Rx for Illich

Medical Nemesis: The Expropriation of Health

by Ivan Illich
Pantheon, 294 pp., $8.95

As a physician, I’ve had a hard time with Medical Nemesis, but not, as you might be thinking, because of wincing or hurt feelings at all the harsh things Ivan Illich wants to say about contemporary medicine. Indeed, most of his arguments, taken singly, are not all that bad, or all that wrong. It is possible to read the whole book through, nodding much of the time in general agreement with one point after another. The hard part comes when it is finished, thousand-odd footnotes and all, and you try to figure out what Illich wants to have done about it.

The footnotes are impressive at first sight, occupying in fine print at least a third of the book, and symbolizing scholarship, rigor, and a firm grasp of the subject. They give the reader rather more confidence than he may actually be earning from the book, and there is, regrettably, no footnote to the footnotes to suggest how extraordinarily selective they are. If, for instance, you’d like to look further into the literature of medicine in order to find out what, if anything, medicine is really good at, you’ll find no help in the fine print, nor will you find any reference to Alexander Fleming or Howard Florey or Selman Waksman—who were responsible for the early antibiotics—or George Minot and George Whipple, who devised the liver treatment for pernicious anemia, or John Enders, whose work helped produce both the polio vaccine and the measles vaccine, or even Salk or Sabin. No Sir William Osler, the doctor’s doctor. Walter Cannon is mentioned, in a footnote, not for his great work in physiology but only because of something he once wrote about voodoo death. Robert Koch and Rudolf Virchow are in footnotes, but not because of their scientific work, only because they helped to compound what Illich presumes to be a generally false epistemology of disease by launching, respectively, medical microbiology and pathology.

This could make for annoying reading, if you were misled at the outset, as you might well be, into expecting any sort of balanced appraisal of contemporary medicine. This is not Illich’s intention, and once that is clear the annoyance wears away.

There’s a lot to agree on, when Illich gets down to pounding out his arguments. Everyone knows that modern medicine can do harm when used unwisely and excessively; iatrogenic illnesses—those caused by treatment itself—are a real problem. There is too much unnecessary surgery done, and (probably a more serious matter) too much unnecessary medicine. It is the scale of the problem that is arguable, and Illich argues only the one extreme side: health care has been turned into a “sick-making enterprise”:

The pain, dysfunction, disability and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war-related activities, and make the impact of medicine one of the most rapidly spreading epidemics of our time.

There is some overkill here …

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