Ivan Illich
Marion Boyars
London
1976
294 pages
According to the Art:
Illich argues that health care as a social organization does more to hinder equality and opportunity for individuals than to improve the chances for them. He builds his argument around the concept of iatrogenesis (harm from health care), and discerns three forms of it: clinical, social, and cultural.
Synopsis:
In this book, Ivan Illich offers a harsh critique of health care as provided in western industrialized societies during the 1970s. However, he did not write this book as a health care expert. He was trained as a medieval historian and philosopher, and taught the history of friendship and the history of the art of suffering. Indeed, he admitted: “I do not care about health.” (p. i) And yet, he could have written the same critique 40 years later.
What brought Illich’s attention to health care was his broader interest in how modern responses to societal level challenges become counterproductive and even harmful:
The threat which current medicine represents to the health of populations is analogous to the threat which the volume and intensity of traffic represent to mobility, the threat which education and the media represent to learning, and the threat which urbanization represents to competence in homemaking.
p. 7
Illich’s general thesis is that health care can work against the healing people seek from it, that health care can be as pathogenic as disease, and that health care can expropriate health. Health care is a nemesis to its subjects, he asserted, because it is “a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.” (p. 275)
Illich builds his argument around the concept of iatrogenesis, which he differentiates into three categories: 1) clinical iatrogenesis, 2) social iatrogenesis, and 3) cultural iatrogenesis, each of which is given a separate section in the book.
Clinical iatrogenesis is the harm done to people as the result of actions taken to restore health or prevent illness, such as an adverse drug event, a hospital-acquired infection, or perforated bowel from a screening colonoscopy. Illich characterizes clinical iatrogenesis as it is understood and used in biomedical circles, but he brings a particular poignancy to it when he refers to “remedies, physicians, or hospitals [as] the pathogens, or ‘sickening’ agents” at work. (p. 27)
With social iatrogenesis, Illich is referring to the harm societal arrangements for health care can inflict on people it’s meant to help. These arrangements comprise hospitals, physicians, health care product industries, insurers (all forms of payers), and government agencies. The net effect of their actions is to standardize health care, and in Illich’s view, standardizing health care amounts to the “medicalization of life.” The more life is medicalized, the more people are forced to operate under the influence of organized health care, 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.” (p. 41) Harm results to people whose ideas of what constitutes illness and whose preferences in the management of their illnesses do not match up with standardized health care. They could be harmed by treatments they don’t think they need, such as drugs to blunt grief, or in the ways they do not prefer, such as in a hospital. Thus, in social iatrogenesis, the social arrangements of health care are the pathogens.
Before the social movements and transformations produced standardized health care, people of various cultures coped and adjusted in their own ways to the suffering they experienced. Illich’s cultural iatrogenesis occurs when societies capitulate to “professionally organized medicine [that] has come to function as a domineering moral enterprise that advertise industrial expansion as a war against all suffering.” (p. 127) Illich is not saying that suffering is good and should be preserved, but rather that societies coming under the control of industrialized health care suffer more and suffer in ways they no longer have the authority or will to manage. Cultural iatrogenesis also manifests when professionally organized medicine supplants community responses to health problems people in that community experience: “The siren of one ambulance can destroy Samaritan attitudes in a whole Chilean town.” (p. 8) He elaborates on how cultural iatrogenesis works against people with examples involving treatment of pain, creating and eliminating diseases, and death and dying.
Illich’s thoughts on countering the counter productivity of industrial health care take up the last section of the book. He does not propose tearing down organized health care, but rather getting it to where “health is identical with the degree of lived freedom,” because “beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom.” (p. 242) Illich is beseeching organized health care to leave life less medicalized so as to leave more room for people to decide themselves if their challenges are a matter of health or not, and how they would prefer to manage them when health care may have a role. To this end, he concentrated this section of the book mostly on the political responses required to restore “freedom and rights” people ought to have to manage their health.
Analysis:
When I first encountered this book in 2005 I was skeptical that it could be relevant at the time having been first published in 1976. The insights the book offered vanquished my skepticism, and a return to the book in 2017 finished off any recrudescence. The persistent relevance of the book is all the more impressive given the loads of books published on a continual basis about health care in western societies.
Illich’s book remains relevant amidst the onslaught of other books because his use of clinical iatrogenesis, social iatrogenesis, and cultural iatrogenesis as a foundation still works to explain a fuller range of factors determining the net effect health care produces on individuals and societies. Studies in the mid-2010s showing that clinical interventions rank near the top among causes of death confirms that clinical iatrogenesis remains an important determinant of health care outcomes. Social iatrogenesis has become a greater threat with health care becoming more standardized and concentrated: health care insurers and health care providers are transforming into for profit commercial entities; accrediting agencies and professional organizations are demanding compliance with treatment protocols; and state and federal governments are determining which diseases and conditions warrant payment coverage. Cultural iatrogenesis looms more now also as individuals, patient groups, professional groups, and special interest groups demand that variances in health, function, and behavior once considered “within normal limits” be recognized as diseases or conditions qualifying for health care management.
Illich’s model of iatrogenesis is thus not just still relevant, but more relevant than when he first proposed it, and is an important reminder that harm can come from health care in forms other than clinical interventions. His book, then, is not just for health care providers, but for all those who have an impact on how health care affects health, which is everyone.
Also:
A version of this review is posted at the NYU Literature, Arts and Medicine Database.
