - and Sterling College's unique 'Surviving the Future: Conversations for Our Time' online courses. For more information on all of the above, including Lean Logic, click the little globe below!

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