Némésis médicale: L'expropriation de la santé

by Ivan Illich

Némésis médicale Lorsque leur développement dépasse certains seuils critiques, certaines institutions deviennent les principaux obstacles à la réalisation des objectifs qu’elles visent. Cette « contre-productivité paradoxale », version moderne du mythe de la Némésis (déesse grecque de la vengeance), Ivan Illich en fait ici la théorie systématique à propos de la médecine. Il critique tout particulièrement la diminution de la santé des hommes sous l’effet du développement sans fin de l’institution médicale, en soulignant l’inefficacité globale d’une médecine coûteuse, la perte de la capacité personnelle des individus de s’adapter à des environnements variés et le mythe de l’immortalité qui conduit au déni de la douleur, du vieillissement et de la mort. Ivan Illich (1926-2002) Philosophe, penseur de l’écologie politique, il a fondé, au Mexique, le Centre international de documentation (CIDOC). Il est l’auteur d’une œuvre importante qui a contribué à l’analyse critique de la société industrielle, parmi laquelle on trouve les deux best-sellers Une société sans école (1971)et La Convivialité (1973).

Genres: Philosophy, Medicine, Nonfiction, Health, Science, Sociology, Politics

368 pages, Pocket Book

First published December 12, 1974

About the author

Ivan Illich was an Austrian philosopher, Roman Catholic priest and critic of the institutions of contemporary western culture and their effects of the provenance and practice of education, medicine, work, energy use, and economic development.

Reviews

[David M · Rating 5 out of 5]

The perception of nemesis leads to a choice. Either the natural boundaries of human endeavor are estimated, recognized, and translated into politically determined limits, or compulsory survival in a planned and engineered hell is accepted as the alternative to extinction.

When you read, say, Foucault or Agamben you notice that they occasionally shy away from the radical implications of their own line of thinking; rather than clearly state their conclusions they'll indulge in literary flourishes of erudition. Not so with Ivan Illich. He is at least as radical (and as erudite) as either of them, but his prose is considerably more lucid. The result is a pretty astonishing polemic. I would guess very few readers are willing to go as far as Illich does here. Nonetheless, Medical Nemesis remains one of the most prescient works of social theory written in the past half century. I'd say it's one of the key texts for making sense of what happened in 2020.

[Marilyn McEntyre · Rating 4 out of 5]

Ilych can easily be dismissed as a radical, a curmudgeon, or a blowhard by people who don't want to hear his sharp and penetrating critiques of two core social institutions--medicine and education. But his work is deeply thoughtful, drives to the theoretical and ideological heart of what ails medical practice and schooling, and surprises a willing reader (as I was) into questioning assumptions--an important thing to keep doing. In this book he challenges the deepest assumptions behind capitalistic medicine, or medicine practiced in a culture where virtually everything, including care, is commodified and done for profit. The profit motive becomes so pervasive that even when it's done not for profit, it's hard to retrieve the ground-level conviction that communities of people need to care for themselves and each other, that that care giving is not something to be consigned to impersonal professionals, and that a good bit of what passes for standard care is defined by pharmaceutical and insuance companies. Though it was written 30+ years ago, his analysis stands, and, I think, applies even more urgently now.

[Tara · Rating 5 out of 5]

Modern discussion about politics, the future, culture, etc. paralyze me. Mass media and the internet facilitate the adoption of easy slogans. Healthcare is a 'right' and we should get as much of it as we want the second we want it.

But who defines what healthcare is, or what goal it should work towards? Who draws up the balance sheet that includes the poisonous chemicals the medical complex produces, the waste, the populace unable to provide any degree of self-care, the elderly abandoned by their families in old-age homes? Who asks what is lost by forcing modern treatment upon third world people, while their own medicines are patented up and forbidden them? They protest, and we don't listen - the medical-industrial complex is a 'right' we will force upon them!

I don't think anyone needs to, or should, agree with every single statement in this book to realize that it's a perspective desperately, badly missing at the table of our current debates. Illich is the counterbalance we need if we're to remember what words mean, what we want to be working towards, the kind of world we'd like to live in, and what makes up a good life.

That's not something the corporate state wants us to think about. So, all the more reason I urge everyone to read this; it would be nice to have the whole story, rather than just parroting the fashions our bloggers and talking heads care about this minute.

[Chris · Rating 2 out of 5]

Important book everyone should read. The medical system has failed, is economically unsustainable, and it mostly serves to promote sickness. It really needs drastic change, but we need more people to educate themselves and take back responsibility over their own health.

Having worked in the health industry in public and private settings, I couldn't help but see the glaring problems in the system. The horrific amount of waste of time and resources. The bullshit marketing to lure in more 'health consumption' that people don't need - until we tell them they do. The harmful way we remove autonomy of healing - only the expert can be trusted to facilitate (read:intervene) your bodies natural processes. We've created a cotton wool society where no one trusts their innate ability to regulate their own health.

Everyone's living in fear of pain/discomfort and ill health and have been led to believe that doctor (aka drugdealer) is the one to solve all ailments with an assortment of quick fixes. We buy our health like our food - fast, fake and unfulfilling.

This book has been largely confirming of my ideas and hunches, but it has been even more eye opening. Illich presents a powerful case to show the wider context and grander scale of the problem. Though the book was written in the 70s so a lot of the research is dated, much of the book still rings true - its the same shit just with more forward momentum. It doesnt take much to see - worldwide illness and disease soaring that are EASILY preventable - obviously something is not right.

He gives us a look at the iatrogenesis (harm caused by medical intervention) at a clinical, social and cultural level. We get a fascinating look at the history of our concept of life, death, healing and the doctor and our cultural myths through time. We're now in a myth of consumption from industrial progress, and blinded by it, we know no limitations.

There is no doubt that self care is the best care and the medical institution robs us of that. Illich argues the solution is a "political program aimed at the limitation of professional management of health....such a program is integral to a society-wide criticism and restraint of the industrial mode of production".

"The recovery of personal autonomy will thus be the result of political action reinforcing an ethical awakening."

"That society which can reduce professsional intervention to the minimum will provide the best conditions for health

"Health designates a process of adaptation. It is not the resilt of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to aging, to healing when damaged, to suffering and to peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it"..

"Health is a task and as such is not comparable to the physiological balance of beasts. Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions".

"The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organisation that set out to improve and equalise the opportunity for each man to cope in autonomy and ended up destroying it".

[Adriana Scarpin · Rating 5 out of 5]

A verdade é que o Illich escreve bem pra caraleo.

[Colin]

'Specific counterproductivity' - when the intensity of a kind of industrial activity increases beyond a certain point and begins to actively undermine the intent with which that activity was initiated. WRT counterproductivity, think cars and travel times. Illich argues that biomedicine and health constitute parallel categories.

Separated principally into 3 sections - clinical iatrogenesis, social iatrogenesis, and cultural iatrogenesis. Clinical iatrogenesis is likely the most dubious section, depending to the greatest extent on empirics that seem outdated and are used to support overbroad claims. Nonetheless, there are many notes of truth here, and it's easy to find loads of clinical research and meta-research that describe the counterproductivity of elements of clinical care and research.

The sections on social and cultural iatrogenesis are fantastic. The medical establishment conceives of (and conceals) social problems as individual ones - and even research programs that attempt to bring in broader patient context tend to think in risk factors not relations. The curative paradigm leaves little room for suffering and death as a part of life - a major problem given that neither can ever be completely eliminated - though he is careful to note that suffering is not meaningful or virtuous. Illustrating the pointedness of his critique of cultural iatrogenesis, The Lancet just released a report that cites Illich by name as someone who rightly criticized the medicalization of death at the root of unsustainable and unbalanced practices around death and dying. As health workers grow increasingly concerned with the ecological sustainability of the curative model of care dominant in high-income countries, 'Limits to Medicine' strikes at the heart of why it seems impossible to shake our desire for more 'care'.

[Erik Graff · Rating 2 out of 5]

My office at Loyola sponsored Illich to speak to our pre-med students on which occasion I was introduced to him. At the time, the early nineties, he has a pronounced tumor on his neck for which, I was told, he had received no treatment. Reading this book and presuming it was malignant, I can see why.

I wasn't much impressed by Medical Nemesis, finding its prose rather difficult and its reliance on footnotes (a very substantial proportion of the text) too great. If I had read all these notes I would have gotten more from his arguments as they seem to have been there to document his claims. However, my eyes being poor, I read only some of them and those with difficulty.

Illich and Foucault are similar in that both of them revel in attacking commonplace understandings: here, of the role to medicine in promoting health, elsewhere, of the rold of schools in promoting education (Illich) or of the role of reformatories in improving behavior (Foucault). These are salutory enterprises. Unfortunately, and somewhat surprisingly, I find Foucault, the Frenchman, easier to grasp.

[Tentatively, Convenience · Rating 5 out of 5]

review of
Ivan Illich's Medical Nemesis
by tENTATIVELY, a cONVENIENCE - July 15-24, 2021

For my complete review go here to "Backlash to Arrogance": https://www.goodreads.com/story/show/...

1st, this bk is truly brilliant. I've been hearing about Illich for a long time, mainly in connection w/ his Deschooling Society, but it wasn't until I finally read this that I realized that he's a thinker who seriously rethinks major institutions in society in a way that's incredibly well-researched & very, VERY thorough. Medical Nemesis was published in 1976. I remember having revelations about things like preplanned obsolescence in the early '70s - thinking that it was such an obviously bad thing that corporations wd be forced to stop structuring their profits around it. No such luck, preplanned obsolesence is worse than ever now BY FAR. The same applies to all of the problems that Illich points out about medicalization & iatrogenesis. Not only have they not gone away, they've reached a sort of melting point in today's day & age.

I read recently someone's opinion that the saying 'Those who don't know history are doomed to repeat it' (credited in various forms to various people) isn't true b/c even people who do know history are doomed to repeat it anyway - & that's the way I feel about the times I'm currently living in. I, e.g., understand the way that the mass media manipulates public opinion as a form of mind control but I also see it working time & again regardless of how much I point out things that I, at least, think are obvious. The result is that I'm stuck in a 'reality' where history repeats itself not b/c I don't remember but b/c the majority of the people around me are so easily kept in a destructive loop that goes unquestioned. Illich has done the questioning about as intelligently as any human being can be expected to - but very few people I know wd ever read one of his bks & even if they did their minds wd gloss over at the lack of sound-bytes & simple talking points. The absence of oversimplification in Medical Nemesis is just too challenging for people whose mindset is Good Guys vs Bad Guys - if everything isn't reduced to the good guys wearing white hats & the bad guys wearing black ones then how can anyone understand it, eh?! Put sadists & vampires in white coats & it's all good, right?!

The subtitle of this bk is "The Expropriation of Health". As I understand Illich's position, & I hope I don't misrepresent it, that means that the less autonomy the individual has to deal w/ their own health in their own way b/c of the encroachment of domineering impersonal medical institutions, the more a person's health ceases to even be theirs anymore: it becomes the 'property' of 'caretakers' rather than 'caregivers' - thusly undermining what's truly healthy for the individual. Keep in mind that this review is my interpretation of Illich's highly articulated points. It's possible that I slant this interpretation too much one way or the another w/o intending to.

In the author's opening "Acknowledgments" he references what I think we cd all use more of: intelligent conversation between well-informed & thoughtful friends. I don't mean the regurgitation of what passes for such things amongst the lazy: viz. stock propaganda phrases from NPR of Fox News or whatever, I mean actual discourse between people who take their own opinions seriously enough to actually have them be their own instead of just dummy-speak provided by their ventriloquists.

"My thinking on medical institutions was shaped over several years in periodic conversations with Roslyn Lindheim and John McKnight. Mrs. Lindheim, Professor of Architecture at the University of California at Berkeley, is shortly to publish The Hospitalization of Space, and John McKnight, Director of Urban Studies at Northwestern University, is working on The Serviced Society. Without the challenge from these two friends, I would not have found the courage to develop my last conversations with Paul Goodman into this book." - p v

Lindheim's bk title struck my fancy but, alas, if it ever made it to publication I didn't find it online. Instead I found her Changing Hospital Environments for Children (1972) as her only available publication. Illich may very well have had a ms copy of The Hospitalization of Space.

"The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic. Iatrogenesis, the name for this new epidemic, comes from iatros, the Greek word for "physician," and genesis, meaning "origin." Discussion of the disease of medical progress has moved up on the agendas of medical conferences, researchers concentrate on the sick-making powers of diagnosis and therapy, and reports on paradoxical damage caused by cures for sickness take up increasing space in medical dope-sheets." - p xi

"Dorland's Illustrated Medical Dictionary, 25th ed. (Philadelphia: Saunders, 1974): "Iatrogenic (iatro—Gr. physician, gennan—Gr. to produce). Resulting from the activity of physicians. Originally applied to disorders induced in the patient by autosuggestion based on the physician's examination, manner, or discussion, the term is now applied to any adverse condition in a patient occurring as the result of treatment by a physician or surgeon."" footnote 5, pp 4-5

I've made myself very unpopular during the time of the QUARANTYRANNY by expressing opinions similar to this. Think of deaths caused by putting people on ventilators to hypothetically save their lives, think of drug addiction enabled by prescriptions of pain-killers, think of mental states changed negatively by an excessive medical tendency to diagnose 'disorders' that might've previously just been moods or temporary states of mind, think of people slotted into bureaucracies who get oversimplified as a result.

"This book offers the lay reader a conceptual framework within which to assess the seamy side of progress against its more publicized benefits. It uses a model of social assessment of technological progress that I have spelled out elsewhere1 and applied previously to education2 and transportation,3 and that I now apply to the criticism of the professional monopoly and of the scientism in health care that prevail in all nations that have organized for high levels of industrialization.

******

1 Tools for Conviviality (New York: Harper & Row, 1973).

2 Deschooling Society (New York: Harper & Row, 1971).

3 Energy and Equity (New York: Harper & Row, 1974)." - pp xii-xiii

I include the footnotes in the above for 2 main reasons: 1. the footnotes in this bk are very important, Illich references bks, journal articles, manuscripts, & even mimeographs in at least 5 languages: English, Spanish, French, German, & Italian - making this one of the most exhaustively researched things I've ever read - there're pages where the footnotes cover almost the entire page: that will be undoubtedly tedious & distracting for many or most readers but I appreciate the opportunity to be referred elsewhere; 2. these are the titles of 3 of his other bks, I shd probably read them to see what such an extraordinary mind is capable of coming up w/ in relation to other subjects.

"The layman in medicine, for whom this book is written, will himself have to acquire the competence to evaluate the impact of medicine on health care. Among all our contemporary experts, physicians are those trained to the highest level of specialized incompetence for this urgently needed pursuit." - pp xiii-xiv

Illich has an amazing ability to cut thru the bullshit. Note that he refers to "the impact of medicine on health care" - to many or possibly even most people "medicine" has come to be synonymous w/ "health care": an aspect of Illich's importance is that he's capable of separating the 2.

"The recovery from society-wide iatrogenic disease is a political task, not a professional one. It must be based on a grassroots consensus about the balance between the civil liberty to heal and the civil right to equitable health care. During the last generations the medical monopoly over health care has expanded without checks and has encroached on our liberty with regard to our own bodies. Society has transferred to physicians the exclusive right to determine what constitutes sickness, who is or might become sick, and what shall be done to such people." - p xiv

&, as w/ so much in this bk, I find that to be extremely prescient of the present tension (2020-2021). Talk of forced vaccination & vaccine passports foisted upon the public against our will but ostensibly 'for our own good'. I'm reminded of forced sterilizations & the testing of dangerous birth-control devices on people in '3rd world' countries by drs in more industrialized nations. There's always some 'superior' person who 'knows what's best' for the people they pretend to care about but actually look down upon.

Belief in mass-media hysteria, the cowardice of conformity to peer-pressure, & the overmedication of people who simply don't have the mental resourcefulness or strength to cope w/ their own lives are things that've led to a phenomenal level of stupidity. This particular stupidity doesn't necessarily cut across all intellectual activities, only the ones dominated by fear. A lack of fear doesn't necessarily mean damage to the amygdala or even bravery, simply a common-sensical ability to see thru lies that contradict one's own experience. A friend of mine recently informed me that I'm 100 times more at risk for not being vaccinated - &, yet, he's still alive & I'm still alive. One might think that being 100 times more at risk wd've killed me off by now. IMO, a sensible person wd recognize the ridiculousness of such "100 times" nonsense simply by seeing how many people are still alive who defy such illogic - but, no, the fear is too compelling for logic to take hold.

""Health," after all, is simply an everyday word that is used to designate the intensity with which individuals cope with their internal states and their environmental conditions."

[..]

"Health levels can only decline when survival comes to depend beyond a certain point on the heteronomous (other-directed) regulation of the organism's homeostasis. Beyond a critical level of intensity, institutional health care—no matter if it takes the form of cure, prevention, or environmental engineering—is equivalent to systematic health denial." - p xv

& it's this basic premise of the bk that many people are likely to find challenging. Illich's position is that health is dependent on autonomy, the individual is healthiest when they're self-regulating - if self-regulation becomes undermined by the imposition of both toxic environmental conditions & an external health system that's essentially invasive then the individual becomes deprived of their ability to cope. 'Health' that's imposed is no longer health at all b/c it's not natural to itself, it's parasitic to the host organism.

"This study of pathogenic medicine was undertaken in order to illustrate in the health-care field the various aspects of counterproductivity that can be observed in all major sectors of industrial society in its present stage." - p xvi

People seem to have a tendency to respect power as having been earned. As such, domineering institutions can be taken for granted as somehow 'deserving' their place. If the propaganda shield around these institutions is omnipresent & effective enuf then they become even less subject to paradigm-shifting criticisms. Illich is a paradigm-shifter. It's about time that more people realized that the medical industry's self-promotion as a wholy benevolent phenomena is glossing over greed, sadism, reckless experimentation, & substantial harm.

"Almost everyone believes that at least one of his friends would not be alive and well except for the skill of a doctor, there is in fact no evidence of any direct relationship between this mutation of sickness and the so-called progress of medicine.3"

[..]

"3 René Dubos, The Mirage of Health: Utopian Progress and Biological Change (New York: Anchor Books, 1959), was the first to effectively expose the delusion of producing "better health" as a dangerous and infectious medically sponsored disease. Thomas McKeown and Gordon McLachlan, eds., Medical History and Medical Care: A Symposium of Perspectives (New York: Oxford Univ. Press, 1971), introduce the sociology of medical pseudo-progress. John Powles, "On the Limitations of Modern Medicine," in Science, Medicine and Man (London: Pergamon, 1973), 1:1-30, gives a critical selection of recent English-language literature on this subject. For the US situation consult Rick Carlson, The End of Medicine (New York: Wiley Interscience, 1975)." - pp 3-4

"The study of the evolution of disease patterns provides evidence that during the last century doctors have affected epidemics no more profoundly than did priests during earlier times. Epidemics came and went, imprecated by both but touched by neither. They are not modified any more decisively by the rituals performed in medical clinics than by those customary at religious shrines.8"

[..]

"8 On the clerical nature of medical practice, see "Cléricalisme de la fonction médicale? Médicine et politique. Le 'Sacerdoce' médical. La Relation thérapeutique. Psychanalyse et christianisme," Le Semeur, suppl. 2 (1966-67)." - p 5

"For more than a century, analysis of disease trends has shown that the environment is the primary determinant of the state of general health of any population." - p 7

That seems accurate enuf to me. If you live in an industrialized area where there's air & water pollution is it any surprise that you're sick? &, yet, if you went to a dr about a cough wd s/he advise shutting down the locally air polluting company? Or wd s/he give you some sort of medicine to make yr throat more insensitive to the damage being done to it?

There are paradoxes & ironies.

"27 J. E. Davies and W. F. Edmundson, Epidemiology of DDT (Mount Kisco, N.Y.: Future, 1972). A good example of paradoxical disease control from Borneo: Insecticides used in villages to control malaria vectors also accumulated in cockroaches, most of which are resistant. Geckoes fed on these, became lethargic, and fell prey to cats. The cats died, rats multiplied, and with rats came the threat of epidemic bubonic plague. The army had to parachute cats into the jungle village (Conservation News, July 1973)." - footnote, p 11

A similar example wd be the importation of cane toads to Australia to eat cane beetles. This backfired. "The long-term effects of toads on the Australian environment are difficult to determine, however some effects include "the depletion of native species that die eating cane toads; the poisoning of pets and humans; depletion of native fauna preyed on by cane toads; and reduced prey populations for native insectivores, such as skinks."" (https://en.wikipedia.org/wiki/Cane_to...) It seems to be more common for the natural environment to have its own checks & balances although some people, such as the author Michael Crichton (see my review of his State of Fear here: http://www.goodreads.com/book/show/15... ), mock these. In recent times (2020-2021) there seems to be an anti-naturist mvmt that somehow believes itself to be rooted in science w/o, as far as I can tell, any real substance to that belief.

"28 A good example of medical persecution of innovators is given by G. Gortvay and J. Zoltan, I. Semmelweis, His Life and Work (Budapest: Akademiai Kiado, 1968), a critical biography of the first gynecologist to use antiseptic procedures in his wards. In 1848 he reduced mortality from puerperal fever by a factor of 15 and was thereupon dismissed and ostracized by his colleagues, who were offended at the idea that physicians could be carriers of death. Morton Thompson's novel The Cry and the Covenant (New York: New American Library, 1973) makes Semmelweis come alive." - footnote, p 11

This review isn't very saucy - am I getting too serious in my old age?

"31 Alain Letourmy and François Gibert. Santé, environnement, consommations médicales: Un Modèle et sonestimation à partir des données de mortalité; Rapport principal (Paris, CEREBE (Centre de Recherche sur le Bien être), June, 1974). Compares mortality rates in different regions of France: they are unrelated to medical density, highly related to the fat content of the sauces typical of each region, and somewhat less to alcohol consumption." - footnote, p 12

Even tho I prefer to not be vaccinated, I'm not entirely against vaccines. One of the reasons for this is that I was born in 1953 & was vaccinated against polio. I've had friends who were born slightly before me who weren't vaccinated b/c the vaccine didn't exist yet & who got polio. Some of them have disabled legs as a result. Illich addresses this.

"The reappearance of malaria is due to the development of pesticide-resistant mousquitoes and not any lack of new anti-malarial drugs.33 Immunization has almost wipred out paralytic poliomyelitis, a disease of developed countries, and vaccines have certainly contributed to the decline of whooping cough and measles,34 thus seeming to confirm the popular belief in "medical progress."35 But for most other infections, medicine can show no comparable results." - pp 13-14

The perceptive reader will've noted by now that I'm only up to page 14 but I've already quoted an enormous amt. That gives you an idea of how important I think every statement in this bk is.

For my complete review go here to "Backlash to Arrogance": https://www.goodreads.com/story/show/...

[Tamara · Rating 4 out of 5]

Kontroverzna promišljanja Illicha danas su aktualnija nego ikad prije, samo prva rečenica u kojoj iznosi tezu da "medicinski establišment predstavlja ugrozu ljudskom zdravlju" je dovoljna da vas privuče. S obzirom da je Medicinska nemeza ipak filozofsko-sociološki osvrt, u nekim trenutcima zna biti naporno čitati, treba popratiti sve fusnote, izvore i podatke, međutim vrlo uvjerljivo je prikazana "druga strana priče" - ona u kojoj sustav kao takav (ne sami liječnici i medicinski djelatnici) predstavlja prijetnju dobrobiti ljudi (pacijenata). Ne treba ovo djelo shvatiti doslovno niti je Illich protiv medicine i znanosti, već služi predstavljanju šire slike o tome kako su medicina i farmacija napredovale i ušle u svaki kutak naših života. Preporučila bih Medicinsku nemezu posebno kolegama zdravstvenim djelatnicima.

[Meg · Rating 4 out of 5]

There are a few dry, statistics-heavy sections in the book. But I thought the end of the book, Part IV: The Politics of Health, is the clearest presentation I've read yet of Illich's critique of industrial institutions. He argues for institutions that balance the possibilities for autonomous action with that of managed dependence focused on industrial output. He clearly believes that most of our major systems today focus on the latter, to the detriment of what they are intended for. So for the health care system, the focus on industrial output of new treatment creates a dependence on hospitals and medicines and insurance that prevent citizens from understanding their own power for self-care, so that in the end we end up dumping ever more resources into a system that in fact is now harming, rather than helping, health. His term for this is "specific counterproductivity," and he presents a solid argument for how this does exist in our current health care system, and for how problematic it is.
Such a perspective is entirely lacking from current debates around health care, and I'd really encourage folks thinking about current health care issues to take a look at Medical Nemesis. And I think his analysis in Part IV is useful for anyone thinking about the balance of rights and liberty in society and how those are shaped, strengthened, or limited by major institutions.

[SoulSurvivor · Rating 3 out of 5]

Illich had a small cult following in the 1970s. The principle of this book is that the political and 'scientific' communities have ursurped the freedom of the people, partly through misinformation.
Timely because of pandemic and focus on documenting vaccinations.

[Griffin Wilson · Rating 5 out of 5]

Insightful criticism of the modern healthcare industry.

[Kevin Carson · Rating 3 out of 5]

Rereading for C4SS paper

[Simon Howard · Rating 5 out of 5]

I dug this 1976 book out of the library in response to my Goodreads friend Richard Smith re-posting his 2002 piece about it. I’d never heard of it before, but blimey its force of argument blew me away.

Illich’s central argument is that “the medical establishment has become a major threat to health … A vast amount of contemporary clinical care is incidental to the curing of disease, but the damage done by medicine to the health of individuals and populations is very significant.”

Some of the specific arguments and statistics Illich uses show their age, but it is hard to substantially disagree with most of his central points. Illich’s lengthy arguments about the various forms of iatrogenic harm lead him to argue for keeping most of the population away from the medical establishment and instead bolstering the ability of communities to maintain their health and cope with ill-health. “The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population … A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying.”

For me personally, this book has come at the perfect time. I have been worrying about the extent to which the response to the covid-19 pandemic has emphasised a professional / medical model of healthcare to an extent that I have never before seen in my medical career. Even at the ‘slightest symptom’ the population is encouraged to engage with the ‘establishment’ via formal testing. I worry that we will struggle to put the genie back in the bottle.

The age-adjusted mortality rate for the most deprived quintile of the UK is a multiple of that for the least deprived quintile, yet—at least from what we have heard to date—the mainstay of the plan for future pandemics appears to be to beef up the medically driven response (people like me) rather than doing anything meaningful to tackle the underlying social issues.

This book was a timely reminder of the limits of the medical approach to health that articulated much of what I’ve been worrying about. I’m not sure I would go as far as Illich in arguing against medicine, but having a polemic like this certainly stimulates thought.

A few of the highlights I noted…

❦

The study of the evolution of disease patterns provides evidence that during the last century doctors have affected epidemics no more profoundly than did priests during earlier times. Epidemics came and went, imprecated by both but touched by neither. They are not modified any more decisively by the rituals performed in medical clinics than by those customary at religious shrines.

❦

For more than a century, analysis of disease trends has shown that the environment is the primary determinant of the state of general health of any population.

❦

Every twenty-four to thirty-six hours, from 50 to 80 percent of adults in the United States and the United Kingdom swallow a medically prescribed chemical. Some take the wrong drug; others get an old or a contaminated batch, and others a counterfeit; others take several drugs in dangerous combinations; and still others receive injections with improperly sterilized syringes. Some drugs are addictive, others mutilating, and others mutagenic, although perhaps only in combination with food coloring or insecticides. In some patients, antibiotics alter the normal bacterial flora and induce a superinfection, permitting more resistant organisms to proliferate and invade the host. Other drugs contribute to the breeding of drug-resistant strains of bacteria.

❦

It has also been established that one out of every five patients admitted to a typical research hospital acquires an iatrogenic disease, sometimes trivial, usually requiring special treatment, and in one case in thirty leading to death. Half of these episodes result from complications of drug therapy; amazingly, one in ten comes from diagnostic procedures. Despite good intentions and claims to public service, a military officer with a similar record of performance would be relieved of his command, and a restaurant or amusement center would be closed by the police.

❦

When cities are built around vehicles, they devalue human feet; when schools pre-empt learning, they devalue the autodidact; when hospitals draft all those who are in critical condition, they impose on society a new form of dying.

❦

Medicine has the authority to label one man’s complaint a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability, and even his death. It is medicine which stamps some pain as “merely subjective,” some impairment as malingering, and some deaths—though not others—as suicide. The judge determines what is legal and who is guilty. The priest declares what is holy and who has broken a taboo. The physician decides what is a symptom and who is sick.

❦

Most of man’s ailments consist of illnesses that are acute and benign—either self-limiting or subject to control through a few dozen routine interventions. For a wide range of conditions, those who are treated least probably make the best progress. “For the sick,” Hippocrates said, “the least is best.” More often than not, the best a learned and conscientious physician can do is convince his patient that he can live with his impairment, reassure him of an eventual recovery or of the availability of morphine at the time when he will need it, do for him what grandmother could have done, and otherwise defer to nature.

❦

Diagnosis always intensifies stress, defines incapacity, imposes inactivity, and focuses apprehension on nonrecovery, on uncertainty, and on one’s dependence upon future medical findings, all of which amounts to a loss of autonomy for self-definition. It also isolates a person in a special role, separates him from the normal and healthy, and requires submission to the authority of specialized personnel.

[Jonathan Hockey · Rating 5 out of 5]

This is one of the most concise and clear books I have read illustrating the dangers and pitfalls of our industrial model of life in secular societies and our unhealthy dependence on centralised state systems. Here at the beginning he lays out the criticism of our health-care system:

"A professional and physician-based health care system
which has grown beyond tolerable bounds is sickening for
three reasons: it must produce clinical damages which
outweigh its potential benefits; it cannot but obscure the
political conditions which render society unhealthy; and it
tends to expropriate the power of the individual to heal
himself and to shape his or her environment..."

This last factor is the most critical and the one that will ultimately be the nemesis of the attempted medicalization of life. We have already seen, since this book, a lot of backlash to it. But we yet also do still see ourselves heavily burdened with overgrown welfare states, and dangerously low birth rates. Indicating our continued dependence on medicine and our lack of independent thriving and autonomy in our lives.

There is so much in this book that gets right to the heart of the problem we face. I don't agree with some of his suggested solutions, such as his claim that our only alternative is to create conditions in society for equitable autonomy. As much as this would be a nice thing, I don't see it as realistic in the light of human nature that tends to prefer hierarchies to equity. So I think you would have to enforce that equity unnaturally, which would rely on a kind of state dependence he is trying to warn us away from.

The common theme though of the book is the absolute critical importance of retaining human dignity into our future society, and the hubris of reliance on technologies and ideologies to save us from basic human realities of life. These latter things always create a nemesis as an unintentional consequence, and so we must learn to get back to understanding and promoting basic human dignity in our own lives and in the lives of those around us.

Here is how he concludes things:

"Man's consciously lived fragility, individuality and
relatedness make the experience of pain, of sickness
and of death an integral part of his life. The ability
to cope with this trio autonomously is fundamental
to his health. As he becomes dependent on the
management of his intimacy, he renounces his
autonomy and his health must decline. "

"The true miracle of modern medicine is diabolical.
It consists not only of making individuals but whole
populations survive on inhumanly low levels of personal
health.That health should decline with increasing health
service delivery is unforeseen only by the health managers,
precisely because their strategies are the result of their
blindness to the inalienability of life. "

We need to take back some self responsibility for our pains in life. Not just for our own, but in our responsibility to the health of our families and the community around us. In this setting we function a million times more efficiently because we have natural capabilities in our brain for sensing illness and problems in our lives. These need to be nourished, educated and developed once more, so we can move into a future of less reliance on experts and professionals who cannot know what is best for us when times get tough, but only in an unsustainable situation of perpetual economic growth and expansion. We no longer can rely on this latter. Something we have certainly learned in the last 10-20 years. So we must get back to reclaiming our birthright to have autonomy over our own vital life processes. And resist the dangers of those such as the transhumanists and those who insist we must expand further industrially and those who think we can prop up our own health with the labour of poor and helpless people from more disadvantaged parts of the world.

[Jurjen van der Helden · Rating 5 out of 5]

This book is truly prophetical and shattering. It shatters not only my belief in medicine as a clinical phenomenon, but also as social and cultural phenomena. Written in 1975, it foresaw all the major problems in health-care, but also its manifestations in society. Illich compares the overconfident posture that medical science is taking to Prometheus’ hubris that lead him to steal the fire from heaven and resulted in his Nemisis; an ever-lasting painful punishment. But unllike Prometheus, we are all suffering from the ever-lasting punishment of our medical hubris. It is a sobering truth against the over-optimistic sounds of Enlightment, like Pinker’s recent book, and Illich’ thought can be used to explain even, why such Enlighted books fill our prospect with suspicion and discomfort.
My world view has truly changed by this book. Though not optimistically, but positively. Everyone in health-care, medicine, or the likes should read this.

[Louise · Rating 4 out of 5]

eu amo que as críticas do Illich são mais atuais do que nunca

[Joe Olipo · Rating 1 out of 5]

Theoretical Janus: Ideological Iatrogenesis: Oneirography of Wrong Dreams

"Beyond a certain level of industrial hubris, nemesis must set in, because progress, like the broom of the sorcerer’s apprentice, can no longer be turned off." – I. Illich

Illich has few reservations against wielding the portentous Greek mythos. He is eager to apply Nemesis, the mythical functionary of retribution against hubris, to further his argumentative ends. I would take similar license to personify Janus, the two-headed god of dualities and new beginnings, to describe a particular quality of aporetic argument. Janus is invoked when confused ideology (bad beginnings/“wrong dreams”) wields the spear of critical analysis such that every forward advance also threatens back toward itself. To date I have yet to encounter another work in which every accusation of “inhumanity” or “unfreedom” or “idealism” is uncritically reflected in the same text, often on the same page, paragraph or even the preceding sentence.

“Beyond a certain level of ideological aporia, Janus must set in, because argument, like the ouroboros, is gorged upon itself.” – J. Olipo

In this review I would like to discuss Ideological Iatrogenesis, the unspoken fourth term in Illich’s argumentative triptych, which implicates the first three: Clinical, Social, and Cultural Iatrogenesis.

What is Ivan Illich thinking? Perhaps it’s possible to extrapolate Illich’s perspective from the following emblematic statement, and to begin our analysis with a few questions regarding his use of terms such as “People”, “[Natural] Limits”, and “Minimal Bureaucratic Interference”:

"Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die."

Where do Illich’s “People” function as “Non-Persons”? Where do “subaltern groups” exist in his analysis, e.g. “women” “BIPOC”, “Gender and Sexual Minorities”, and most significantly “The Unhealthy” i.e. those disproportionately impacted by iatrogenesis, and who are conspicuously excluded from the term “healthy people”. Illich is not interested in extending the analysis of iatrogenesis to consider specific groups within the multitude other than “the rich” and “the poor”, which is striking in the setting of a discussion of healthcare disparities within the United States. Illich begs the question in both senses of the phrase. Even the inattentive reader must ask, “What about the Not-Healthy?” In the other sense, Illich is already past this discussion, building his analysis upon the assumption that such life is not worth living. For the disabled, congenitally malformed, old, and mentally ill, the answer is – and trust that I do not exaggerate – “Just let them die.”

On the Old: “A new myth about the social value of the old was developed. Primitive hunters, gatherers, and nomads had usually killed them, and peasants had put them into the back room, but now the patriarch appeared as a literary ideal. Wisdom was attributed to him just because of his age. It first became tolerable and then appropriate that the elderly should attend with solicitude to the rituals deemed necessary to keep up their tottering bodies.”

On the Young: “The engineering approach to the making of economically productive adults has made death in childhood a scandal, impairment through early disease a public embarrassment, unrepaired congenital malformation an intolerable sight, and the possibility of eugenic birth control a preferred theme for international congresses in the seventies.”"

On the Suicidal: “I know of a woman who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with a bullet lodged in her spine. Using heroic measures the surgeon kept her alive, and he considers her case a success: she lives, but she is totally paralyzed; he no longer has to worry about her ever attempting suicide again."

On the Dialysis-Dependent: "The modern fear of unhygienic death makes life appear like a race towards a terminal scramble and has broken personal self-confidence in a unique way. It has fostered the belief that man today has lost the autonomy to recognize when his time has come and to take his death into his own hands."[…] "Complex bureaucracies sanctimoniously select for dialysis maintenance one in six or one in three of those Americans who are threatened by kidney failure. The patient-elect is conditioned to desire the scarce privilege of dying in exquisite torture."

Illich hovers between willful ignorance and partisan denial of the healthcare needs of women, most conspicuously regarding prenatal medical care and hospital delivery, and most anachronistically against women in the workforce.

"Although physicians did pioneer antisepsis, immunization, and dietary supplements, they were also involved in the switch to the bottle that transformed the traditional suckling into a modern baby and provided industry with working mothers who are clients for a factory-made formula."

This is one step removed from the modern left-misogynist meme phrasing "👏More👏Women👏 Factory👏Workers👏". The only mention of BIPOC is the following, which actually appears to subsume “race” entirely within the idea of “the poor” and then appears to conflates “poor” and “black”.

"While in gross infant mortality the United States ranks seventeenth among nations, infant mortality among the poor is much higher than among higher-income groups. In New York City, infant mortality among the black population is more than twice as high as for the population in general, and probably higher than in many underdeveloped areas such as Thailand and Jamaica."

Where do “[Natural] Limits” function as “[Arbitrary Socially-Determined] Limits”? To the question of “Who deserves care,” Illich answers indirectly via return to Hippocrates in brief:

“For the sick,” Hippocrates said, “the least is best.”

For Hippocrates, the Asclepian ideal of medicine is a return to Nature. Yet, in the particular context of the Greek polis in which this perspective arises, the concept of “Natural” medicine was, even at its moment of conception, socially determined. Throughout the work, Illich cites how “Traditional Cultures” approach medicine in ways that imply this is the “Natural” way such things should be handled. Although he heaps significant praise on “China’s program of Barefoot Doctors”, he remains vague regarding how these cultures specifically approach the social and cultural aspects of medicine and speaks mostly in generalities.

"Duty, love, fascination, routines, prayer, and compassion were some of the means that enabled pain to be borne with dignity. Traditional cultures made everyone responsible for his own performance under the impact of bodily harm or grief. "People knew that they had to heal on their own, to deal on their own with their migraine, their lameness, or their grief."

[…]

"Traditional cultures and technological civilization start from opposite assumptions. In every traditional culture the psychotherapy, belief systems, and drugs needed to withstand most pain are built into everyday behavior and reflect the conviction that reality is harsh and death inevitable." […] "The sufferings for which traditional cultures have evolved endurance sometimes generated unbearable anguish, tortured imprecations, and maddening blasphemies; they were also self-limiting."

Curiously, Illich appears to reify the un-reflected judgment of the worst, most alienated physicians who observe "undignified pain" in the patient with a not insignificant quantity of disgust. Here I am actually in agreement with Illich that the Natural state is already capable of bearing any pain. Even literally unbearable pain can be borne in the Natural state because it occurs behind closed doors as a private holocaust. Imagine the woman literally torn apart from the inside during delivery of a fetus in transverse lie. That Nature maintains this unimaginable depth within itself in an incommunicable state is the other interpretation of Alice Goodman’s libretto: If every scar / on this poor back / could only speak, / these walls would crack. Any appeal to nature in this setting is complicity with worse torture than Illich wants to prevent.

Illich's proscription against “modern medicine” produces ideological surplus in the form of artificial socially-determined limits extending beyond their original justification.

"Powerful medical drugs easily destroy the historically rooted pattern that fits each culture to its poisons; they usually cause more damage than profit to health, and ultimately establish a new attitude in which the body is perceived as a machine run by mechanical and manipulating switches."

Ignoring the nebulous terminology (what does “powerful” mean?) there is no basis for opposition to safe and effective medications in the frame of Clinical Iatrogenesis. Bizarrely, the antipathy for the “Unnatural” extends to birth control, an instance in which the Catholic ideology peaks through the Marxist cloth:

"Oral contraceptives, for instance, are prescribed “to prevent a normal occurrence in healthy persons."

Where does Illich’s “Minimal Bureaucratic Interference” function as “Domination”? In his dogged insistence that “modern healthcare” is bad (although still true in some aspects) he would paternalistically deny access to this system to those who want it. Non-Persons living in “Traditional Cultures” are invited to simply die with dignity.

"In many a village in Mexico I have seen what happens when social security arrives. For a generation people continue in their traditional beliefs; they know how to deal with death, dying, and grief. The new nurse and the doctor, thinking they know better, teach them about an evil pantheon of clinical deaths, each one of which can be banned, at a price. […] By their ministration they urge the peasants to an unending search for the good death of international description, a search that will keep them consumers forever."

[…]

"However, delivery of effective basic health services for the entire population is cheap enough to be bought for everyone, provided no one could get more, regardless of the social, economic, medical, or personal reasons advanced for special treatment. If priority were given to equity in poor countries and service limited to the basics of effective medicine, entire populations would be encouraged to share in the demedicalization of modern health care.”

Social security, socialized medicine, and organized labor unions are recurring villains in his narrative. In direct opposition to the stated principle of self-determination, Illich would dissolve these organizations, or at least deny the medical care desired by their members (even if it provided qualitative improvements in health). This dissonant note extends beyond the stated objective of this work and into the realm of ideology (according to which workers’ rights perpetuate the bad conscience of Capitalism precisely by making it tolerable) where it is opposed to the goal of improving individual-collective health this work ostensibly promotes.

"But the fundamental reason why these costly bureaucracies [socialized medicine] are health-denying lies not in their instrumental but in their symbolic function: they all stress delivery of repair and maintenance services for the human component of the megamachine, and criticism that proposes better and more equitable delivery only reinforces the social commitment to keep people at work in sickening jobs. "

[…]

"As a lawyer, the doctor exempts the patient from his normal duties and enables him to cash in on the insurance fund he was forced to build. As a priest, he becomes the patient’s accomplice in creating the myth that he is an innocent victim of biological mechanisms rather than a lazy, greedy, or envious deserter of a social struggle for control over the tools of production."

[…]

"In every society the classification of disease—the nosology—mirrors social organization. The sickness that society produces is baptized by the doctor with names that bureaucrats cherish. […] The more convincing the diagnosis, the more valuable the therapy appears to be, the easier it is to convince people that they need both, and the less likely they are to rebel against industrial growth.”

I would like to conclude this review with a discussion of Illich’s presentation of Clinical-Social-Cultural Iatrogenesis. In discussing Clinical Iatrogenesis, the first, and most striking section of this work, Illich demonstrates the power of supplementary statistics toward a material historical analysis. Herein Illich argues that modern medical care is not only too expensive, but also does not produce improved health outcomes by the numbers. Yet by extending beyond the orthodox ground of "incommensurability", the statistical ground on which he stakes his claim is moving beneath his feet. Perhaps an emblematic quotation from this section:

"Medicine just cannot do much for the illness associated with aging, and even less about the process and experience of aging itself. It cannot cure cardiovascular disease, most cancers, arthritis, advanced cirrhosis, not even the common cold."

Ironically, since the 1970’s we have new and highly-effective treatments for these diseases including, briefly, percutaneous coronary intervention, drug eluting stents, heart transplant, autologous bone marrow transplant, DMARDs, arthroplasty, and liver transplant. Effective treatment that quantifiably improves mortality and quality of life (in some circumstances) has been developed for each disease in this this “index damnatorum” except the common cold.

The above amounts to a "systemic critique" of the medical establishment which can be solved by adjusting the numbers a little bit (morbidity, mortality, out-of-pocket costs). One is reminded of the screaming discontent of a certain frictive element of the social media discourse for whom the ardent demand for complete destruction of the “Capitalist system” is merely the rephrased demand for a 25% raise in pre-tax income and matched 401k contribution.

Culturally, “End of Life Care” continues to be an issue (unresolved), however there is no indication this cannot be improved via the quantification of end of life outcomes vs stated desires and the incremental implementation of quality improvement projects directed at integrating palliative options into frank “goals of care” discussions with patients and family members. One improvement already evident toward this goal is the withdrawal of the physician from his prior paternalistic role via the implementation of “patient-centered care” schemata beginning in the late 1980s. This paternalism is precisely the force which proscribed avenues of “self-care” in the past, and which Illich would now like to wield toward his own ends by direct interdiction of medical decisions which protract painful/"Unnatural" life.

“Clinical Iatrogenesis” remains a significant concern in modern medical practice, however there is no indication that incremental quality improvements within the current “evil” scheme could not eventually overcome the institutional inertia which perpetuates the worst abuses. Yet Illich would not be satisfied with this approach even if its success were guaranteed. As we have already demonstrated, Illich’s position overlies the ground of revolutionary Marxist-Catholic ideology which often strikes backward against his stated desire to improve clinical-social-cultural outcomes. Materially improving illness, wages, and working conditions, ostensibly the policy goals of this piece, are sequentially discarded as window dressing when push comes to shove. For Illich, any individual instance of such improvement can be shown to be harmful to the extent that it puts off the Revolution of the Proletariat. Consequently, lest the reader not be seduced by the notion of hard-fought incremental progressive improvements, Illich presents a bombastic vision of the apocalypse – a vision which becomes increasingly difficult to entertain:

"With rising levels of induced insensitivity to pain, the capacity to experience the simple joys and pleasures of life has equally declined. Increasingly stronger stimuli are needed to provide people in an anesthetic society with any sense of being alive. Drugs, violence, and horror turn into increasingly powerful stimuli that can still elicit an experience of self. Widespread anesthesia increases the demand for excitation by noise, speed, violence—no matter how destructive."

[…]

"Now an increasing portion of all pain is man-made, a side-effect of strategies for industrial expansion. Pain has ceased to be conceived as a “natural” or “metaphysical” evil. It is a social curse, and to stop the “masses” from cursing society when they are pain-stricken, the industrial system delivers them medical pain-killers. Pain thus turns into a demand for more drugs, hospitals, medical services, and other outputs of corporate, impersonal care and into political support for further corporate growth no matter what its human, social, or economic cost. Pain has become a political issue which gives rise to a snowballing demand on the part of anesthesia consumers for artificially induced insensibility, unawareness, and even unconsciousness."

[…]

"Famine will increase until the trend towards capital-intensive food production by the poor for the rich has been replaced by a new kind of labor-intensive, regional, rural autonomy."

I concede that Illich is correct in his premise that there is something deeply wrong with modern medicine in the United States. Since the 1970's the cost of care has continued to rise at an astounding rate. Some of the most expensive therapies are also some of the least effective. End-of-life in the ICU remains an exquisite form of torture. Yet, while one face of the work appears to point toward these problems, the other strikes back in dangerous aporia against those most in need of protection. I must conclude this is someone who should never, under any circumstances, be given control of our medical apparatus.

[Oliver Bateman · Rating 5 out of 5]

Another entry in the "deinstitutionalization" series for which Illich is rightly famous. Here, II hopes to reclaim health for the individual: death, therapy, all of that, taking it away from what it has become, a permanent negative "condition" controlled by institutionalized medicine, a "condition" which is always already failing for those unfortunates who (temporarily) have their "health," such as it may be. As is the case with some of his other works, there's a load of detail in the footnotes, too.

[Titik Musyarofah · Rating 5 out of 5]

after read this book, you'll think many time to go to hospital or the others medicine institute.
the fact, there's no good process for our health by medicine intitute...
The medicine intitute just the other face of industrialization.

We or our health growing better without the medicine institutes contribution. its true, and you read the fact from Illich...

[Gijs Limonard · Rating 5 out of 5]

A call for a renewed personal health ethic as the only antidote to iatrogenesis. As such the (gullible) ‘expropriation of health’ caused by the ‘hubris’ of ever-expanding possibilities of industrialized medicine paradoxically (or perversely) leads to the the ‘nemesis’ of iatrogenic harm. Heady stuff, and stridently put, but well thought through and some original insights to be found here.

[Chrisl · Rating 4 out of 5]

Pushing 4 decades since I read this ... expect it might be timely yet ... would like to reread, scan ... Would liked to have spent time with Illich in Mexico

[An · Rating 3 out of 5]

Tinc sentiments barrejats amb aquest llibre perquè la tesi principal (que la iatrogènia és un límit absolut de la medicina) ha demostrat ser històricament falsa, però a la vegada la idea de fons que la medicina suposa un monopoli privat sobre el cuidat de la salut, fet que genera una despossessió i alienació pel que fa a les pràctiques curatives segueix tan rellevant com llavors. Prossegueixo a fer una tremenda xapa pq la crítica d'Ilich em serveix com crítica general a les medicines crítiques.



1. Sobre la falsedat de la iatrogènia com a límit a la medicina dominant

La iatrogènia és l'impacte negatiu en la salut de la pràctica mèdica. Ilich exposa com la medicina genera malaltia buscant salut. Ilich encerta en el caràcter constitutiu de la iatrogènia en la pràctica mèdica, però falla en considerar-la el seu taló d'Aquil·les. Al llarg de les últimes dècades la crítica a la iatrogènia ha sigut perfectament incorporada en el discurs i investigació mèdics i ha entrat dins de la constel·lació de categories mitjançant les quals s'avalua l'efectivitat de la intervenció clínica.

2. De la medicina crítica a la crítica de la medicina

Ilich és el paradigma de la "medicina crítica". Per a mi, la medicina crítica (paraigües per bona part de l'antipsiquiatria, estudis bojos, estudis discas, teories sobre els determinants socials de la salut, etc) es caracteritza per una correcta historització de la salut i la malaltia dominants contra les quals s'oposa una falsa visió utòpica de la salut i la malaltia.

Ilich critica el caràcter ideològic i històricament específic de les categories de salut i malaltia de la medicina i d'aquesta manera les desligitimitza: si en cada moment històric ha canviat allò que s'ha considerat sa/malalt, perquè hauríem d'acceptar que allò que es considera com a sa i malalt en l'actualitat és verdaderament sa o malalt. Aquí hi ha un moment de veritat: verdaderament la salut i la malaltia canvien a mesura que canvien les relacions de producció dominants. Però també hi ha un error fonamental: s'accepta de forma idealista que hi ha unes verdaderes formes de salut i malaltia més enllà de les relacions de producció on s'articulen. Aquest idealisme prové del seu utopisme.

L'utopisme d'Ilich, així com el de la medicina crítica en general, és la contraposició dels falsos diagnòstics de la medicina capitalista amb una suposada verdadera visió de la malaltia que té en compte el seu caràcter social. L'utopisme d'Ilich busca en un futur dissenyat per ell mateix (un futur ahistòric) o en un passat romantitzat (un passat ahistòric) les formes verdaderes de salut i malaltia.

Aquesta és la diferència fonamental entre la medicina crítica i el que proposo anomenar "crítica de la medicina". Ambdues descobreixen en les categories mèdiques fets històrics, polítics i ideològics. Tanmateix, mentre la medicina crítica contraposa unes formes de salut i malalties utòpiques escollides per la seva superioritat moral, la crítica de la medicina troba la possibilitat d'una atenció a la salut superior en les dinàmiques i contradiccions internes de la medicina del present. La medicina crítica és una crítica externa que historitza el present, però és incapaç de reconèixer-se a si mateixa com a històrica i acaba imaginant un futur utòpic ahistòric. La crítica a la medicina és una crítica immanent, és a dir, que es reconeix com a igualment determinada per les relacions socials dominants que determinen a la medicina dominant. El seu impuls utòpic no ve d'enlloc més que dels conflictes del present.

[David Shane · Rating 5 out of 5]

An important book to read in the 2021 United States, but hard to summarize and therefore I'm a little spooked to even try. The first line of the book is rather well-known:

"The medical establishment has become a major threat to health."

Now you read that to most people and probably their brain is going to run to something like the harm from medical mistakes in hospitals... and that is PART of the threat, but actually a pretty small part. The bigger problem is that "health", once upon a time something that was the result of healthy living and, when it was delivered medically was almost always delivered at home, is now a massive industrial production and also a product to be consumed, something that 20-30 years ago you went to the hospital to "buy", but now something that is taking over all of our medicalized society (and disabling the older, accessible to everyone, non-industrialized ways of being healthy as it goes).

Side comment but related, but I caught a tweet this evening about the Democrat's new "Build Back Better" bill subsidizing childcare as long as you're paying someone outside your home for it... but offering no help at all if a family member is providing it inside your home. That is another "good" example of our preference for the industrialized over the traditional today. (And it's progressives, who imagine themselves anti-corporate and anti-industry, leading the charge.)

Back to the book - I'm not going to make this review very long, but I will quote a few snips from the final chapter as summary.

"Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine this damage appears as iatrogenesis..."

Iatrogenesis is a word that basically means the harm caused by medicine.

"...Iatrogenesis is clinical when pain, sickness and death result from medical care;..."

That is basically the "medical mistakes" problem, or other direct harm from medical treatments, but he goes on.

"...is social when health policies reinforce an industrial organization that generates ill-health; it is cultural and symbolic when medically sponsored behavior and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other, and aging, or when medical intervention cripples personal responses to pain, disability, impairment, anguish, and death."

Oh, there is so much buried in those phrases but I will leave you to read the book to discover it all. And then I appreciated, in the next paragraph,

"Medical nemesis is the experience of people who are largely deprived of any autonomous ability to cope with nature, and who are technically maintained within environmental, social, and symbolic systems."

We need to move away from a world where "health" is a product purchased from a doctor or corporation (and, culturally, forced upon you by industrialized medicine as they understand it to be needed, whether you want it or not), and into a world, perhaps back into a world, where health is understood more holistically as part of a well lived life, and available to everyone as part of living that life. Highly recommended read.

[Michael · Rating 5 out of 5]

Though provoking.  Prophetic. Chillingly relevant.

Illich uses historical anthropology to demonstrate how the mission of health has changed over human history and dramatically in the last 100 years. From a mission of healing, to prevention to bureaucratic management.

In the retelling of our myth of modernity, he demasks physicians as playing an overly religious, unscientific role. As high medical high priests they sacrifice human autonomy for a pain-free, utopian salvation.

Friends, momento mori

[Elari · Rating 4 out of 5]

This is a deep and thoughtful critique of medicine as a capitalist, technical, bureaucratic enterprise which prioritizes expansion and profit, while effectively undermining health on a personal, social, and cultural level. The anti-progress rhetoric can be a little over the top at times, but the book is still credible and simply great. It's worth noting that Illich is only interested in medical nemesis and iatrogenesis only insofar as they are "but one aspect of the destructive dominance of industry over society; as but one instance of that paradoxical counterproductivity which is now surfacing in all major industrial sectors. Like time-consuming acceleration, stupefying education, self-destructive military defense, disorienting information, or unsettling housing projects, pathogenic medicine is the result of industrial overproduction that paralyzes autonomous action."

[Sunny · Rating 5 out of 5]

Ivan is probably fast becoming one of my favorite writers. This book is clearly an attack on the formal methods of medicine that we've now become accustomed to. I remember going out to Princeton and Philadelphia in the back end of 2019 early 2020 before the pandemic and remembered going in a taxi on one of the main highways and seeing every 50 meters or so, I'm not exaggerating, a billboard with an advert for some pharmaceutical Drug proposing to support you / mitigate the effects of some disease or another. I think I remember reading somewhere that those billboards are like a cancer of America itself so very ironic that most of them that I saw in that particular stretch of land advertise potentially cancer busting drugs. Personally I fully believe in the power of eating healthy and staying fit as a major driver for the prevention of a lot of the diseases that currently inflict us in the western world. Can't remember the last time I took an aspirin or a paracetamol.

Anyway here are some of the best bits from the book:

The Greeks only word for drug: pharmakon, did not distinguish between the power to cure and the power to kill. Pharmakon in original Greek means poison. Sunny: wow

So the late 20th century practices it's necromancy by giving substance to system concepts and by reducing persons born for suffering and delight to provisionally self-sustaining information loops.- sunny: wowowow.

The threat which current medicine represents to the health of populations is analogous to the threat which the volume and intensity of traffic represents to mobility, the threat which education and media represents to learning, and the threat which urbanization represents to competency in home making. In each case a major institutional endeavor has turned counterproductive. Sunny: wow

The organized pursuit of health has become the principal impediment to suffering experienced as a dignified meaningful patient loving beautiful resigned and even joyful embodiment.

The medical establishment has become a major threat to health.

During the last generations the medical monopoly over healthcare has expanded without checks and has encroached on our liberty with regard to our own bodies. Society has transferred to physicians the exclusive right to determine what constitutes sickness who is or might become sick and what shall be done to such people.

The siren of one ambulance can destroy Samaritan attitudes in a whole Chilean town.

Social history of attitudes towards illness have shown that food, water, and air in correlation with the level of socio political equality and the cultural mechanisms that make it possible to keep the population stable, play the decisive role in determining how healthy grown-ups feel and at what age adults tend to die.

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

Every 24 to 36 hours from 50 to 80% of adults in the United States and the United Kingdom swallow and medically prescribed chemical.

Nemesis was the inevitable punishment for attempts to be a hero rather than a human being. Like most abstract Greek nouns, nemesis took the shape of a divinity. She represented natures response to hubris: to the individuals presumption in seeking to acquire the attributes of a God. Our contemporary hygienic hubris has led to the new syndrome of medical nemesis.

In a survey of 1000, 11 year old children from the public schools of New York, 61% were found to have had their tonsils removed. The remaining 39% were subjected to the examination by groups of physicians who selected 45% of these for tonsillectomy and rejected the rest. The rejected children were re examined by another group of physicians who recommended tonsillectomy for 46% of those remaining after the first examination. When theyrejected children were examined a third time a similar percentage was selected for tonsillectomy so that after three examinations only 65 children remained who had not been recommended for tonsillectomy. Out of the original 1000.

Placebo: Latin for “I will please”.

In a morbid society the belief prevails that defined and diagnosed ill health is infinitely preferable to any other form of negative label or to no label at all. It is better than criminal or political deviants, better than laziness, better than self chosen absence from work. More and more people subconsciously know that they are sick and tired of their jobs and of their leisurely passivity, but they want to hear the lie that physical illness relieves them of social and political responsibilities.

To be human is not just to breathe: it is to control one's breathing by yoga like techniques so as to hear in inhalation and exhalation the literal voice of God pronouncing his own name, “hu allah”.

Only those cultures survive that provide a viable code that is adapted to a group's genetic makeup, to its history, to its environment and to the peculiar challenges represented by competing groups of neighbors.

Any society in which the intensity of discomforts and pains conflicted rendered them culturally insufferable could not but come to an end.

For the Muslims it is kismet, God willed destiny: for the Hindus : karma, a burden from past reincarnation: for the Christians a sanctifying backlash of sin.

I firmly believe that if the whole “materia medica” as now used could be sunk to the bottom of the sea it would be better for mankind and all the worse for the fishes.

A new sensibility had developed which was dissatisfied with the world, not because it was dreary or sinful or lacking in enlightenment or threatened by Barbarians but because it was full of suffering and pain. Progress in civilization became synonymous with the reduction of the sum total of suffering.

With rising levels of induced intense insensitivity to pain the capacity to experience the simple joys and pleasures of life has equally declined. Increasingly stronger stimuli are needed to provide people in an anesthetic society with any sense of being alive.

In 1635 at the behest of Cardinal Richelieu the king of France formed an Academy of the 40 supposedly most distinguished men of French letters for the purpose of protecting and perfecting the French language. In fact they imposed the language of the rising bourgeoisie which was also gaining control over the expanding tools of production. The language of the new class of capitalist producers became normative for all classes.

Most of what remains could probably be handled better by barefoot and non professional amateurs with deep personal commitment than by professional physicians, psychiatrists, dentists, midwives, physiotherapists or oculists. Malevolent amateurs could quickly organize into monopoly custodians of scarce and precious medical knowledge.

The arrangement of society in favor of managed commodity production has two ultimately destructive aspects: people are trained for consumption rather than for action and at the same time their range of action is narrowed.

[David Elpern · Rating 5 out of 5]

This is the Bible of books about health care. It was written ~ 1974. Illich said virtually everything about today's health care "crisis." It's a hard book to read as it is not all that well-written -- but the truths it uncovers are worth the effort. Illich does not get the credit he deserves for being one of the first to shed light on this area. He begins his book with this sentence: "The greatest threat to the health of the commonweal is the medical profession."

[Tom Muddiman · Rating 4 out of 5]

I found this a difficult read but a good introduction both to iatrogenic disease itself and broader questions of the creation of industrial intradependence and what he terms "specific counter-productivity". Personally, I thought this as a critique of modernity was reminiscent of Adorno and Horkheimer's critique of the cuture industry with for example its emphasis on standardisation and psudoindividualisation as specific symptoms of beaurocratic culture.

[Justin · Rating 5 out of 5]

Honestly, one of the most important books I've ever read.