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<address><a class="moz-txt-link-freetext" href="https://www.nytimes.com/1976/05/02/archives/medical-nemesis-the-20thcenturys-leading-luddite-turns-to-medicine.html">https://www.nytimes.com/1976/05/02/archives/medical-nemesis-the-20thcenturys-leading-luddite-turns-to-medicine.html</a></address>
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<h1 id="link-13adcc8a" class="css-3snf05 e1h9rw200"
itemprop="headline" data-test-id="headline">Medical Nemesis</h1>
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<p class="css-1nuro5j e1jsehar1"><span class="css-1baulvz"
itemprop="author">By H. Jack Geiger</span> </p>
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<li class="css-ccw2r3 epjyd6m1"><time class="css-129k401
e16638kd0" datetime="1976-05-02T01:00:00-04:00">May 2,
1976</time></li>
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<div class="css-6hi8ev">This is a digitized version of an article
from The Times’s print archive, before the start of online
publication in 1996. To preserve these articles as they
originally appeared, The Times does not alter, edit or update
them.</div>
<div class="css-6hi8ev">Occasionally the digitization process
introduces transcription errors or other problems; we are
continuing to work to improve these archived versions.</div>
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<p class="css-158dogj evys1bk0">The great steel‐and‐glass
structures of our hospitals, medical centers and research
institutes—the new cathedrals of industrialized society—rear
up on our urban skylines from Stockholm to Wichita, and in the
developing world as well. Inside, brigades of physicians and
armies of technologists command computers, rebuild our bodies
with scalpel and graft, make molecules dance to order, preside
over incredibly complex machines that breathe for us, or pump
blood or wash our innermost cells. They are defying death, and
conquering disease and disability.</p>
<p class="css-158dogj evys1bk0">Outside, by the hundreds of
millions, we visit our doctors, certify our diseases, are
processed through the multiphasic screening units, take our
powerful (and dangerous) pills and confidently await our aging
and our cardiac resuscitations. Collectively, we are creating
“health.”</p>
<p class="css-158dogj evys1bk0">This is a mad dream of progress,
says Ivan Illich in “Medical Nemesis,” a part of the
overreaching nightmare of industrialization. Far from helping
us, modern medicine has made us sicker. Worse, it has created
in us a worldwide addiction, as passive medical consumers, to
“therapeutic” relationships with monopolizing professionals
and arrogant medical bureaucracies and institutions. Worst of
all, it has robbed us of our autonomy and our acceptance of
the human condition—including disease, pain and death.</p>
<p class="css-158dogj evys1bk0">With them, he adds angrily, has
gone our human uniqueness, our capacity to struggle and adapt,
our ability to care for ourselves and each other. There are
echoes here of Rousseau's Noble Savage: the paradise we have
lost was the one within us; it was whatever enabled us, on our
own, to make life feel whole and coherent, even if painful. We
have traded it in for compulsory survival in a planned and
engineered hell, an anesthetized existence in a world turned
into a hospital ward, a “managed maintenance of life on high
levels of sub‐lethal illness.”</p>
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<p class="css-158dogj evys1bk0">Illich—priest, historian,
theologidn, philosopher, polemicist, iconoclast and, in some
ways, the leading Luddite of the 20th century—is thus back
with another major critique of the relentless
industrialization of our so ciety. Once again, his method is
the examination of a major social institution—what Illich sees
as technologized, institutionalized, dehumanizing, dangerous,
all‐pervasive and insatiably expanding medicine. His intended
audience, it seems clear, is the American public, for the
technology, institutional forms, values and processes he
describes have, for better or for worse, reached their
apotheosis in the United States. The ultimate target of his
blame is not the professionals but the rest of us—all of us,
at once the eager consumers and the passive slaves of
industrialism, and, therefore, the willing participants in our
own dehumanization. He wants us—the world's biggest
medical‐care users and spenders—to think about our implicit
beliefs in salvation through science and immortality through
medical care.</p>
<p class="css-158dogj evys1bk0">Readers of Illich's earlier work
will recognize at once that this view of medicine is only part
of a larger picture. Institutionalized education stifles and
crushes our ability to learn (“Deschooling Society”);
transportation systems not only devalue human feet but
paralyze us in frustrated, polluted immobility (“Energy and
Equity”); urbanization destroys our competence in homemaking
and our integrity as neighbors (“Tools for Conviviality”). The
major institutions of industrialized society inevitably turn
counterproductive and rob us precisely of what they set out to
offer. Medicine is just another slow dance on the
industrialized killing ground.</p>
<p class="css-158dogj evys1bk0">The process by which it makes us
sick—individually and as a society —is iatrogenesis, the
causation of disease by physicians, or by the whole of the
medical complex. It is an old word and an old idea, but Illich
has enlarged upon the concept, and connected it in myriad ways
to larger issues of society and culture. His identification
and discussion of three kinds of iatrogenesis is the core of
“Medical Nemesis,” and its chief contribution to our thinking
about the relationships between our medical‐care complex, our
political economy and our values.</p>
<p class="css-158dogj evys1bk0">First, and most conventional, is
clinical iatrogenesis, the damage done to us by individual
clinical intervention. Here Illich has seized on a powerful
truth. He knows that most of the improvements in health over
the past few centuries are not due to medical advances but
simply to improvements in the standard of living: more food,
clean water, sanitation, better housing, more income and
edcation. The great plagues of pre‐and early industrial
society, the epidemics of infectious disease, were on the
decline long before physicians knew clearly what they were,
let alone what to do about them.</p>
<p class="css-158dogj evys1bk0">Against the new epidemics of
chronic disease, medicine is not “miraculous,” it is not even
very effective. For all the early intervention, the powerful
drugs, the incredibly skilled surgery, the complex machines,
life expectancy beyond infancy has not improved significantly
in the past 100 years. Cancer survival rates resist change,
many heart attack victims survive as well at home as in
coronary care units, and today's drug “breakthrough” has a way
of becoming tomorrow's tragic mistake. Further, Illich knows
all about the unnecessary surgery, the drug reactions, the
malpractice and the “accidents” of technical malfunction.</p>
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<p class="css-158dogj evys1bk0">There are two troubles with all
this. First, none of it is news; a growing number of
scientists, physicians and medical journalists, from René
Dubos in “The Mirage of Health” through Rick Carlson in “The
Limits of Medicine,” have been saying the same things to the
general public, with increasing urgency, throughout the past
decade. Second, Illich concentrates on the curing functions of
medicine, where the record is not very good and overlooks the
caring functions—the ability to relieve, to support, to
rehabilitate, to make life not only tolerable but rich and
useful even in the presence of continuing disease.</p>
<p class="css-158dogj evys1bk0">Much more important is social
iatrogenesis, the over‐medicalization of society, the
manipulated addiction of populations so they depend on medical
care and medical institutions, the mystification of medical
knowledge, the expenditure of enormous sums for medical care
and research, the infiltration of patient and therapist roles
into all areas of social life, the medical preemption of
normal stages of life, so that pregnancy becomes “a state of
risk,” old age becomes “geriatrics,” and dying becomes
indecent outside the intensive care unit.</p>
<p class="css-158dogj evys1bk0">Let Ilitch describe it, for he
is nowhere more eloquent than here. Social iatrogenesis
obtains, he says, when: “… health care is turned into a
standardized item, a staple; when all suffering is
‘hospitalized’ and homes become inhospitable to birth,
sickness and death; when the language in which people could
experience their bodies is turned into bureaucratic
gobbledegook; or when suffering, mourning and healing outside
the patient role are labeled a form of deviance.” It induces
people to “forgo their own lives to get as much treatment as
they can” and furthers “the fallacy that society has a supply
of health locked away that can be mined and marketed.”</p>
<p class="css-158dogj evys1bk0">It continues to the point at
which, “until proved healthy, the citizen is now presumed to
be sick … the result is a morbid society that demands
universal medicalization and a medical establishment that
certifies universal morbidity.”</p>
<p class="css-158dogj evys1bk0">Finally, there is cultural
iatrogenesis, which “sets in when the medical enterprise saps
the will of people to suffer their reality.” Professionally
organized medicine, Illich contends, “has oome to function as
a domineering moral enterprise that advertises industrial
expansion as a war against all suffering. It has thereby
undermined the ability of individuals … to accept inevitable
and often irremediable pain, impairment, decline and death.”
In effect suffering, healing and dying, which are essentially
intransitive activities that culture taught each man, are now
claimed by technocracy as new areas of policy making, and
treated as malfunctions from which populations ought to be
institutionally relieved. When pain is killed and death
denied, when culture—a system of values and beliefs—is
replaced simply by a system of techniques, autonomy withers
and an essential aspect of our humanity fades.</p>
<p class="css-158dogj evys1bk0">What does Illich want us to do?
Just as we must stop—even retrogress —general
industrialization, he says, so must we eliminate much of the
output of the medical industry, reappropriate our own health
care and return it to the individual. Illicit suggests
specifically that we deprofessionalize and demystify healing
by prohib iting the licensing and regulation of doctors or any
other group of healers, leaving anyone free to practice
anything and leaving all of us free to choose anyone (or no
one) to give us treatment. He wants an end to “the myth that
increasing dependence of people on the right of access to
impersonal institution is better than trust in one another.”
Indeed, he attacks even modest liberal strategies for change,
such as national health insurance, for it would increase the
access of the poor to medical care and hospitals, reinforcing
their passive‐addictive dependency, when what we need is fewer
organized health services, not more! He wants an emphasis on
self‐care, with responsibility for treatment shifted to the
sick man and his next of kin. He wants us to be free to drop
out, reverse the growth of industrialization and organize for
a less destructive way of life. Nowhere does he explicitly
argue for a major redistribution of resources, or public
control of the process of industralization.</p>
<p class="css-158dogj evys1bk0">Despite coy suggestions,
scattered everywhere in “Medical Nemesis,” of the need for
radical political and economic change, Illich thus rejects
political and economic solutions in favor of a sterile
individualism. These are the politics of life style—and the
economics of Milton Friedman. Medicine would become the
province of small‐scale entrepreneurs in an ideal free market
(an Implicit statement of its commodity nature). Real change
in the distranition of resources and power would be
approached, if at all, through an individualist ideal of
personal action, and enlightenment—a kind of spiritual
recognition of the limits of growth and material progress
—substituted for economic reform. The polemic that began with
such a sociocultural bang ends in a political whimper.</p>
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<p class="css-158dogj evys1bk0">“Medical Nemesis” already has a
history, as a result of an unusual (and highly intelligent)
idea. An earlier and much simpler version was published in
England more than a year ago as “an outline for a seminar and a
draft for a book”—a trial balloon, a lightning rod intended to
draw criticism, commentary, correction and rebuttal. The new
American version is enlarged and reworked in response to those
responses.</p>
<p class="css-158dogj evys1bk0">The professional responses—in the
British Medical Journal, Lancet and elsewhere — took Illich
seriously, agreed that unlimited demand for medical care is
self‐defeating and that the provision or ever.increasing
resources for medicine will solve nothing, quarreled with the
feasibility of his proposals that we turn back and disassemble
the industrial machine and argued that he was not radical
enough! One physician, in the unkindest and elitist cut of all,
pointed out that Illich has said nothing that has not already
been said by doctors: “There are already more radical thinkers
within the ranks of medicine than Illich, and they understand
more about biology.”</p>
<p class="css-158dogj evys1bk0">It is all the more disappointing,
then, that from Mich's cocoon of apparent radical humanism there
ultimately emerges no bright butterfly of revolutionary change
but rather, in a curious inversion, a caterpillar of petty
conservatism.</p>
<p class="css-158dogj evys1bk0">There are good arguments for more
self‐care and personal responsibility in health. Whatever the
responses to the arguments in this book and despite his
political shortcomings, we should be grateful to Illich. No
polemicist writing today has his passion, his range, his
glittering and pyrotechnic arsenal. At this point it is the
questons that count, not the answers. Illich is not concerned
with how we can “improve” our medical care system, or finance
it, or increase the access of the poor to it in its present
form, or better organize it. Instead, he asks why we have it,
what we really expect from it, how it mirrors—and reinforces—our
social order, what it reveals about us. He uses medicine to ask
us what we want from life, and he questions our dreams of
reason. He cares deeply about the human condition, and he has
maintained the essential ingredient of that oaring, a capacity
for outrage. If we can confront his outraged—and outrageous
—questions, we will, inevitably, begin to change.</p>
</div>
<div class="moz-cite-prefix">On 19-08-2020 20:48, R.O. wrote:<br>
</div>
<blockquote type="cite"
cite="mid:ba6bbbc6-eecd-9fdf-59c1-71c58deed6cf@ziggo.nl">
<meta http-equiv="content-type" content="text/html; charset=UTF-8">
<p><img
src="https://www.kb.nl/sites/default/files/styles/plaatje_260px/public/illich.png?itok=ka8nPZqd"
alt="https://www.kb.nl/sites/default/files/styles/plaatje_260px/public/illich.png?itok=ka8nPZqd"
class="transparent" moz-do-not-send="true"></p>
<address><br>
</address>
<address><a class="moz-txt-link-freetext"
href="https://www.kb.nl/zorg-voor-de-gezondheid-en-zorgen-over-de-gezondheidszorg"
moz-do-not-send="true">https://www.kb.nl/zorg-voor-de-gezondheid-en-zorgen-over-de-gezondheidszorg</a></address>
<address><br>
</address>
<p>[...]</p>
<p>Achterhuis werd in zijn kritiek op de gezondheidszorg uit de
jaren 90 geïnspireerd door de
Oostenrijks-Amerikaans-Mexicaans-Duitse filosoof Ivan Illich<span
class="ext"><span class="element-invisible"></span></span>. In
zijn boek <em>Het medisch bedrijf</em> (1976) onderscheidt
Illich drie aspecten in de gezondheidszorg die problemen kunnen
opleveren: 1. klinisch, 2. sociaal 3. structureel. Een voorbeeld
van een probleem veroorzaakt door sociale factoren is de keuze
om wel of niet behandeld te worden. Volgens Illich en Achterhuis
is dit niet altijd gerelateerd aan de ziekte zelf. Het heeft
vaak te maken met hoe dicht je bij een arts woont of hoe je
omgeving op je ziekte reageert. Daarbij worden mensen
structureel vaker medicijnen voorgeschreven waar ze afhankelijk
van worden. Een voorbeeld hiervan is slaappillen. Het gebruik
van slaappillen intensiveert het gebruik van deze medicijnen.
Dit resulteert vaak in verslavingen die iemand juist zieker
maken.</p>
<p><br>
</p>
<p>[...]<br>
</p>
<br>
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