Rhodri Evans is a GP in Newport, South Wales. He is interested in the environment and health. He is on X: @DrRhodriEvans
2024 has seen the 50th anniversary of the publication of Medical Nemesis: The Expropriation of Health by Ivan Illich,1 a book which has had the same impact on the language of healthcare as George Orwell’s 1984 has had on the language of politics. Illich did not invent terms such as iatrogenesis and medicalisation, but he was the first to synthesize them in an excoriating critique of modern medicine. However, whilst 1984 has never been out of print, Medical Nemesis is largely forgotten. Why?
The radical nature of Medical Nemesis is immediately visible from its provenance: it was published as part of a ‘series of working papers dealing with alternatives to industrial society.’ Re-printed in 1976 as Limits to Medicine2, it pulled no punches with the first sentence, ‘The medical establishment has become a major threat to health.’ To some doctors this came as an enlightenment moment: Richard Smith, former editor of the BMJ, described it ‘as the closest I came to a religious experience’.3 For the most doctors and policymakers, however, the message was perplexingly extreme, and Illich faded into obscurity.
It is impossible to pigeon-hole Illich, but it is reasonable to describe him as an Austrian priest/philosopher/sociologist As the title Medical Nemesis suggests, he was heavily influenced by Greek philosophy and mythology. Nemesis represents divine retribution for the hubris of mortals, in this case what Illich described as ‘hygienic hubris’, or the medicalisation of life. Medical nemesis is the consequence, and it takes the form of iatrogenesis, the key concept in Illich’s argument. Iatros is a Greek word for physician, and iatrogenic illness or injury are now common phrases in healthcare, and they are synonymous with errors made by doctors. However, iatrogenesis as defined by Illich is a much broader concept, and he defined it in three forms: clinical iatrogenesis, social iatrogenesis and cultural iatrogenesis. These three forms of iatrogenesis form a ‘self-reinforcing loop of negative institutional feedback’, and this is Illich’s medical nemesis.
Medical Nemesis therefore is arguably one of the first calls for Evidence Based Medicine, a movement which would take at least another 20 years to gather steam.
Of the three, clinical iatrogenesis is probably most widely known, but in fact this is given the least discussion by Illich. Nevertheless, there is plenty of space to give doctors both barrels, notably in the section headed ‘Doctors’ Effectiveness – An Illusion’ where he states for example that in the 19th century ‘doctors have affected epidemics no more profoundly than did priests in earlier times.’ Illich correctly attributes reductions in fatal infectious diseases to environmental improvements such as sanitation and nutrition, where the role of doctors is minimal. Extending the religious comparison, ‘rituals in medical clinics’ are no more effective than those ‘customary at medical shrines.’ Illich does respect certain medical innovations such as smallpox vaccination, contraception and the use of antiseptics in surgical procedures. Crucially these are low-cost innovations which can be applied cheaply and widely in all populations, and often opposed by the medical establishment. He is highly critical however of most technological innovations, stating that ‘most of today’s skyrocketing medical expenditures are destined for the kind of diagnosis and treatment whose effectiveness at best is doubtful.’ Amongst his references Illich notes A.L. Cochrane, whose work gave rise many years later to the eponymous library of systematic reviews. Medical Nemesis therefore is arguably one of the first calls for Evidence Based Medicine, a movement which would take at least another 20 years to gather steam. What doesn’t give Illich this recognition however, especially to a 21st century readership, is his broad-brush approach, and frankly dangerous criticisms. He states that apart from skin-cancer, there ‘is little evidence of effective treatment of most other cancers.’ Similarly for heart disease, treatments are effective only in ‘exceptional circumstances;’ and as for hypertension, Illich claims that most patients on antihypertensives are at risk of ‘serious harm’ from the prescriptions of the ‘rash artery-plumbers.’
Actual ‘doctor-inflicted injuries’ are, of course, at the highest level of harm, and llich argues that ‘they now rival the morbidity due to traffic and industrial accidents and even war-related activities’. Medication attracts particular criticism, and presciently Illich states that ‘antibiotics alter the normal bacterial flora and induce a superinfection, permitting more resistant organisms to proliferate and invade the host.’ Clinical iatrogenesis also occurs indirectly by defensive medicine: over-investigating and over-treating in order to avoid litigation and prosecution. This, according to Illich, is the consequence of doctors’ changing role in society, specifically the ‘transformation from an artisan exercising a skill on personally known individuals into a technician applying scientific rules to classes of patients’.
The second form of iatrogenesis, social, is the medicalisation of life. It is difficult to grasp how radical this would have sounded 50 years ago: ‘medicine creates ill-health by increasing stress, multiplying dependence, by lowering the levels of tolerance for discomfort.’ According to Illich, self-care and ‘mutual care’ were banished by society to the status of ‘misdemeanours or felonies’. Furthermore, medicine, like law and religion was now defining what was normal, to the point that ‘all deviance has to have a medical label.’ The medicalization of life results in the medicalization of the economy, with costs far outstripping GDP in poor and rich countries. The USA is clearly the main target for this particular attack, but other healthcare systems are not spared. Talking about the NHS in the UK, Illich states that ‘demedicalization of health care is as essential here as it is elsewhere.’
The medicalisation of society is heavily dependent on medication, or ‘The Pharmaceutical Invasion’ as Illich calls it. In Illich’s eyes, each culture traditionally had its own ‘poisons, remedies and placebos’, and modern pharmaceuticals serve to destroy that connection, with very little benefit to society. Most modern medicines ‘are destined for the healthy rather than for the sick,’ and in a medicalised society, this creates a form of dependency, or, in Illich’s words: ‘two groups of addicts: those for whom they prescribe drugs, and those who suffer from their consequence.’ The other form of medical control resides with the power of medical certification, or ‘diagnostic imperialism’ as Illich calls it. Through certification, doctors can assign people to different categories in society, most notably sick roles whereby people can be exempted from work. In more subtle effects, life becomes a ‘pilgrimage through check-ups and clinics,’ removing the need for personal responsibility.
Death features prominently in Medical Nemesis, and Illich argues that social iatrogenesis reaches its apogee in what he calls ‘terminal ceremonies’, or the ‘death-dance around the terminal patient’, where ‘celebrants in white and blue envelop what remains of the patient in antiseptic smells.’ So medicalized is modern death, that a death without medical supervision is ‘synonymous with romantic pig-headedness, privilege or disaster.’ Thereby, modern society becomes fearful of an ‘unhygienic death’, rendering terminal or palliative medicine with the ultimate level of power, with the physician ‘beyond potential control and criticism’. Society has become ‘pathetically dependent’, and Illich predicts a move towards medical euthanasia: ‘the right to be professionally killed has become a major issue’.
Both clinical and social iatrogenesis are dependent, to a large degree, on the third form of iatrogenesis – cultural, and I would argue that this is the most important for Illich, but also the most problematic. He sees cultural iatrogenesis as a hugely powerful force, distorting life for people, or in his words, ‘the medical enterprise saps the will of people to suffer their reality.’ Modern medicine results in mass denial, with people being unable to accept ‘inevitable and often irremediable pain and impairment, decline and death.’ A healthy culture for Illich is one which equips people ‘with the means for making pain tolerable, sickness or impairment understandable and the shadow of death meaningful.’ Cultural and psychological factors are undoubtedly strong factors in the genesis and maintenance of chronic pain, as any professional working in a pain clinic or in general practice will know. However, it is also true that there are many patients who suffer intractable physical pain which requires medical treatment. To state, as Illych does, that people ‘learn to interpret every ache as an indicator of their need for paddling or pampering’ is glib, and detracts from his otherwise strong argument. It would be interesting to see Illich’s response to the palliative care movement, which simply did not exist in his time, but now takes the holistic approach to pain that he professes. I suspect that he would still be dismissive, seeing it as merely another approach by industrialized medicine to judge which pains are ‘authentic’, and which are to be ‘controlled.’ Ultimately for Illich, there has been a tragic loss, where the medicalization of pain has stripped away the framework in traditional cultures which gave pain ‘meaning’ and over centuries allowed the development of the ‘art of suffering.’ After a career of caring for patients with intractable pain, this romantic viewpoint is one I struggle with.
Where Medical Nemesis remains highly topical is the argument that health-systems need to reconnect with environmental matters.
Having defined the three elements of iatrogenesis, Illich broadens his criticisms to the politics of health, and in so doing he links iatrogenesis to other aspects of what he calls ‘industrial overproduction’, for instance ‘stupefying education.’ It should be remembered that if anything, Illich was more exercised about education than he was by health, as evidenced by his earlier radical book Deschooling Society (1971). The aim of an industrialized society, according to Illich, is to teach, not learn; similarly in health care the aim is to treat, not heal. The solution is to move to a model of what he terms ‘autonomous production.’ In its essence this is an extreme form of self-care, and it is easy to laugh at some of Illich’s examples, for example fractures, ‘people recover the use of broken bones.’ However, self-care is now increasingly seen as crucial for managing the epidemic of long-term conditions in developed countries, and even Illich recognised the need for it to co-exist with industrialized medicine. Surely he would approve of fairly new concepts such as ‘co-production’, where a patient and a clinician are both involved in managing long-term conditions.
Therefore, does Medical Nemesis have anything new to say 50 years later? The arguments relating to iatrogenesis are widely accepted by doctors and wider society, and few now would have qualms about deprescribing and taking an evidence-based approach to medical interventions. Where Medical Nemesis remains highly topical is the argument that health-systems need to reconnect with environmental matters. Arguing against the effectiveness of much of modern medicine, Illich states that ‘the environment is the primary determinant of the state of general health of any population,’ and that modern conurbations cause harm because they ‘disable people from coping with their environment.’ In contrast, a healthy, thriving environment provides the ‘shelter of a local subsistence community’, where people are able to produce food on marginal land and are able to access networks of family and neighbours. It is easy to ridicule this call for self-reliance, but the argument 50 years ago that ‘the ecological movement has created an awareness that health depends on the environment’ seems prophetic now. It is also radical, as it calls for equity in environmental health: only when environments are equally healthy can there be the ‘freedom of self-care’ for all, with peoples living in ‘healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing and dying.’ Ever the sceptic, in time Illych became critical of the environmental movement, and he was afraid it would end up spawning a new set of institutions staffed by a ‘new set of experts in the surveillance and management of daily life.’4 Instead, for Illich the answer as always lay locally: ‘the only solution to the environmental crisis is the shared insight of people that they could be happier if they could work together and care for each other.’
References
- Ivan Illich, Medical Nemesis, Calder and Boyars, London, 1974
- Ivan Illich, Limits to Medicine, Marion Boyars, London, 1976
- Smith, R. Limits to medicine. Medical Nemesis: The expropriation of health. BMJ 2002; 324: 923
- David Cayley, Ivan Illich in conversation, Anansi, Toronto, 1992
Featured photo taken by Andrew Papanikitas, November 2024
