A Wrong Diagnosis

...Modern medicine is alienating, forcing the individual to sacrifice his autonomy and become entirely dependent on the physician and institutions of industrial medicine that cannot provide the human supportiveness characteristic of the traditional cultures...

...Unfortunately, there is little else here...

...The achievements of the antibiotic revolution of the early 1950s have never been matched...

...this is a profoundly worthless book...

...This situation has created an irresistible target for Ivan Illich, the sage of Cuernavaca...

...But Ulich is missing the point here...

...There is a more basic error in Illich's discussion of clinical iatrogenesis, too...

...Least original is the section on clinical iatrogenesis...

...and the dubious value of many currently popular medical techniques...

...And while this appears to be primarily a result of inflation, for the first time since before World War II widespread doubt is being expressed about the legitimacy of the huge investment in "scientific" medicine...

...Illich's citations for his discussion of clinical iatrogenesis come, again, from the medical literature itself...

...the great advances in life expectancy in this century are more the result of improved nutrition and sanitation than of medicine narrowly defined...

...The nemesis Illich deals with is "iatrogenesis," a technical term currently in vogue describing illness produced by medical care itself...

...Several readily identifiable factors have contributed to the new skepticism...

...Like most diseases, the major lacunae of medicine are probably self-limiting...

...Some of the fruits of modern medicine have also begun to backfire: There is now an epidemic of uterine cancer, probably caused by the widespread prescription of estrogen therapy for menopausal and postmenopausal women...

...Ironically, of all contemporary institutions Illich has attacked, medicine is perhaps the one most capable of reforming itself within the confines of the modern industrial system...

...In attempting to "cure" human suffering, the author argues, instead of seeking creative ways to encompass it in human experience to promote health, medicine today destroys health...

...His response is Medical Nemesis, a tour de force of scholarship and offhanded erudition...

...There is a medical care "crisis" in almost every Western nation...

...It must be emphasized that Illich's view of this process is not tragic but simply conservative...

...And there is no question that notions of illness differ from one society to the next, or that stigmatization can have baleful affects on the individual...

...In addition, the exalted position science as a whole occupied for a generation has begun to be challenged by the generalized disillusionment with social institutions and the reemergence of belief in (he mystical and occult...

...the major killers of Western man can be partially controlled by diet, exercise, and abstinence from tobacco and alcohol, but hardly at all by physicians...

...Nonetheless, those questions are all receiving attention from the medical establishment-in the very articles and studies the writer cites...

...To a considerable extent, all the problems discussed are the result of what Mao might have called "nonantagonistic contradictions" in contemporary medicine...

...Given the importance of the health sector in the nation's economy, it is surprising that people have only recently begun to examine the efficacy of conventional practices, or the control of medical institutions...

...Indeed, those living in the United States have, as Tocqueville knew, no remnants of a feudal past to fall back on...

...Overblown expectations about the power of science also play a role...

...that is, they are not inherent in the underlying logic of medical science and could be overcome without radical change...

...His solution is developing more high technologies to treat currently intractable conditions, a task that is not far-fetched...

...He takes the "labeling theory" of thinkers like Goffman, Laing and Szasz and beats it to death in an attempt to identify medicine as a primary mechanism of social control in industrialized society...

...The inappropriate employment of sophisticated technologies to prolong terminal illnesses has, for the first time in human history, made it-to steal a line from a colleague-more difficult to leave the world than to enter...

...He even has a nice little theory to sum it ail up: To the extent that the putative values of the industrial system exceed those of spontaneous, unrationalized social activity-to the extent individuals become more reliant on the bureaucratic system than on their own resources-society is destructively counterproductive...

...The best weapons available for changing or challenging the awkward beast of modern medicine are not appeals to traditional simplicity, but Bacon's canons-medicine's own favorite tools...

...For one, expenditures for health services in the industrialized nations may well have reached the point of diminishing returns...

...The problem, as Lewis Thomas has argued, is that medicine has very few technologies like immunization and is therefore forced to employ "halfway" measures...

...he explicitly prefers Job to Prometheus...

...It is easy to sympathize with Illich...

...the in appropriateness of capital-intensive, hospital-based, specialty-oriented "tertiary" care for the Third World...

...his dominant metaphor is that of the Greek goddess responsible for what unromantic moderns rightly call "unintended consequences"-Sartre called it "counterfmality"-who responds to hubris by turning human endeavors back on themselves...

...extra billions contribute little to increasing life expectancy or reducing disability...

...Borrowing heavily from medical literature, Illich recites increasingly weM-recognized information about the volume of adverse reactions to overpre-scribed drugs...

...It is heartening to find an author- especially so radical a critic of existing society-who still believes in reading as well as writing, classical metaphor as well as technical jargon, and the use of the footnote to instruct as well as to meet the requirements of the academy...

...Thus we are informed that the volume of surgery performed in a given locality is primarily a function of the number of surgeons practicing there...

...The bulk of the book consists of exposition on what he defines as the three levels of the malady: clinical, social and cultural...

...From the perspective of the underdeveloped Third World that he self-consciously identifies with, attempts to impose Western technological standards often destroy most of what is supportive, humane and productive in traditional culture without creating suitable alternatives...

...But not everyone lives in the Third World...

...Here he confronts the Promethean dream directly...

...Despite Illich's view, we are going to have science and bureaucracy one way or another...

...Illich's discussion of social iatro-genesis-the "medicalization" of modern life-is substantially more interesting and provocative than his assessment of clinical problems, if still unconvincing...

...In this sense, the relationship of Western medicine to traditional society is no different than that of Western education, housing or transportation...

...He smiles approvingly at some basic medical techniques- notably immunization against infectious disease-while insisting these can be administered by individuals with substantially less training than physicians, and that they are only tangential to the current practice of medicine, which concentrates on more complicated and questionable procedures...

...Biomedical research has produced not a steady stream of new miracles but a more irregular flow of problems, hypotheses and questions...

...Health, says Illich, is equivalent to individual autonomy, a condition dependent on the cultural context...

...We are stuck in a post-Cartesian world, with no way to escape, and Illich's exhortations to adopt the simple and unsophisticated ring hollow...

...On these and many related matters, Illich's analysis is more sophisticated than that of the New York Times, though not much more enlightening...

...More important, compared to what it was a generation ago, medical care in the United States today is impersonal and frightening-as well as frighteningly expensive...

...The family physician has virtually disappeared, replaced by the institutional emergency room...

...So does his rejection of any form of conventional political opposition that might reenforce the characteristics of modern society...

...People rarely die from an overdose of labels...

...The socially-delegated power of physicians to determine who is sick-with all that implies-and who is well undoubtedly has some important consequences, although probably less in instances of physical than emotional illness...

...Illich's use of "nemesis" is central to both his specific argument and broader conceptual scheme...

...we can only try to make certain that they are as benevolent as possible...

...Illich's definition of the problem, then, is hardly radical and he totally ignores the abundant potential for meliorative reform...

...Reviewed by Bruce C. Vladeck Assistant Professor of Public Health and Political Science, Center for Community Health Systems, Columbia University THINKING about health and medical care, both popular and technical, has reached something of a watershed...

...The expropriation of pain, death, healing, and health by the medical profession thus constitutes one of the major components of the destruction of human society by the forces of modernity...

...Illich's central thesis becomes apparent only in the section on cultural iatrogenesis...

...To make this argument, Hllich puts himself in the position of defending pain, suffering and premature death, for they are inherent in the human condition and produce only nemesis when they are opposed by the bureaucratic rationality of the 20th century...

...Thomas, incidentally, is not offering a technological fix, only suggesting that there are sound reasons why medicine-at this point in its history-is better at coping with some diseases than others...

...By turning health into a commodity produced in an industrial system, modern medicine has broken the interconnection between somatic status and culture, between the individual and his own identity...

...Ulich does little to demonstrate medicine's interconnection with other structures of power in society, a necessary corollary to the idea of medicine as a technique for social control...

...After all, polio was once only treatable by the most painful, expensive and largely ineffective methods...

...Most things physicians call diseases, however, have concrete reality to patients and concrete effects...

...From the book's definition of social iatrogenesis, one might conclude Illich is going to talk about the relationship between the way physicians "manage" patients and the needs of a capitalist or postin-dustrial system, but all he offers is a rather fragmented catalogue of medical follies and misdeeds...

...to the degree that practitioners of modern medicine see themselves as parts of a scientific traditon, they are likely to share a restlessness about approved knowledge and practical inconsistency...