Let
me be very clear at the outset: I am not against health care - the same way as
I am not against smart phones! I do not disagree with the positive impact
medicine, and precisely, healthcare as a whole has had on humanity so far. The
services of vast majority of doctors and other healthcare professionals are highly
commendable; there is no doubt. My reasoning is beyond the layer of healthcare
delivery, beyond the ‘institutional pampering of using medicine to stabilise an
industrial society.’1 My question is whether
we are medicalising care, cure and everything in between?
My
question is also about the ‘medicalisation of life’ itself. If so, at what ‘non
marketable use-value’ (Note, I am not using the term ‘cost’) of things that
people freely produce such as learning to see and do, moving on their feet,
produce children and bring them up, healing, taking care of their health and
contributing to others’ health, prepare the local diet? These are valuable
activities which most of the time will not and cannot be undertaken for money,
but it can be devalued if too much money is around.2
The
medicalisation of life has already happened to an extent in the United States
of America (health care spending in the USA amounts to nearly 18% of its GDP).
The BRICS (BRICS is the acronym for an association of five major emerging national economies:Brazil, Russia, India, China and South Africa) and the MINT (MINT is a neologism referring to the economies of Mexico, Indonesia, Nigeria, and Turkey) countries are more likely to increase their spending perhaps up to 4-10% of GDP
on health care in the near future. These countries will at some point be
spending the OECD average2
(9.3% of GDP in 2011) on healthcare as more and more western medical care model
is exported to these areas. All these countries would generate the same level
of dependence on clinicians and health care professionals (relative to their
spend) irrespective of their ideology and nosology3
(the branch of medicine that deals with classification of diseases).
The
medical establishment has become a major threat to health.. .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
urbanisation represents to competence in homemaking. In each case a major
institutional endeavour has turned counterproductive.4
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The
more I explore the growing industrialisation and overexpansion of medical care,
the more I realise that health care does not foster self-care and personal
autonomy strongly enough. It is during this time of search for an alternative
view, I stumbled upon Ivan Illich and his works.
This
essay is a dedication to Ivan Illich and his radical ideas contained in one of
his seminal works.
Reading
Ivan Illich’s ‘Limits to Medicine - Medical Nemesis: The Expropriation of
Health’ was the closest to a heightened spiritual experience (if there was one)
for me. The ideas put forward in the work were so original, radical and
reasoned that it would have been very easy to dismiss it as outright nonsense
because that is what we sometimes do to original works of art. It takes
many decades or even centuries to understand the true value of a great work. I
was moved by the force of many of Illich’s arguments and questions and the
simple but robust principles he builds them from.
Nearly
forty years since its original publication, the ideas contained in Ivan
Illich’s book, I think, are so vital, relevant and urgent, if we are to truly
understand what ‘health’ actually means in the 21st century.. As a
matter of fact, for sometime now I was trying to understand what the word
‘normal’ meant…what ‘being normal’ meant for me? just me; not from what you
would perceive me to be...
In Latin, ‘norma’ means ‘square,’ the
carpenter’s square. Until 1830s the English word ‘normal’ meant standing at a
right angle to the ground. During the 1840s it came to designate conformity
to a common type. In 1880s, in America, it came to mean the usual state or
condition not only of things but also of people.5
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Likewise,
I have been contemplating the meaning of the word ‘health’ as well. Tracing its
etymology, I gathered it meant: holy, whole, uninjured, sacred, to heal etc. at
various times in history. In fact, the word ‘healthy’ was only attested in
1552. Looking at what the word ‘health’ has been made to mean or represent
across the world is a disturbing phenomenon. I am looking at its current
use which informs its etymon (true sense) and I am perturbed.
Enter,
Ludwig Wittgenstein.
Wittgenstein
said that the ‘meaning of a word is sum total of its possible uses.’ One of his
favourite slogans was ‘Don’t ask for the meaning, ask for the use’.6
The
word ‘health’ has been commodified beyond recognition around the world and the
discourse surrounding it from the majority of politicians, policy makers and a
few health economists is not at all helpful. Moreover, I would attribute the
biggest blame to the ‘modern society’ as a whole which has let the
industrialisation of its world-view being applied to health as well. In a
managed commodity production, people are trained for consumption rather than
action, and at the same time their range of action is narrowed. Health care is
now on this conveyor belt.
Is
there a way out of this delusion? Illich gives us some great options.
For
Illich, ‘Health’ is simply an everyday word that is used ‘to designate the
intensity with which individuals cope with their internal states and their
environmental conditions.’
In
his writings, Ivan Illich combines the solemn, soul-stirring expressions of a
parish priest with the deep, evidenced historian’s insights to produce a
discourse on health that supports enhancement of individual autonomy: of
coping, suffering, sharing, and healing oneself rather than becoming a
commodified entity that impinges on an individual’s freedom and independence
i.e., a system that supports the expropriation of health.
Schools produce
education, motor vehicles produce locomotion, and medicine produces health
care….Their production costs can be added to or subtracted from the GNP,
their scarcity can be measured in terms of marginal value, and their costs
can be established in currency equivalents. By their very nature, these
staples create a market. Like school education and motor transportation,
clinical care is the result of a capital-intensive commodity production; the
services produced are designed for others, not with others nor for the
producer.7
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Illich
elucidates the three ways in which the predominance of medicalised health care
becomes an obstacle to a healthy life; firstly, clinical iatrogenics,
which results when organic coping capacity is replaced by heteronomous
management; secondly, social iatrogenics, in which the environment is
deprived of those conditions that endow individuals, families and
neighbourhoods with control over their own internal states and over their
milieu; and, thirdly, cultural iatrogenics, in which the medical
enterprise saps the will of people to suffer their reality. Illich then coins a
new term called ‘medical nemesis’ and provides ideas to reverse it
without falling prey to the ‘medicalisation of life’ itself.
Clinical
Iatrogenics:
Clinical
Iatrogenics has been there since the time of the Romans. Roman law did protect
the slaves and citizens to an extent with mistakes made by the doctors (‘damnum
injuria datum per medicum’).8
Jurisprudence in Rome made the doctor ‘legally accountable not only for
ignorance and recklessness but for bumbling.’ Illich details the reasons for
professional callousness, negligence and sheer incompetence. According to him,
when the doctors’ trade moved over the centuries from artisan to professional
individuals applying scientific rules,malpractice acquired an anonymous, almost
respectable status.
Only doctors ‘’know’’ what constitutes
sickness, who is sick, and what shall be done to the sick and to those whom
they consider at a special risk. All deviance now has to have a medical
label. The divorce between medicine and morality has been defended on the
ground that the medical categories, unlike those of law and religion, rest on
scientific foundations exempt from moral evaluation.
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Finally,
clinical iatrogenics for Illich, not only includes the damage inflicted by
doctors with the intent of curing or of exploiting the patient,
but also torts that results from the doctor’s attempt to protect
himself. Such attempts to ‘avoid litigation and prosecution may now do
more damage than any other iatrogenic stimulus.’
A
contemporary example for clinical iatrogenics could include quacks operating in
rural India who tempt people to undergo unnecessary surgeries, in some cases,
removing vital organs such as kidneys without the patient’s knowledge when in
fact the patients visit the quacks for other conditions/ailments. In England,
the findings of the investigations into Mid Staffordshire NHS trust between
2005 to 2009 about the reasons for needless deaths of patients, among other
issues, is another example. A ‘’duty of candour’’ is now being introduced the
world over so that clinicians and other health staff are to have the moral
imperative to be open to patients when things go wrong. Moreover, as Illich
says, the ‘new devices, approaches, and organisational arrangements, which are
conceived as remedies for clinical and social iatrogenics, themselves tend to
become pathogens contributing to the new epidemic.’
Social
Iatrogenics:
To
Illich, social iatrogenics is at work when healthcare is turned into a
standardised item, a staple: when all suffering is ‘hospitalised’ 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. An important fact more relevant to the current time is that
not only production but also consumption stresses the scarcity of time, space
and choice.9
Illich
rightly says that the more time, toil and sacrifice spent by a population in
producing medicine as a commodity, the larger will be the by-product, namely,
the fallacy that society has a supply of health locked away which can be mined
and marketed.10 The negative
function of money is that of an indicator of the devaluation of goods and
services that cannot be bought. Illich concludes by saying: ‘the higher the
price tag at which well being is commandeered, the greater will be the
political prestige of an expropriation of personal health.11
Cultural
Iatrogenics:
For
Illich, cultural iatrogenics represents the third dimension of medical health
denial. It sets in when the medical enterprise saps the will of people to
suffer their reality. Cultured health is bounded by each society’s style in the
art of living, feasting, suffering and dying.12
To Illich, the ideology promoted by contemporary cosmopolitan medical
enterprise runs counter to traditional cultural functions.13
In
the medicalised world, the classification of diseases (nosology) mirrors social
organisation. He adds that the ‘sickness that society produces is
baptised by the doctor with names the bureaucrats cherish such as: ‘learning
disability’, ‘hyperkinesis’, or ‘minimal brain dysfunction’ which explains why
their children do not learn, serving as an alibi for the school’s intolerance
or incompetence; high blood pressure serving as an alibi for mounting stress;
degenerating disease for degenerating social organisation.14
‘Language is taken over by the doctors: the sick person is deprived of
meaningful words for his anguish which is thus further increased by linguistic
mystification.’15
Writing
about ‘built-in Iatrogenics affecting all social relations’ , Ivan Ilich states
how ‘the siren of one ambulance can destroy the Samaritan attitudes of a
whole Chilean town.’ He goes on to say that it is because of ‘internalised
colonisation of liberty by affluence.’ For him it is this ‘medicalisation of
life’ which deserves ‘articulate political recognition.’
In
the contemporary world, the reasons for social isolation and discrimination
faced by people who deviate from the so called ‘‘normal’’ because they have
been branded as ‘‘that someone with mental health problem’’ (note, mental
health is a ‘problem’ as identified by the professionals) by the so called
qualified person (a Consultant Psychiatrist for example) is as challenging for
a person in 2014 as it was for someone during the 1970s. Also, someone having
“dementia” becomes an excuse for ridding themselves of their family and living
with unknown people in an institutional setting like a residential home.
Medical
Nemesis
The
word ‘’Nemesis’’ means ‘’to give what is due’’ (‘’nemein’’ in Greek). In Greek
tragedies, Nemesis, the goddess, appears as the avenger of crime and punisher
of hubris (extreme pride or arrogance).
Illich
believes that our contemporary hygienic hubris has led to the new syndrome of
‘’medical nemesis’’ (‘’Nemesis medicale’’ as a term was first used by the
French Caricaturist, Honore Daumier during the 19th century). Illich thinks
that the current breakdown of medicine is foreign to the industrially
determined logic and ethos. He believes that the ‘’reversal of nemesis’’ can
come only from within man and not from yet another managed (heteronomous)
source depending once again on presumptuous expertise and subsequent
mystification.
For
Illich, Nemesis has spread so far and as wide as universal schooling, mass
transportation, industrial wage labour, and the medicalisation of health.
Illich advocates that the political exploration and recognition of the
necessary material conditions for survival, equity, and effectiveness will have
to set limits to the industrial mode of production. Nemesis has become
structural and endemic.
To
Illich, the main source of pain, of disability, and of death is now engineered,
albeit nonintentional, harassment. Our prevailing ailments, helplessness, and
injustice are largely the side-effects of strategies for more and better
education, better housing, a better diet, and better health. Illich adds that
just as Galileo’s contemporaries refused to look through the telescope at
Jupiter’s moons because they feared that their geocentric world-view would be
shaken, so our contemporaries refuse to face nemesis because they feel
incapable of putting the autonomous rather than the industrial mode of
production at the centre of their sociopolitical constructs.
Health
as a Virtue
When
I finished Illich’s book, I was asking myself, how to reverse this nemesis
(medicalisation of health care) we have created so well in this technological
and industrial age?
In
the 21st century, politically, when one studies the type of strategies majority
of politicians bring forth depending on their ideological leanings about health
care reform, there doesn’t seem to be any radical departure from this
‘medicalised, commodified health care’. The politicians and policy makers on
the right usually look for the extra effectiveness and efficiencies that health
systems could deliver through increased competition - usually through
privatisation. There is a tacit recognition of public good delivered by keeping
health as a public service but there is also a strong desire to bring in some
market forces into it in the hope that if it is governed well, that market
injection would enable innovation and transformation not spearheaded
effectively by the state run services.
The
politicians on the left look at health and education as great public goods not
to be corrupted by the free market forces, which have a dubious track record
around the world in these sectors due to the ‘asymmetry of information’ they
produce and the desire for profit making creating health inequalities. They
also trust the public sector to function effectively and efficiently which in
reality is usually not the case in many countries due to the lack of
accountability, professionalisation, power play and other factors… but
politicians and policy makers from both the right and the left do not seem to
adequately question the goods produced by medical systems, the self-serving
rather than health serving nature of this medicalisation of health at an
industrial scale that is eroding the personal autonomy of individuals. Modern
medicine has disabled the whole population to survive on inhumanly low levels
of personal health.
Only
a society which reduces professional intervention to the minimum will provide
the best conditions for health. I agree with Illich’s conclusion that ‘a world
of optimal and widespread health is obviously a world of minimal and only
occasional intervention. Healthy people need minimum bureaucratic interference
to mate, give birth, share the human condition and die.’16
References
The
title of this essay is borrowed from the late psychiatrist, Franco Basaglia’s
La maggioranza deviante: L’ideologia del controllo sociale totale, Nuovo
Politecnico no 43 (Turin: Einaudi, 1971)
2.
Ivan Illich, Limits to Medicine - Medical Nemesis: The Expropriation of
Health (London: Marion
Boyers:
2013)
3.
Ibid., p. 55.
4.
Ibid., p. 7.
5.
Ibid., p. 164.
6.
Bryan Magee, The Great Philosophers (New York: Oxford Univ Press, 2000)
7.
Ibid. 2, p.214
8.
Plinius Secundus, Naturalis Historia 29.19
9.
Staffan B Linder, Harried Leisure Class (New York: Columbia Univ. Press,
1970): Herbert
Marcuse,
Eros and Civilisation (Boston: Beacon Press, 1955)
10.
Victor Fuchs, ‘’Some Economic Aspects of Mortality in Developed Countries,’’
paper
presented
at the Conference on the Economy of Health and Medical Care, Tokyo, 1973
11.
Ibid. 2, p. 62.
12.
Erwin H. Ackerknecht, ‘’Natural Diseases and Rational treatment in Primitive
Medicine,’’
Bulletin
of the History of Medicine 19 (May 1946): 467-97
13.
Ibn Khaldun, The Muqaddimah: An introduction to History, trans. Franz
Rosenthal, Bollingen
Series
XLIII, 3 vols. (Princeton, N.J.: Princeton Univ.Press, 1967)
14.
Ibid. 2, p. 169.
15.
B.L Whorf, Language, Thought and Reality (New York: Wiley, 1956)
16.
Ibid. 2, p. 275.
