Medical Nemesis: The Expropriation of Health (hardcover) and $4.00 (paper))
Ivan Illich’s attack on what he calls excessive “medicalization” is the latest of his critical studies of the basic institutions of modern industrial society. In earlier works he has criticized the modern systems of schooling, transport, and industrial growth itself. Excellent for its purpose of provocative propaganda, this new book creates enough doubts, objections, and disappointments to serve admirably in its publishers’ series “Ideas in Progress.” It is explicitly a first draft, inviting critical comment which Illich will take into account in a fuller version for later publication in the US, 1 and he asks for comments to be sent to him at his research center in Mexico.
The book has already raised much controversy in the press and in medical papers in France and England. It is an effective polemical expression of the diffuse dissatisfaction with medicine which has been gathering force for the last decade or so. Illich marshals, in formidable array, the facts and reasoned arguments that are generally missing from conventional grumbles about the medical profession. At the same time he sets the problem in a social perspective, in order to show how much we ourselves—as individuals and in our institutions—are answerable for the situation.
But Illich directs his attack mainly to the medical profession itself, and it is as fierce as a strongly emotional publicist can make it. After prefatory thanks to a colleague for having “refined my judgment and sobered my expression” he opens with the assertion, “The medical establishment has become a major threat to health.” To validate the charge he turns first to his easiest target, iatrogenic illness, illness actually caused by the physician, including of course the side effects and long-term effects of medication. This is a familiar matter of concern to doctors themselves, and Illich notes that in the standard Index Medicus over a thousand items are listed each year under the heading of iatrogenic diseases. The statistics he gives are not very full, but the rhetoric is vivid:
Total suffering increases with more therapy…. More and more patients are told by their doctors that they have been damaged by previous medication and that the treatment now being given is conditioned by the consequences of their previous treatment, which sometimes had been given in a life-saving endeavour, and much more often for weight control, hypertension, flu or mosquito bite.
However, this is only his starting point. He goes on to extend the limited notion of clinical iatrogenesis to the much broader ones of “social” and “structural” iatrogenesis: those policies and practices that encourage people to accept sickness rather than rebel against the conditions of their lives, and those that undermine our trust in ourselves as largely self-healing organisms with enough resilience and adaptability to meet most of the challenges that the successive stages of life must bring.
In his belief that medicine is a flourishing part, and a prop, of an industrial society which must be drastically changed Illich might seem to be echoing such run-of-the-mill socialist sociology as The Exploitation of Illness in Capitalist Society by Howard B. Waitzkin and Barbara Waterman (Bobbs-Merrill, 1974). Their recommendations are fairly predictable: nationalize the drug firms, end fee-paying for medical care, do away with commercial profit from “health insurance,” follow the lead of Cuba and China in medical organization, devote more of the national budget to health, and ensure that poor people get medical care regularly, not just in acute sickness.
Illich is altogether more revolutionary. He would flatly oppose the last two of these recommendations, and although he likes the barefoot doctors of China, he sees the medicine of communist countries going as fast as it can, though more cheaply, in the same direction as that of capitalist industrialism. On the contrary, as his earlier books made clear, he wants the growth rate of industry itself reversed. He accuses the medical establishment of helping to conceal the human cost not of capitalism but of overindustrialization:
More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivities, but they want to be lied to and told that physical illness relieves them of social and political responsibilities.
The political aspects of Illich’s book have commanded perhaps too much attention. Many of the contributors to the extensive exposition and discussion of his views arranged by Le Nouvel Observateur in four successive issues (October 21 to November 9, 1974) respond as much to the political overtones as to the problem of medicine, whether they object to his utopianism or suspect him of innocently playing into the hands of those who support a reactionary meanness in the financing of medical services, or whether they want him to go further in the particular left-wing direction they favor.
In reality the malign alliance between medicine and industrialization is much more questionable than Illich makes out. In any era, as far as medicine does keep people well (or offer them the relief of being respectably ill), it keeps them functioning in whatever employment system is in force—whether serfdom or unionized assembly work. Suppose it could be demonstrated (and it would not be easy) that certain illnesses result from identifiable conditions peculiar to over-industrialization (and not, for instance, from competitiveness or from driving oneself too hard), there is no reason why that medical finding should not be used to support action against the noxious features of our lives—just as medical findings have supported action against industrial poisonings and other occupational hazards. No doubt nineteenth-century doctors had to do what little they could to alleviate the misery of phossy jaw, but their knowledge of the condition helped to reform rather than condone conditions in the match factories.
Illich might reply that the prosperity of the medical profession depends too much on maintaining the status quo for doctors to risk changing society radically. Yet where they have suspected that their patients’ habits and ways of life are producing illness—lung cancer, peptic ulcers, or coronaries, for instance—they have not hesitated to say so. As citizens they may or may not want to campaign with Illich for radical reform of society; as doctors they have done their job once they establish and announce the facts. If the politics implicit in medicine is not a red herring in Illich’s context, it needs to be more fully argued in the promised revision.
A second theme running through the book, and again a distraction from the main design, is the inequality in the medical services available to the poor and the rich, the industrialized and the “developing” countries, the urban and the rural populations. However much it excites a just indignation, inequality is still a false trail, since Illich’s main contention is that the rich are buying an evil from the medical profession. He has no enthusiasm for “equal access to professional care, illusions and torts.” In effect he admits the inconsistency. In one passage he denounces the power given to doctors to deploy medical resources provided by public funds where they choose, commonly to the benefit of prosperous city dwellers; but then for the sake of his main thesis that modern medicine itself undermines health he has to add:
This professionally consecrated favouritism, however, does not constitute the most important aspect of the mis-allocation of funds. The concentration of resources on a cancer hospital in São Paulo might deprive dozens of villages in the Mato Grosso of any chance for a small clinic, but it does not undermine the ability of people to care for themselves. Public support for a nationwide addiction to therapeutic relationships is pathogenic on a much deeper level, but this is usually not recognized. More health damages are caused by the belief of people that they cannot cope with illness without modern medicines than by doctors who foist their ministrations on patients.
The politics of industrialism and of social inequalities, however important in its own right, is independent of Illich’s main and most disturbing contention, that medicine has been encouraged to oversell itself, to offer more of its services than are beneficial, and to exaggerate their effectiveness. An “addiction to therapeutic relationships” is an aspect of what he calls “structural iatrogenesis,” the undermining of people’s faith in their natural capacity for health and healing. In this, and in much else, he is extraordinarily close to what Montaigne was saying about the medical establishment 400 years ago:
Physitians are not contented to have the government over sickenesses, but they make healthe to be sicke, lest a man should at any time escape their authority.
Similarly Illich speaks of the
…iatrogenic labelling of the ages of man. This labelling becomes part of a culture when laymen accept it as a trivial verity that people require routine medical ministrations for the simple fact that they are unborn, newborn, infants, in their climacteric, or old. When this happens, life turns from a succession of different stages of health into a series of periods each requiring different therapies. Each age then demands its own health-producing environment: from the crib to the workplace, to the retirement home and the terminal ward…. The environment comes to be seen as a mechanical womb and the health professional as the bureaucrat who assigns to each his proper corner.
Submissive as we already are to the bureaucrat, we might think this a reasonable price for better health and longer life. The second prong of Illich’s double attack is more disturbing: this encroaching medicalization, he maintains, is not effective. This is the nub of his case, and he adopts curious arguments to support it. He sweeps aside the undeniable improvements in health in recent times by attributing them to better housing and nutrition, disregarding any guidance medical knowledge has given here. Other techniques, such as vaccination, avoidance of infection in midwifery, the purification of water supplies, he describes as having been carried out “with the contribution of doctors” but becoming most effective when they “are applied by the general public,” as if medicine should have none of the credit for all the instruction in health measures which has been one of its major services.
Still more oddly, Illich minimizes the importance of cures for infectious illnesses, including tuberculosis, by showing that mortality from these diseases had been steadily declining, without specific medication, ever since the nineteenth century. This, for a man who is not unfeeling, shows a strange disregard for the individual: if you get tuberculosis it must be small comfort to know that you are one of a rapidly dwindling minority, but it means everything that medicine can now cure you. When Illich concludes that “the professional practice of physicians” cannot be given the credit for these advances in health he is grotesquely narrowing the range of medical work and influence.
These maneuvers leave him free to concentrate on the illnesses for which medicine has at present no cure and can provide only alleviation of disability, or slightly prolong life, by means of drugs with uncertain side effects or surgery with hazards and mutilations. The more you have to spend the more of these dubious benefits you will be sold. (A study cited by Illich and summarized more fully by Michel Bosquet in Le Nouvel Observateur showed that of more than 6,000 hysterectomies performed in 1948 in thirty-five Los Angeles hospitals, postoperative investigation justified only 40 percent.)
In spite of the sometimes exaggerated and always emotive presentation of his case, which several of Illich’s French critics reacted against (sometimes because it offers establishment medicine too easy a rebuttal of an essentially valid charge), it is evident that he is raising issues that responsible doctors are not inclined to brush aside. In the British medical press, which has given his views a cautious fair hearing, a representative reaction comes from Dr. Philip Rhodes, of Adelaide, Australia, in the British Medical Journal (December 7, 1974). Arguing that neither “high-cost technological medicine” nor the “simplistic medicine” that Illich advocates will meet the needs of large populations, he believes that some mixture of the two is necessary:
The decisions about the mixture must still largely remain with the doctors even though neither Illich nor politicians like it. The reason is that the statements about medicine made by amateurs such as Illich demonstrate only how little they understand, and this is obvious on nearly every page of Medical Nemesis. They do not understand what medicine is, nor what it can achieve, nor what its claims are. The medical profession is at least as self-critical as any other body of people, and probably more so than most. Nothing said by Illich has not already been said by some doctor.
Two comments are unavoidable: first that amateurism cannot be a total disqualification if it has led one amateur, Illich, to say what doctors have said themselves; secondly that if doctors have indeed been saying all that Illich says, it must have been in a discreetly professional undertone, and it is high time somebody amplified it. Of course the suggestion that a man of Illich’s intelligence can’t understand what medicine claims and achieves is a sample of the old-fashioned professional mystification that nowadays increasingly meets with derision, and rightly.
But it is undoubtedly to the credit of the profession that Illich gets so many of his facts from the doctors’ own reports. A.L Cochrane’s Effectiveness and Efficiency: Random Reflections on Health Services (Nuffield Provincial Hospitals Trust, 1972) provides the model study, says Illich, of “the dangerous delusion that contemporary medicine is highly effective.” Dr. Cochrane, like Illich, concentrates on less successful medical practices and shows that properly controlled statistical studies cast great doubt on the effectiveness of many currently accepted forms of regimen and medication. For example, these studies leave great uncertainty about the value of coronary care units and the effectiveness of anticoagulant therapy in heart conditions; they have shown that in mature diabetes tolbutamide is doubtfully useful and possibly dangerous and that insulin has no advantage over diet; they have undermined the belief in the value of iron for anemia in nonpregnant women and of ergotamine tartrate for newly diagnosed migraine; and whether in the long run tranquilizers and antidepressants do more good than harm is an unresolved problem.
But, as Cochrane admits, unfavorable results from large-scale studies may conceal the positive value of a treatment for certain subgroups of patients, and so it is not surprising that clinicians dealing with an illness for which there is no cure will continue to make exploratory trials with anything of promise. They will note too from Dr. Cochrane’s report that equally well-designed statistical studies may produce rather different results.
A more general uneasiness set up by the kind of statistical approach used by Dr. Cochrane arises from his glimpses of distant prospects. Cochrane looks ahead to the time when “only proven effective treatments” are used for each group of illnesses, and their availability, in view of their cost, is decided in advance by administrators; and this, as he sees it, means quantifying the various types of “medical output”:
i.e., if the saving of a man’s life aged 20 and restoring normal expectation of life is rated as 100, what number should be assigned to the care of a severe schizophrenic? Many people have a reasonable dislike of quantifying value judgements, but I am now convinced it is necessary.
What number would the administrators have assigned to Van Gogh, or to Cézanne, or to Dostoevsky or Solzhenitsyn? Cochrane argues that the allocation of funds to different aspects of a public health service means that this quantifying of value is “being done every year unconsciously and inaccurately.” The inaccuracy is the one hope for the survival of those persons who do not fall into categories deserving much care. They have at least a slender chance when the conscience and emotions of individual doctors are involved; as members of a category cost-coded by an administrator they can be dealt with as accurately as “kulaks,” “non-Aryans,” or “nie Blankes.” In this general outlook Cochrane makes a strange ally for Illich, however useful the ammunition that his figures supply.
Without positive proposals for reform, the most withering criticism of the medical establishment will not get far. Illich’s constructive suggestions are at present inadequately thought out; what seems most needed for a revision is that they be clarified and developed.
For what Illich sees as the basic trouble—overindustrialization—his formula is that of any naïvely indignant citizen, “There ought to be a law against it,” though he phrases it less succintly: “political and juridical procedures become necessary to reverse industrial expansion.” To cut back the medical industry, he proposes that no tax funds should be made available for “the more costly kinds of technical devices of medical magic.” He says the state need not “protect individual people against exploitation by ministers of medical cults,” but also (it would seem inconsistently) that “no professional shall have the power to lavish on any one of his patients a package of curative resources larger than that which any other could claim for his own.” No one who knows the facts is likely to deny the gross wastefulness of much of the medical empire building that goes on; but it seems unlikely that further advances in medicine can come without expensive new theoretical and applied research being pushed out beyond the broad front of simple and strictly egalitarian medicine.
Illich has more faith than most people in the ability of patients and their families to use the effective resources of modern medicine:
…the careful observation of instructions by people who personally care would probably guarantee more effective and responsible use than medical practice ever could. Most of what remains could probably be handled better by “barefoot” nonprofessional amateurs with deep personal concern than by professional physicians, psychiatrists, dentists, midwives, physiotherapists or oculists.
Can he seriously mean that you would gain by exchanging your dentist for an amateur equipped with instructions and “deep personal concern”?
But in spite of exaggerations and needlessly sweeping proposals (such as a complete deprofessionalization of medical practice), the broader aim of his suggestions gets some support among doctors themselves. Clearly he is right in pointing out that important gains to health in the last hundred years have come from the incorporation of medical principles into everyday routines. He now argues that with the increasing availability of simple and effective remedies or preventatives this process of devolution from the doctor to the layman could go much further. The family medicine cupboard would obviously become much more sophisticated, and packaging and instructions would be modified for the layman.
The overwhelming majority of diagnostic and therapeutic interventions which demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members….
A good recent example of the deprofessionalization of biological interventions is certainly provided by abortion. The pregnancy test represents the highest technology now packaged for self-application by laymen. The vacuum extraction method has rendered the interruption of pregnancies safe, cheap and simple.
As a constructive critic of the British National Health Service, Dr. Cochrane similarly, though much more cautiously, recommends a devolution of responsibility down the medical hierarchy, together with a movement away from the more advanced hospitals and toward the patient’s home.
Implicit in the best of Illich’s proposals is the need for a change of attitude among patients and physicians toward each other and toward health, sickness, and death. Dr. Philip Rhodes is in complete accord with Illich (though without seeming to realize it) when he complains that many doctors and patients think that complete mental and physical well-being is the norm:
The search for this mythical kind of health is what leads to the demand for a medical treatment for every kind of discomfort. Manifestly this is not achievable, nor should it be striven for. It is here that there ought perhaps to be more personal responsibility and the recognition that some ailments and diseases just have to be borne, and that particular pathological processes cannot be reversed or extirpated. [British Medical Journal, December 7, 1974]
Nor, Illich would add, should doctors go to macabre lengths to prolong the process of dying.
For the doctor to relinquish mystification and bluff in the face of an illness for which he has no cure, the patient must be mature and informed enough to respect him for what he can do and courageous in accepting his limits. How far a good relation can be achieved depends on the particular patient and the particular doctor; neither can move in the right direction without the other.
To be published by Pantheon in the spring of 1976.↩
To be published by Pantheon in the spring of 1976.↩