REVIEW OF BOOKS
H.J. Eysenck on
Ivan, the terrible obscurantist
There is a lot wrong with medical cafe, just as there is a lot wrong with education, or with any Other human activity. We are very ignorant, in spite of scientific advances made mainly during the past one hundred years; we are very opinionated, and refuse to act in conformity With the little that we do know; we refuse to do the right thing (eat less, exercise more, stop smoking) even when we know that it is the right thing to do. A critic consequently will have much to criticise, and what he says will hit many tender spots. This is all to the good; human institutions should be held up to scrutiny, rather than being accepted at their own evaluation. Medicine clearly is in a vulnerable position. Politics keeps interfering With the proper exercise of medical skill, and doctors tend to vote with their feet, and leave the country. But criticism must be constructive, and it must be just; the critic must impartially recognise what is good as well as what is bad. How does Ivan Illich stand up to these demands*?
Note first of all the shrillness of his tone. "The Medical establishment has become a major threat to health," he shouts. "Dependence on professional health care affects all social relations. In rich countries medical colonisation has reached sickening proportions; poor countries are quickly following suit." (What can he mean by "medical colonisation"?) "This Process, which I shall call the 'medicalisation of life,' deserves articulate political recognition. Medicine is about to become a prime target for political action that aims at an inversion of industrial society. Only people who have recovered the ability for mutual self-care by the application of contemporary technology will be ready to limit the industrial mode of production in other major areas as well." I am willing to bet that this is wrong. I have very little doubt that in fact medicine is not about to become a prime target for political action that aims at an inversion of industrial society, and in fact I very much doubt whether there is any such political action likely to be launched, or to attract any following should it be launched. This is political rabble-rousing, not objective reporting or meaningful criticism. What in fact are Illich's criticisms?
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 powers of the individual to heal himself and to shape his or her environment. The medical and Para-medical monopoly over hygienic methodology and technology is a glaring example of the political Misuse of scientific achievements to strengthen industrial rather than personal growth. Such medicine is but a device to convince those who are and tired of society that it is they who are ill, Inpotent and in need of technical repair.
;Medical Nemesis: The Expropriation of Health an Mich (Calder and Boyars £1.25) Note the double-entendre contained in the words "render society unhealthy"; also the implicit assumption that society, in some vague meaning of the word, is in fact "unhealthy." There is no proof, there is no proper definition of what "unhealthy" means in this context; there is simply shrill assertion. Note also the admixture of political obscurantism; what on earth can a professional health care system do to obscure political conditions, and just what are these political conditions? I never really found out, nor did I discover the alleged relationship. All this is a great pity, because some of the facts cited by Illich should be more widely known, and some of the criticisms he makes are well taken. Iatrogenesis (the production of disease by the exercise of medical treatment) is a reality, and much more ought to be done about it than is in fact done; this is particularly true in psychiatry, but is also true in physical medicine. Drugs have important and sometimes very serious side effects; infections occur in hospitals, as do accidents. "The US Department of Health calculates that 7 per cent of all patients suffer compensatable injuries while hospitalised, though few of them do anything about it. Moreover, the average frequency of reported accidents in hospitals was higher than in all industries but mines and high-rise construction." True, but tHen of course patients in hospitals are particularly liable to accidents because of their weakened state, and for other reasons; the comparison is hardly a fair one. But then little of what Illich says is fair; he means to hurt, not to give a rational picture of the situation as it is.
"The undesirable side-effects of approved, -mistaken, callous or contra-indicated technical contacts with the medical system represent
only the first level of pathogenic medicine." He calls this clinical iatrogenesis. "On a second level, medical practice sponsors sickness by reinforcing a morbid society that not only industrially preserves its defectives, but also exponentially breeds demand for the patient role. . . Second level iatrogenesis finds its expression in various symptoms of social over-medicalisation." This level he designates as social iatrogenesis, but worse is to come. "On a third level, the so-called health professions have an even deeper, structurally health-denying effect insofar as they destroy the potential of people to deal with their human weakness, vulnerability and uniqueness in a personal and autonomous way. Structural iatrogenesis. . . is the ultimate backlash of hygienic progress and consists in the paralysis of healthy responses to suffering." There is some truth in all these criticisms, but they are expressed in such a one-sided, opinionated, ideologically-motivated manner that few readers at all familiar with the facts will take them seriously.
To take but one example: Illich spends much time on "debunking" the idea that medicine has anything to do with the better health enjoyed by modern industrial man. "Awe-inspiring medical technology has combined with egalitarian rhetoric to create the dangerous delusion that contemporary medicine is highly effective. Although contemporary medical practice is built on this erroneous assumption, it is contradicted by informed medical opinion." He reluctantly admits a few exceptions; "during the last generation, a limited number of specific procedures have indeed become effective. . . . Chemotherapy has played a significant role in the control of pneumonia, gonorrhoea and syphylis.... Malaria, typhoid, syphylis and yaws can be cured quite easily. . . ." But "for most other infections, medicine can show no comparable results." And: "The effectiveness of medical intervention in combating non-infectious diseases is even more questionable." One looks for a discussion of pros and cons, but finds only condemnation; there is for instance no mention of insulin, a life-line if ever there was one, and a saviour of millions of lives. To debunk is one thing; to omit important facts is quite another.
Illich writes his highly sensationalised books by doing the latter; he can never be trusted to play fair, or to give a balanced view. He would probably agree; his purpose is to shock, not to enlighten. But for that very reason this book can hardly be recommended; it does by screaming from thehousetops, haranguing, and humourless politicising what A. L. Cochrane has done wittily, knowledgeably, and quietly in his excellent book, Effectiveness and 'Efficiency: random reflections on health services. I very highly recommend Cochrane; I wish I could do the same for Illich, but I have a prejudice against highly charged salesmanship, whether of ideas or more mundane matters. I do not believe that serious problems should be discussed in this sort of tone, or with so much show of bias. A scream of rage is no substitute for patient, rational analysis, although by its very extremeness it may excite more comment — more's the pity!
H. T. Eysenck is Professor of Psychiatry at the University of London
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