Medical Nemesis: The Expropriation of Health
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, or at least overmaim. Does Ivan Illich really mean that iatrogenic illnesses match in incidence and severity the deaths and permanent crippling injuries of all the country’s auto accidents? And industrial accidents? And those of the Vietnam war? Or is he using the term morbidity very carefully here, and simply calculating the total number of iatrogenic episodes (which could be a very large number if you include all the transient skin rashes and mild fevers due to allergic reaction, especially to antibiotics), and then matching this number against the total injuries (not deaths) caused by cars, industries, and the war?
But this would be grossly unfair; one cannot really compare a rash to paraplegia, nor can it be stated so flatly that iatrogenic disease is worse than war without offering some firm facts about comparative death rates. I’ve never been able to find reliable data anywhere on the incidence of iatrogenic death resulting from needless surgery or as a complication of drug therapy, and I expected to be helped in the search by the array of references in Illich’s abundant footnotes. I was not at all helped. Indeed, many of the references to the technical literature turned out, on checking, to be descriptions of a much milder set of problems than the picture of human devastation called up by Illich’s prose. (In a recent study from the University of Florida, it was found that only sixteen patients out of 7,423 died of drug-associated causes [0.22 percent], and most of the sixteen were terminally ill beforehand, with fatal malignancies being treated at the last ditch with anti-neoplastic drugs.) There are, in real life, a great many untoward reactions to drugs, and there are too many unnecessary operations; it is a matter of genuine concern, no question about it. But it is not at all the threat to human survival that Illich makes it out to be.
The rest of Illich’s case rests on his persuasiveness about these matters, all dealt with in the first thirty-six pages of the book. If you become convinced by this section that modern medicine has little or nothing of real value to offer, with that little overwhelmed by its destructive and lethal effects, then the following sections on “social” and “cultural” iatrogenesis must seem logical extensions of the same theme. Medicine is bad luck for societies because of the useless and harmful overmedicalization of almost everything, from ordinary unhappiness to ordinary dying. Cultural iatrogenesis is even worse, in Illich’s view; it is the loss of nerve and the giving up of autonomy and dignity on a societal scale.
These are interesting and provocative ideas, whether or not you agree with the first thirty-six pages. We are overmedicalized, tending to become a psychoneurotic people. Never before has there been so much public anxiety about health and its jeopardy, at the very time when we have achieved the healthiest society in history. We have a longer average life expectancy (seventy-two years) than ever before; our death rate is running at less than 1 percent per year, substantially below our birth rate. But we seem to be more worried than ever, about cyclamates and air pollution, food additives, sludge, sonic booms, germs, above all germs. The television commercials deal mostly with minor ailments, piles, headaches, stomach gas, bad breath, smelly feet and the like, but they are so skillfully staged as to make even dandruff seem a sort of threat to life. We are nervous about the fallibility of the human form, distrustful of the way we are made, and so we turn more than ever to the doctor or his surrogate, for checkups, for reassurance, for advice about how to live a life. There is, in this failure of confidence in ourselves, a certain loss of autonomy, even dignity. Illich is right about this.
But the news is not as solidly bad as he asserts. He has left out some things. The thought ought to arise, but does not in this book, that things could be a great deal worse. Had it not been for the biomedical science which began in the late nineteenth century we might, for instance, still have at our disposal only the medical knowledge and technology of Montaigne’s time, but with a system for delivering health care built on today’s scale. Montaigne, who detested medicine and doctors with hotter eloquence than Illich does, would have been swept off his feet by such a system, overwhelmed, bled and purged to death, poisoned to death by heavy metals and noxious plant extracts, goaded to death by incantations and charms, leeched away.
Illich seems to believe, with ardor and intensity, that medicine has become worse rather than better. To be sure, he concedes briefly and hastily, almost as though uncomfortable with the thought, that a few useful things may have happened, antibiotics and chemotherapy for infection for example, or immunization, or vitamin B-12 for pernicious anemia, maybe insulin for an aspect of diabetes, a few other odds and ends; but he has a generally low regard for medical therapy and believes that on balance it does considerably more harm than good. And anyway, he seems to say, the few effective measures available to medicine in, say, dealing with infection, are far out-balanced by a long array of health disorders for which medicine has nothing to offer beyond dangerous meddling.
Give it up, says Ivan Illich. Root the doctors out, and all the rest of the bureaucracy along with them. Return to the people their responsibility for self-healing. Demedicalize illness, disability, and dying. Above all, get rid of those hospitals. Go back, society, to nature. Learn to live with pain, abide early death, naturally.
The real trouble with this book, in my view, is that Illich so overestimates the power of medicine and its science. He asserts that medicine has fully matured, has already run its full distance, and has failed. Everything we are likely to know we have already learned, and we are not helped by the information. Medicine has become a high technology and, like the other manifestations of industrial society, including compulsory fast transportation and mass education, it simply doesn’t work. Therefore, give it up and rescue mankind.
What Illich doesn’t know, or anyway doesn’t reveal in this book, is that medicine has hardly begun as a science, is still at its earliest beginnings, just now about to emerge as a coherent scientific discipline. Compared with the rest of biology, or with the harder physical sciences, medicine is still largely a pre-Darwin, pre-Newton enterprise. We have not learned everything. There is nothing like a unifying theory we can work with. The early and astonishing insights into the phenomenon of infection cannot be extrapolated to other diseases about which we are still almost totally ignorant. We do not yet understand the underlying mechanisms of the major illnesses which plague humanity, and therefore much of what is done in the treatment of illness must still be empirical, trial-and-error therapy. We are compelled by our limitations to resort to shoring things up, applying halfway technology, trying to fix things after the fact. Most diseases, if the truth be told, cannot be prevented because we do not comprehend their mechanisms.
This is the truth. We are very good at some things in medicine, most spectacularly in the infectious diseases, but there are lots of other afflictions which we cannot influence one way or the other. We can cure lobar pneumonia, a commonplace cause of death thirty-five years ago, outright; we can prevent and cure tuberculosis; tertiary syphilis is now almost a fossil disease; polio and smallpox have departed. But we cannot do more than palliate schizophrenia; we are defeated by more than half the varieties of cancer; we are bewildered by multiple sclerosis; chronic nephritis must lead to renal failure (with the artificial kidney or kidney transplantation as our only last resort); coronary thrombosis and stroke cannot yet be much affected by any technology, nor, for that matter, can they be prevented. We could prevent lung cancer if we only knew how to prevent smoking, but we don’t; senile dementia is still the ultimate and unavoidable humiliation for many of us. We do not yet comprehend the process of dying, and death is universally perceived as an outrage, a violation of nature. We have a long way to go, a lot to learn.
But the way is now open to science, and this is the great point, clean missed by Illich. Having proved, once and for all, that science can provide conclusive measures for disease control, we have begun to discern clues, feasible scientific approaches to each of the major diseases still at large. The biological revolution of the past quarter century—from the discovery of DNA to the analysis of the body’s immunological system—has opened things up, and there are no longer any disease problems standing there as blank mysteries; they now have the look of soluble puzzles, even though we haven’t solved them. A new way of thinking scientifically has been developing in medicine, and it is justified by this century’s yield of new information, most of it the product of research in the last twenty-five years.
There is another point, taken from the history of medicine within our lifetime. Whenever we do achieve a genuine insight into a particular disease, deep enough so that we can figure out what to do precisely for prevention or cure, the measure turns out to be both simple and inexpensive. The cure of typhoid fever by antibiotics has changed a life-threatening disease lasting eight weeks or so, demanding the most costly kind of hospital care imaginable, into a trivial illness lasting less than a day and costing a couple of dollars. Meningitis, polio, subacute bacterial endocarditis, neurosyphilis, scarlet fever, and diphtheria in no sense present economic problems today. Where we run into the insupportable costs and unbearable technologies described by Illich is in the care of those diseases by which we are still mystified. We would not be arguing confusedly about a nuclear-powered, four-pound artificial heart of plastic and metal, costing hundreds of millions to develop and entailing impossible ethical decisions once developed, if only we knew enough about the central factors involved in coronary occlusion to reverse the process or prevent it.
What we need is more science, not less. We should not be talking about abandoning modern medicine; it is not yet really here. When we have it as a genuine science, truly perceptive and charged with insights, the technology of medicine will be easy to deliver, and will no longer cost the moon.
Perhaps there will always be, as Illich maintains, human problems that are not the business of medicine, in which we are likely to do more harm than good by meddling. Unhappiness, discontent, anomie, worry about meaning, ill will, grabbiness, and loss of nerve are huge problems for our society, but they are not medical problems. Medicine’s professional task is the prevention and cure of illness, most of all the prevention of premature death. If it can stick to this line, taking advantage of all the biological science coming into view, learning more whenever the opportunity arises, admitting ignorance more candidly than is its old habit, and keeping at it, it will earn its keep among useful human endeavors.