Tuesday, 7 January 2014

Until proved healthy, the citizen is now presumed to be sick.

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

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

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

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.

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

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.

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