We live in interesting times. A global pandemic and the existential threat of climate catastrophe have recently been eclipsed by the local challenges of a recession, a cost of living crisis, and other domestic shockwaves where global events meet local social conditions. In this issue Paquita De Zulueta reviews Turning the World Upside Down Again. Global Health in a Time of Pandemics, Climate Change and Political Turmoil, by Nigel Crisp, arguing that: ‘... Western scientific models of health and health care are inadequate for 21st century problems such as global warming, mass migration, demographic changes, chronic disease epidemics, and escalating inequality. The world has become more complex, more interconnected, more global, and less predictable. We are living in ‘VUCA’ times — volatile, uncertain, complex, and ambiguous.’ 1
LIVING IN A DOUGHNUT
Truly, this is the age of the doughnut. It is ever more important that we are mindful of both the sustainability of our living space — our world in all its facets — and the wellbeing of the people in it. Kate Raworth’s book Doughnut Economics. Seven Ways to Think Like a 21st-Century Economist is concerned about how we deal with the problems of scarcity in society, but uses a profound ‘household’ basis for economics; how to budget for human society within the finite limits of planet Earth. She conceives of the problem as a doughnut (the American kind with a hole in the middle). The inner ring represents the needs of humanity. The outer ring represents the limits of human interference that the planet can sustain without damage. She argues that 21st century economists, and by extension society, should abandon ‘growth’ in favour of sustainable wellbeing.2
BUSINESS AS USUAL
Alas there are many examples in this issue of how ‘business as usual’ has global and local impacts on health and health care. Richard Armitage illustrates the consequences of short-sighted economic decisions focused on economic growth, with subsequent impact on ecosystems and public health alike, by discussing the impact of untreated human sewage in British waterways for wild swimming. Wild swimming in this case includes designated bathing sites — British beaches.3 Joshua Parker takes a bite from an ethical ‘doughnut’ in the GP consultation. How should we prescribe environmentally-friendly inhalers for asthma and chronic obstructive pulmonary disease in general practice? Often it is a win–win in terms of the efficacy of dry powder inhalers, or of cost with metered dose inhalers. But cost, difficulties with inhaler use, and patient preference can be problematic as well — is this the end of the world (or a contribution to it) or just the inner ring of the doughnut?4
FINDING MEANING, LOCATING HOPE
Human need and the resources to enable health and wellbeing find their tragic nadir in Austin O’Carroll’s article on suicide hierarchy.5 He critiques a moralistic definition of suicide that culminates in an unjust hierarchy of worthiness for receiving compassion and support. Those who act in a suicidal manner whose intentionality is compromised by adverse social circumstances and/ or substance misuse may not be seen as deserving of follow-up and clinical support. Seeing beyond intention to the causes of despair may be a more helpful approach. Rupal Shah et al search for meaning in our times of crisis and call for action — manifested as the inspiration, skills, and physical resources to act on behalf of patients.6 Some of this action needs to come from within general practice as a profession, some of it from civil society and some from the state.
In the UK, GPs are holding their breath to see how new Prime Minister Liz Truss is going to address the lack of GP appointments. As Don Berwick called for ‘a moral era’ to emerge from the industrial era of regulation, output, and measurement,7 British GPs will be hoping for support to offer meaningful care rather than more targets. A restoration of the ability to practice meaningfully, Rupal Shah et al argue, will help stem the exodus of GPs from the NHS and the UK. Saul Miller reminds us that both doctors and patients have moral agency,8 and Ahmed Rashid9 expands our horizons on the fronts of physical, mental, and social wellbeing.
Clearly GPs can be ‘doughnut’ doctors, with an eye on both sustainability of the NHS and indeed the planet, and the welfare and flourishing of its people. The hope is that the two are not seen as mutually exclusive in the days to come.
On our BJGP Life site, www.bjgplife.com, an inspiring array of opinion, education, and arts and humanities pieces are being continuously submitted. These are open access, and we would love to see more discussion and (collegial) debate in response to them.
- © British Journal of General Practice 2022
REFERENCES
- 1.↵
- 2.↵
- 3.↵
- 4.↵
- 5.↵
- 6.↵
- 7.↵
(2020) Ratio. 2. Berwick and the Three Eras,
- 8.↵
- 9.↵
