Medical Nemesis: The Expropriation of Health(Ivan Illich)

Medical Nemesis:
The Expropriation of Health

[Includes acknowledgements, introduction and Part1 - Clinical
Iatrogenesis]

IVAN ILLICH / Random House 1976
Ivan Illich, Pantheon Books, A Division of Random House, New York.
First American Edition. Copyright 1976 by Random House, Inc. All
rights reserved under International and Pan-American Copyright
Conventions. Published in the United States by Pantheon Books, a
division of Random House, Inc., New York. Originally published in
Great Britain by Calder & Boyars, Ltd., London. Copyright © 1975 by
Ivan Illich. Manufactured in the United States of America. Library of
Congress Catalog Card Number: 75-38118 ISBN: 0-394-40225-1

Acknowledgments

My thinking on medical institutions was shaped over several years in
periodic conversations with Roslyn Lindheim and John McKnight. Mrs.
Lindheim, Professor of Architecture at the University of California at
Berkeley, is shortly to publish The Hospitalization of Space, and John
McKnight, Director of Urban Studies at Northwestern University, is
working on The Serviced Society. Without the challenge from these two
friends, I would not have found the courage to develop my last
conversations with Paul Goodman into this book.

Several others have been closely connected with the growth of this
text: Jean Robert and Jean P. Dupuy, who illustrated the economic
thesis stated in this book with examples from time-polluting and space-
distorting transportation systems; André Gorz, who has been my
principal tutor in the politics of health; Marion Boyars, who with
admirable competence published the draft of this book in London and
thus enabled me to base my final version on a wide spectrum of
critical reaction. To them and to all my critics and helpers, and
especially to those who have led me to valuable reading, I owe deep
gratitude.

This book would never have been written without Valentina Borremans.
She has patiently assembled the documentation on which it is based,
and refined my judgment and sobered my language with her constant

v

criticism. The chapter on the industrialization of death is a summary
of the notes she has assembled for her own book on the history of the
face of death.

IVAN ILLICH
Cuernavaca, Mexico January 1976

Contents

Introduction    3

PART I. Clinical Iatrogenesis

The Epidemics of Modern Medicine    13

Doctors' Effectiveness—an Illusion
Useless Medical Treatment
Doctor-Inflicted Injuries
Defenseless Patients

PART II. Social Iatrogenesis

2. The Medicalization of Life        39

Political Transmission of Iatrogenic Disease
Social Iatrogenesis
Medical Monopoly
Value-Free Cure?
Medicalization of the Budget
The Pharmaceutical Invasion
Diagnostic Imperialism
Preventive Stigma
Terminal Ceremonies
Black Magic
Patient Majorities

vii

PART III. Cultural Iatrogenesis

Introduction 127

3. The Killing of Pain 133

4. The Invention and Elimination of Disease 159

5. Death Against Death 179

Death as Commodity
The Devotional Dance of the Dead
The Danse Macabre
Bourgeois Death
Clinical Death
Trade Union Claims to a Natural Death
Death Under Intensive Care

PART IV. The Politics of Health

6. Specific Counterproductivity    211

7. Political Countermeasures    221

Consumer Protection for Addicts
Equal Access to Torts
Public Controls over the Professional Mafia
The Scientific Organization—of Life
Engineering for a Plastic Womb

8. The Recovery of Health        261

Industrialized Nemesis
From Inherited Myth to Respectful Procedure
The Right to Health
Health as a Virtue

Index        279

About the Author        289

viii

Introduction

The medical establishment has become a major threat to health. The
disabling impact of professional control over medicine has reached the
proportions of an epidemic. Iatrogenesis, the name for this new
epidemic, comes from iatros, the Greek word for "physician," and
genesis, meaning "origin." Discussion of the disease of medical
progress has moved up on the agendas of medical conferences,
researchers concentrate on the sick-making powers of diagnosis and
therapy, and reports on paradoxical damage caused by cures for
sickness take up increasing space in medical dope-sheets. The health
professions are on the brink of an unprecedented housecleaning
campaign. "Clubs of Cos," named after the Greek Island of Doctors,
have sprung up here and there, gathering physicians, glorified
druggists, and their industrial sponsors as the Club of Rome has
gathered "analysts" under the aegis of Ford, Fiat, and Volkswagen.
Purveyors of medical services follow the example of their colleagues
in other fields in adding the stick of "limits to growth" to the
carrot of ever more desirable vehicles and therapies. Limits to
professional health care are a rapidly growing political issue. In
whose interest these limits will work will depend to a large extent on
who takes the initiative in formulating the need for them: people
organized for political action that challenges status-quo professional
power, or the health

3

professions intent on expanding their monopoly even further.

The public has been alerted to the perplexity and uncertainty of the
best among its hygienic caretakers. The newspapers are full of reports
on volte-face manipulations of medical leaders: the pioneers of
yesterday's so-called breakthroughs warn their patients against the
dangers of the miracle cures they have only just invented. Politicians
who have proposed the emulation of the Russian, Swedish, or English
models of socialized medicine are embarrassed that recent events show
their pet systems to be highly efficient in producing the same
pathogenic—that is, sickening—cures and care that capitalist medicine,
albeit with less equal access, produces. A crisis of confidence in
modern medicine is upon us. Merely to insist on it would be to
contribute further to a self-fulfilling prophecy, and to possible
panic.

This book argues that panic is out of place. Thoughtful public
discussion of the iatrogenic pandemic, beginning with an insistence
upon demystification of all medical matters, will not be dangerous to
the commonweal. Indeed, what is dangerous is a passive public that has
come to rely on superficial medical housecleanings. The crisis in
medicine could allow the layman effectively to reclaim his own control
over medical perception, classification, and decision-making. The
laicization of the Aesculapian temple could lead to a delegitimizing
of the basic religious tenets of modern medicine to which industrial
societies, from the left to the right, now subscribe.

My argument is that the layman and not the physician has the potential
perspective and effective power to stop the current iatrogenic
epidemic. This book offers the lay reader a conceptual framework
within which to assess the seamy side of progress against its more
publicized benefits.

4



It uses a model of social assessment of technological progress that I
have spelled out elsewhere' and applied previously to education2 and
transportation,3 and that I now apply to the criticism of the
professional monopoly and of the scientism in health care that prevail
in all nations that have organized for high levels of
industrialization. In my opinion, the sanitation of medicine is part
and parcel of the socio-economic inversion with which Part IV of this
book deals.

The footnotes reflect the nature of this text. I assert the right to
break the monopoly that academia has exercised over all small print at
the bottom of the page. Some footnotes document the information I have
used to elaborate and to verify my own preconceived paradigm for
optimally limited health care, a perspective that did not necessarily
have any place within the mind of the person who collected the
corresponding data. Occasionally, I quote my source only as an
eyewitness account that is incidentally offered by the expert author,
while refusing to accept what he says as expert testimony on the
grounds that it is hearsay and therefore ought not to influence the
relevant public decisions.

Many more footnotes provide the reader with the kind of
bibliographical guidance that I would have appreciated when I first
began, as an outsider, to delve into the subject of health care and
tried to acquire competence in the political evaluation of medicine's
effectiveness. These notes refer to library tools and reference works
that I have learned to appreciate in years of single-handed
exploration. They also list readings, from technical monographs to
novels, that have been of use to me.

Finally, I have used the footnotes to deal with my own

_______________________________________________
1 Tools for Conviviality (New York: Harper & Row, 1973).
2 Deschooling Society, Ruth N. Anshen, ed. (New York: Harper & Row,
1971).
3 Energy and Equity (New York: Harper & Row, 1974).



parenthetical, supplementary, and tangential suggestions and
questions, which would have distracted the reader if kept in the main
text. The layman in medicine, for whom this book is written, will
himself have to acquire the competence to evaluate the impact of
medicine on health care. Among all our contemporary experts,
physicians are those trained to the highest level of specialized
incompetence for this urgently needed pursuit.

The recovery from society-wide iatrogenic disease is a political task,
not a professional one. It must be based on a grassroots consensus
about the balance between the civil liberty to heal and the civil
right to equitable health care. During the last generations the
medical monopoly over health care has expanded without checks and has
encroached on our liberty with regard to our own bodies. Society has
transferred to physicians the exclusive right to determine what
constitutes sickness, who is or might become sick, and what shall be
done to such people. Deviance is now "legitimate" only when it merits
and ultimately justifies medical interpretation and intervention. The
social commitment to provide all citizens with almost unlimited
outputs from the medical system threatens to destroy the environmental
and cultural conditions needed by people to live a life of constant
autonomous healing. This trend must be recognized and eventually be
reversed.

Limits to medicine must be something other than professional self-
limitation. I will demonstrate that the insistence of the medical
guild on its unique qualifications to cure medicine itself is based on
an illusion. Professional power is the result of a political
delegation of autonomous authority to the health occupations which was
enacted during our century by other sectors of the university-trained
bourgeoisie: it cannot now be revoked by those who conceded it; it can
only be delegitimized by popular

6

agreement about the malignancy of this power. The self-medication of
the medical system cannot but fail. If a public, panicked by gory
revelations, were browbeaten into further support for more expert
control over experts in health-care production, this would only
intensify sickening care. It must now be understood that what has
turned health care into a sick-making enterprise is the very intensity
of an engineering endeavor that has translated human survival from the
performance of organisms into the result of technical manipulation.

"Health," after all, 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 Homo sapiens,
"healthy" is an adjective that qualifies ethical and political
actions. In part at least, the health of a population depends on the
way in which political actions condition the milieu and create those
circumstances that favor self-reliance, autonomy, and dignity for all,
particularly the weaker. In consequence, health levels will be at
their optimum when the environ-ment brings out autonomous personal,
responsible coping ability. Health levels can only decline when
survival comes to depend beyond a certain point on the heteronomous
(other-directed) regulation of the organism's homeostasis. Beyond a
critical level of intensity, institutional health care—no matter if it
takes the form of cure, prevention, or environmental engineering—is
equivalent to systematic health denial.

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 which urbanization
represents to competence in homemaking. In each case a major
institutional endeavor has turned counterproductive. Time-con-

7

suming acceleration in traffic, noisy and confusing communications,
education that trains ever more people for ever higher levels of
technical competence and specialized forms of generalized
incompetence: these are all phenomena parallel to the production by
medicine of iatrogenic disease. In each case a major institutional
sector has removed society from the specific purpose for which that
sector was created and technically instrumented.

Iatrogenesis cannot be understood unless it is seen as the
specifically medical manifestation of specfic counterproductivity.
Specific or paradoxical counterproductivity is a negative social
indicator for a diseconomy which remains locked within the system that
produces it. It is a measure of the confusion delivered by the news
media, the incompetence fostered by educators, or the time-loss
represented by a more powerful car. Specific counterproductivity is an
unwanted side-effect of increasing institutional outputs that remains
internal to the system which itself originated the specific value. It
is a social measure for objective frustration. This study of
pathogenic medicine was under-taken in order to illustrate in the
health-care field the various aspects of counterproductivity that can
be observed in all major sectors of industrial society in its present
stage. A similar analysis could be undertaken in other fields of
industrial production, but the urgency in the field of medicine, a
traditionally revered and self-congratulatory service profession, is
particularly great.

Built-in iatrogenesis now affects all social relations. It is the
result of internalized colonization of liberty by affluence. In rich
countries medical colonization has reached sickening proportions; poor
countries are quickly following suit. (The siren of one ambulance can
destroy Samaritan attitudes in a whole Chilean town.) This process,
which I shall call the "medicalization of life," deserves articulate
political recognition. Medicine could

8

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 and have learned to combine it with dependence on the
application of contemporary technology will be ready to limit the
industrial mode of production in other major areas as well.

A professional and physician-based health-care system that has grown
beyond critical bounds is sickening for three reasons: it must produce
clinical damage that outweighs its potential benefits; it cannot but
enhance even as it obscures the political conditions that render
society unhealthy; and it tends to mystify and to expropriate the
power of the individual to heal himself and to shape his or her
environment. Contemporary medical systems have outgrown these
tolerable bounds. The medical and paramedical monopoly over hygienic
methodology and technology is a glaring example of the political
misuse of scientific achievement to strengthen industrial rather than
personal growth. Such medicine is but a device to convince those who
are sick and tired of society that it is they who are ill, impotent,
and in need of technical repair. I will deal with these three levels
of sickening medical impact in the first three parts of this book.

The balance sheet of achievement in medical technology will be drawn
up in the first chapter. Many people are already apprehensive about
doctors, hospitals, and the drug industry and only need data to
substantiate their misgivings. Doctors already find it necessary to
bolster their credibility by demanding that many treatments now common
be formally outlawed. Restrictions on medical performance which
professionals have come to consider mandatory are often so radical
that they are not accept-able to the majority of politicians. The lack
of effectiveness of costly and high-risk medicine is a now widely
discussed fact from which I start, not a key issue I want to dwell on.

9

Part II deals with the directly health-denying effects of medicine's
social organization, and Part III with the disabling impact of medical
ideology on personal stamina: under three separate headings I describe
the transformation of pain, impairment, and death from a personal
challenge into a technical problem.

Part IV interprets health-denying medicine as typical of the
counterproductivity of overindustrialized civilization and analyzes
five types of political response which constitute tactically useful
remedies that are all strategically futile. It distinguishes between
two modes in which the person relates and adapts to his environment:
autonomous (i.e., self-governing) coping and heteronomous (i.e., ad-
ministered) maintenance and management. It concludes by demonstrating
that only a political program aimed at the limitation of professional
management of health will enable people to recover their powers for
health care, and that such a program is integral to a society-wide
criticism and restraint of the industrial mode of production.

10


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PART I
Clinical Iatrogenesis


1
The Epidemics
of Modern Medicine

During the past three generations the diseases afflicting Western
societies have undergone dramatic changes.' Polio, diphtheria, and
tuberculosis are vanishing; one shot of an antibiotic often cures
pneumonia or syphilis; and so many mass killers have come under
control that two-thirds of all deaths are now associated with the
diseases of old age. Those who die young are more often than not
victims of accidents, violence, or suicide.2

These changes in health status are generally equated with a decrease
in suffering and attributed to more or to better medical care.
Although almost everyone believes that at least one of his friends
would not be alive and well except for the skill of a doctor, there is
in fact no evidence of any direct relationship between this mutation
of sickness and the so-called progress of medicine.3 The changes are

13

dependent variables of political and technological trans-formations,
which in turn are reflected in what doctors do and say; they are not
significantly related to the activities that require the preparation,
status, and costly equipment in which the health professions take
pride.4 In addition, an expanding proportion of the new burden of
disease of the last fifteen years is itself the result of medical
intervention in favor of people who are or might become sick. It is
doctor-made, or iatrogenic.5

After a century of pursuit of medical utopia,6 and contrary to current
conventional wisdom,7 medical services

14

have not been important in producing the changes in life expectancy
that have occurred. A vast amount of contemporary clinical care is
incidental to the curing of disease, but the damage done by medicine
to the health of individuals and populations is very significant.
These facts are obvious, well documented, and well repressed.



Doctors' Effectiveness—An Illusion

The study of the evolution of disease patterns provides evidence that
during the last century doctors have affected epidemics no more
profoundly than did priests during earlier times. Epidemics came and
went, imprecated by both but touched by neither. They are not modified
any more decisively by the rituals performed in medical clinics than
by those customary at religious shrines.8 Discussion of the future of
health care might usefully begin with the recognition of this fact.

The infections that prevailed at the outset of the industrial age
illustrate how medicine came by its reputation.9 Tuberculosis, for
instance, reached a peak over two generations. In New York in 1812,
the death rate was estimated to be higher than 700 per 10,000; by
1882, when Koch first isolated and cultured the bacillus, it had
already declined to 370 per 10,000. The rate was down to 180 when the
first sanatorium was opened in 1910, even though "consumption" still
held second place in the mortality tables.10 After World War II, but
before antibi-

15

otics became routine, it had slipped into eleventh place with a rate
of 48. Cholera," dysentery,12 and typhoid similarly peaked and
dwindled outside the physician's control. By the time their etiology
was understood and their therapy had become specific, these diseases
had lost much of their virulence and hence their social importance.
The combined death rate from scarlet fever, diphtheria, whooping
cough, and measles among children up to fifteen shows that nearly 90
percent of the total decline in mortality between 1860 and 1965 had
occurred before the introduction of antibiotics and widespread
immunization.13 In part this recession may be attributed to improved
housing and to a decrease in the virulence of micro-organisms, but by
far the most important factor was a higher host-resistance due to
better nutrition. In poor countries today, diarrhea and upper-
respiratory-tract infections occur more frequently, last longer, and
lead to higher mortality where nutrition is poor, no matter how much
or how little medical care is available.14 In England, by the middle
of the nineteenth century, infectious epidemics had been replaced by
major malnutrition syndromes, such as rickets and pellagra. These in
turn peaked and vanished, to be replaced by the diseases of early
childhood and, somewhat later, by an increase in duodenal ulcers in

16

young men. When these declined, the modern epidemics took over:
coronary heart disease, emphysema, bronchitis, obesity, hypertension,
cancer (especially of the lungs), arthritis, diabetes, and so-called
mental disorders. Despite intensive research, we have no complete
explanation for the genesis of these changes.15 But two things are
certain: the professional practice of physicians cannot be credited
with the elimination of old forms of mortality or morbidity, nor
should it be blamed for the increased expectancy of life spent in
suffering from the new diseases. For more than a century, analysis of
disease trends has shown that the environment is the primary
determinant of the state of general health of any population.16
Medical geography,17

17

the history of diseases,18 medical anthropology,19 and the social
history of attitudes towards illness20 have shown that food,21 water,
22 and air,23 in correlation with the level of



sociopolitical equality24 and the cultural mechanisms that make it
possible to keep the population stable,25 play the

19

decisive role in determining how healthy grown-ups feel and at what
age adults tend to die. As the older causes of disease recede, a new
kind of malnutrition is becoming the most rapidly expanding modern
epidemic.26 One-third of humanity survives on a level of
undernourishment which would formerly have been lethal, while more and
more rich people absorb ever greater amounts of poisons and mutagens
in their food.27

Some modern techniques, often developed with the help of doctors, and
optimally effective when they become part of the culture and
environment or when they are applied independently of professional
delivery, have also effected changes in general health, but to a
lesser degree. Among these can be included contraception, smallpox
vaccination of infants, and such nonmedical health measures as the
treatment of water and sewage, the use of soap and scissors by
midwives, and some antibacterial and insecticidal procedures. The
importance of many of these practices was first recognized and stated
by doctors—often courageous dissidents who suffered for their
recommendations28

20

—but this does not consign soap, pincers, vaccination needles,
delousing preparations, or condoms to the category of "medical
equipment." The most recent shifts in mortality from younger to older
groups can be explained by the incorporation of these procedures and
devices into the layman's culture.

In contrast to environmental improvements and modern nonprofessional
health measures, the specifically medical treatment of people is never
significantly related to a decline in the compound disease burden or
to a rise in life expectancy.29 Neither the proportion of doctors in a
population nor the clinical tools at their disposal nor the number of
hospital beds is a causal factor in the striking changes in over-all
patterns of disease. The new techniques for recognizing and treating
such conditions as pernicious anemia and hypertension, or for
correcting congenital malformations by surgical intervention, re-
define but do not reduce morbidity. The fact that the doctor
population is higher where certain diseases have become rare has
little to do with the doctors' ability to control or eliminate them.30
It simply means that doctors

21

deploy themselves as they like, more so than other professionals, and
that they tend to gather where the climate is healthy, where the water
is clean, and where people are employed and can pay for their services.
31



Useless Medical Treatment

Awe-inspiring medical technology has combined with egalitarian
rhetoric to create the impression that contemporary medicine is highly
effective. Undoubtedly, during the last generation, a limited number
of specific procedures have become extremely useful. But where they
are not monopolized by professionals as tools of their trade, those
which are applicable to widespread diseases are usually very
inexpensive and require a minimum of personal skills, materials, and
custodial services from hospitals. In contrast, most of today's
skyrocketing medical expenditures are destined for the__ kind_ of
diagnosis and treatment whose effectiveness at best doubtful.32 To
make this point I will distinguish between infectious and
noninfectious diseases.

In the case of infectious diseases, chemotherapy has played a
significant role in the control of pneumonia, gonorrhea, and syphilis.
Death from pneumonia, once the "old man's friend," declined yearly by
5 to 8 percent after sulphonamides and antibiotics came on the market.
Syphilis, yaws, and many cases of malaria and typhoid can be cured
quickly and easily. The rising rate of venereal

22

disease is due to new mores, not to ineffectual medicine. The
reappearance of malaria is due to the development of pesticide-
resistant mosquitoes and not to any lack of new antimalarial drugs.33
Immunization has almost wiped out paralytic poliomyelitis, a disease
of developed countries, and vaccines have certainly contributed to the
decline of whooping cough and measles,34 thus seeming to confirm the
popular belief in "medical progress." 35 But for most other
infections, medicine can show no comparable results. Drug treatment
has helped to reduce mortality from tuberculosis, tetanus, diphtheria,
and scarlet fever, but in the total decline of mortality or morbidity
from these diseases, chemotherapy played a minor and possibly
insignificant role.36 Malaria, leishmaniasis, and sleeping sickness
indeed receded for a time under the onslaught of chemical attack, but
are now on the rise again.37

23

The effectiveness of medical intervention in combatting noninfectious
diseases is even more questionable. In some situations and for some
conditions, effective progress has indeed been demonstrated: the
partial prevention of caries through fluoridation of water is
possible, though at a cost not fully understood.38 Replacement therapy
lessens the direct impact of diabetes, though only in the short run.39
Through intravenous feeding, blood transfusions, and surgical
techniques, more of those who get to the hospital survive trauma, but
survival rates for the most common types of cancer—those which make up
90 percent of the cases—have remained virtually unchanged over the
last twenty-five years. This fact has consistently been clouded by
announcements from the American Cancer Society reminiscent of General
Westmoreland's proclamations from Vietnam. On the other hand, the
diagnostic value of the Papanicolaou vaginal smear test has been
proved: if the tests are given four times a year, early intervention
for cervical cancer demonstrably increases the five-year survival
rate. Some skin-cancer treatment is highly effective. But there is
little evidence of effective treatment of most other cancers.40 The
five-year survival rate in breast-can-

24

cer cases is 50 percent, regardless of the frequency of medical check-
ups and regardless of the treatment used.41 Nor is there evidence that
the rate differs from that among untreated women. Although practicing
doctors and the publicists of the medical establishment stress the
importance of early detection and treatment of this and several other
types of cancer, epidemiologists have begun to doubt that early
intervention can alter the rate of survival.42 Surgery and
chemotherapy for rare congenital and rheumatic heart disease have
increased the chances for an active life for some of those who suffer
from degenerative conditions.43 The medical treatment of common
cardiovascular disease44 and the intensive treatment of heart

25

disease,45 however, are effective only when rather exceptional
circumstances combine that are outside the physician's control. The
drug treatment of high blood pressure is effective and warrants the
risk of side-effects in the few in whom it is a malignant condition;
it represents a considerable risk of serious harm, far outweighing any
proven benefit, for the 10 to 20 million Americans on whom rash artery-
plumbers are trying to foist it.46



Doctor-Inflicted Injuries

Unfortunately, futile but otherwise harmless medical care is the least
important of the damages a proliferating medical enterprise inflicts
on contemporary society. The pain, dysfunction, disability, and
anguish resulting from technical medical intervention now rival the
morbidity due to traffic and industrial accidents and even war-related
activities, and make the impact of medicine one of the most rapidly
spreading epidemics of our time. Among murderous institutional torts,
only modern malnutrition injures more people than iatrogenic disease
in its various manifestations.47 In the most narrow sense, iatrogenic
disease includes only illnesses that would not have come

26

about if sound and professionally recommended treatment had not been
applied.48 Within this definition, a patient could sue his therapist
if the latter, in the course of his management, failed to apply a
recommended treatment that, in the physician's opinion, would have
risked making him sick. In a more general and more widely accepted
sense, clinical iatrogenic disease comprises all clinical conditions
for which remedies, physicians, or hospitals are the pathogens, or
"sickening" agents. I will call this plethora of therapeutic side-
effects clinical iatrogenesis. They are as old as medicine itself,49
and have always been a subject of medical studies.50

Medicines have always been potentially poisonous, but their unwanted
side-effects have increased with their power51 and widespread use.52
Every twenty-four to thirty-

27

six hours, from 50 to 80 percent of adults in the United States and
the United Kingdom swallow a medically prescribed chemical. Some take
the wrong drug; others get an old or a contaminated batch, and others
a counterfeit;53 others take several drugs in dangerous combinations;
54 and still others receive injections with improperly sterilized
syringes.55 Some drugs are addictive, others mutilating, and others
mutagenic, although perhaps only in combination with food coloring or
insecticides. In some patients, antibiotics alter the normal bacterial
flora and induce a superinfection, permitting more resistant organisms
to proliferate and invade the host. Other drugs contribute to the
breeding of drug-resistant strains of bacteria.56 Subtle kinds of
poisoning thus have spread even faster than the bewildering variety
and ubiquity of nostrums.57 Unnecessary surgery is a standard
procedure.58 Disabling nondiseases

28

result from the medical treatment of nonexistent diseases and are on
the increase:59 the number of children disabled in Massachusetts
through the treatment of cardiac non-disease exceeds the number of
children under effective treatment for real cardiac disease.60

Doctor-inflicted pain and infirmity have always been a part of medical
practice.61 Professional callousness, negli-

29

gence, and sheer incompetence are age-old forms of malpractice.62 With
the transformation of the doctor from an artisan exercising a skill on
personally known individuals into a technician applying scientific
rules to classes of patients, malpractice acquired an anonymous,
almost respectable status.63 What had formerly been considered an
abuse of confidence and a moral fault can now be rationalized into the
occasional breakdown of equipment and operators. In a complex
technological hospital, negligence becomes "random human error" or
"system break-down," callousness becomes "scientific detachment," and
incompetence becomes "a lack of specialized equipment." The
depersonalization of diagnosis and therapy has changed malpractice
from an ethical into a technical problem.64

loss of the master's income during his protracted sickness. Citizens
were not covered by these statutes, but could avenge malpractice on
their own initiative.

30

In 1971, between 12,000 and 15,000 malpractice suits were lodged in
United States courts. Less than half of all malpractice claims were
settled in less than eighteen months, and more than 10 percent of such
claims remain unsettled for over six years. Between sixteen and twenty
percent of every dollar paid in malpractice insurance went to
compensate the victim; the rest was paid to lawyers and medical
experts.65 In such cases, doctors are vulnerable only to the charge of
having acted against the medical code, of the incompetent performance
of prescribed treatment, or of dereliction out of greed or laziness.
The problem, however, is that most of the damage inflicted by the
modern doctor does not fall into any of these categories.66 It occurs
in the ordinary practice of well-trained men and women who have
learned to bow to prevailing professional judgment and procedure, even
though they know (or could and should know) what damage they do.

The United States Department of Health, Education, and Welfare
calculates that 7 percent of all patients suffer compensable injuries
while hospitalized, though few of them do anything about it. Moreover,
the frequency of reported accidents in hospitals is higher than in all
industries but mines and high-rise construction. Accidents are the
major cause of death in American children. In

31

proportion to the time spent there, these accidents seem to occur more
often in hospitals than in any other kind of place. One in fifty
children admitted to a hospital suffers an accident which requires
specific treatment.67 University hospitals are relatively more
pathogenic, or, in blunt language, more sickening. It has also been
established that one out of every five patients admitted to a typical
research hospital acquires an iatrogenic disease, sometimes trivial,
usually requiring special treatment, and in one case in thirty leading
to death. Half of these episodes result from complications of drug
therapy; amazingly, one in ten comes from diagnostic procedures.68
Despite good intentions and claims to public service, a military
officer with a similar record of performance would be relieved of his
command, and a restaurant or amusement center would be closed by the
police. No wonder that the health industry tries to shift the blame
for the damage caused onto the victim, and that the dope-sheet of a
multinational pharmaceutical concern tells its readers that
"iatrogenic disease is almost always of neurotic origin." 69



Defenseless Patients

The undesirable side-effects of approved, mistaken, callous, or
contraindicated technical contacts with the medical system represent
just the first level of pathogenic medicine. Such clinical
iatrogenesis includes not only the damage that doctors inflict with
the intent of curing or of exploiting the patient, but also those
other torts that result from the doctor's attempt to protect himself
against the

32

possibility of a suit for malpractice. Such attempts to avoid
litigation and prosecution may now do more damage than any other
iatrogenic stimulus.

On a second level,70 medical practice sponsors sickness by reinforcing
a morbid society that encourages people to become consumers of
curative, preventive, industrial, and environmental medicine. On the
one hand defectives survive in increasing numbers and are fit only for
life under institutional care, while on the other hand, medically
certified symptoms exempt people from industrial work and thereby
remove them from the scene of political struggle to reshape the
society that has made them sick. Second-level iatrogenesis finds its
expression in various symptoms of social overmedicalization that
amount to what I shall call the expropriation of health. This second-
level impact of medicine I designate as social iatrogenesis, and I
shall discuss it in Part II.

On a third level, the so-called health professions have an even
deeper, culturally 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. The patient in the
grip of contemporary medicine is but one instance of mankind in the
grip of its pernicious techniques.71 This cultural iatrogen-

33

esis, which I shall discuss in Part III, is the ultimate backlash of
hygienic progress and consists in the paralysis of healthy responses
to suffering, impairment, and death. It occurs when people accept
health management de-signed on the engineering model, when they
conspire in an attempt to produce, as if it were a commodity,
something called "better health." This inevitably results in the
managed maintenance of life on high levels of sublethal illness. This
ultimate evil of medical "progress" must be clearly distinguished from
both clinical and social iatrogenesis.

I hope to show that on each of its three levels iatrogenesis has
become medically irreversible: a feature built right into the medical
endeavor. The unwanted physiological, social, and psychological by-
products of diagnostic and therapeutic progress have become resistant
to medical remedies. New devices, approaches, and organizational
arrangements, which are conceived as remedies for clinical and social
iatrogenesis, themselves tend to become pathogens contributing to the
new epidemic. Technical and managerial measures taken on any level to
avoid damaging the patient by his treatment tend to engender a self-
reinforcing iatrogenic loop analogous to the escalating destruction
generated by the polluting procedures used as antipollution devices.72

I will designate this self-reinforcing loop of negative institutional
feedback by its classical Greek equivalent and call it medical
nemesis. The Greeks saw gods in the forces of nature. For them,
nemesis represented divine vengeance

34

visited upon mortals who infringe on those prerogatives the gods
enviously guard for themselves. Nemesis was the inevitable punishment
for attempts to be a hero rather than a human being. Like most
abstract Greek nouns, Nemesis took the shape of a divinity. She
represented nature's response to hubris: to the individual's
presumption in seeking to acquire the attributes of a god. Our
contemporary hygienic hubris has led to the new syndrome of medical
nemesis.73

By using the Greek term I want to emphasize that the corresponding
phenomenon does not fit within the explanatory paradigm now offered by
bureaucrats, therapists, and ideologues for the snowballing
diseconomies and disutilities that, lacking all intuition, they have
engineered and that they tend to call the "counterintuitive behavior
of large systems." By invoking myths and ancestral gods I should make
it clear that my framework for analysis of the current breakdown of
medicine is foreign to the industrially determined logic and ethos. I
believe that the reversal of nemesis can come only from within man and
not from yet another managed (heteronomous) source depending once
again on presumptious expertise and subsequent mystification.

Medical nemesis is resistant to medical remedies. It can be reversed
only through a recovery of the will to self-care among the laity, and
through the legal, political, and institutional recognition of the
right to care, which imposes limits upon the professional monopoly of
physicians. My final chapter proposes guidelines for stemming medical
nemesis and provides criteria by which the medical enterprise can be
kept within healthy bounds. I do not suggest any specific forms of
health care or

35

sick-care, and I do not advocate any new medical philosophy any more
than I recommend remedies for medical technique, doctrine, or
organization. However, I do propose an alternative approach to the use
of medical organization and technology together with the allied
bureaucracies and illusions.

36

Footnotes

1 Erwin H. Ackerknecht, History and Geography of the Most Important
Diseases (New York: Hafner, 1965).

2 Odin W. Anderson and Monroe Lerner, Measuring Health Levels in the
United States, 1900-1958, Health Information Foundation Research
Series no. 11 (New York: Foundation, 1960). Marc Lalonde, A New
Perspective on the Health of Canadians: A Working Document (Ottawa:
Government of Canada, April 1974). This courageous French-English
report by the Canadian Federal Secretary for Health contains a
multicolored centerfold documenting the change in mortality for Canada
in a series of graphs.

3 René Dubos, The Mirage of Health: Utopian Progress and Biological
Change (New York: Anchor Books, 1959), was the first to effectively
expose the delusion of producing "better health" as a dangerous and
infectious medically sponsored disease. Thomas McKeown and Gordon
McLachlan, eds., Medical History and Medical Care: A Symposium of
Perspectives (New York: Oxford Univ. Press, 1971), introduce the
sociology of medical pseudo-progress. John Powles, "On the Limitations
of Modern Medicine," in Science, Medicine and Man (London: Pergamon,
1973), 1:1-30, gives a critical selection of recent English-language
literature on this subject. For the U.S. situation consult Rick
Carlson, The End of Medicine (New York: Wiley Interscience, 1975). His
essay is "an empirically based brief, theoretical in nature." For his
indictment of American medicine he has chosen those dimensions for
which he had complete evidence of a nature he could handle. Jean-
Claude Polack, La Médecine du capital (Paris: Maspero, 1970). A
critique of the political trends that seek to endow medical technology
with an effective impact on health levels by a "democratization of
medical consumer products." The author discovers that these products
themselves are shaped by a repressive and alienating bourgeois class
structure. To use medicine for political liberation it will be
necessary to "find in sickness, even when it is distorted by medical
intervention, a protest against the existing social order."

4 Daniel Greenberg, "The `War on Cancer': Official Fiction and Harsh
Facts," Science and Government Report, vol. 4 (December 1, 1974). This
well-researched report to the layman substantiates the view that
American Cancer Society proclamations that cancer is curable and
progress has been made are "reminiscent of Vietnam optimism prior to
the deluge."

5 Dorland's Illustrated Medical Dictionary, 25th ed. (Philadelphia:
Saunders, 1974): "Iatrogenic (iatro—Gr. physician, gennan—Gr. to
produce). Resulting from the activity of physicians. Originally
applied to disorders induced in the patient by autosuggestion based on
the physician's examination, manner, or discussion, the term is now
applied to any adverse condition in a patient occurring as the result
of treatment by a physician or surgeon."

6 Heinrich Schipperges, Utopien der Medizin: Geschichte und Kritik der
ärtztlichen Ideologie des 19. Jh. (Salzburg: Muller, 1966). A useful
guide to the historical literature is Richard M. Burke, An Historical
Chronology of Tuberculosis, 2nd ed. (Springfield, Ill.: Thomas, 1955).

7 For an analysis of the agents and patterns that determine the
epidemic spread of modern misinformation throughout a scientific
community, see Derek J. de Solla Price, Little Science, Big Science
(New York: Columbia Univ. Press, 1963).

8 On the clerical nature of medical practice, see "Cléricalisme de la
fonction médicale? Médecine et politique. Le `Sacerdoce' médical. La
Relation thérapeutique. Psychanalyse et christianisme," Le Semeur,
suppl. 2 (1966-67).

9 J. N. Weisfert, "Das Problem des Schwindsuchtskranken in Drama und
Roman," Deutscher Journalistenspiegel 3 (1927): 579-82. A guide to
tuberculosis as a literary motive in 19th-century drama and novel. E.
Ebstein, "Die Lungenschwindsucht in der Weltliteratur," Zeitschrift
für Bücherfreunde 5 (1913).

10 Renè and Jean Dubos, The White Plague: Tuberculosis, Man and
Society (Boston: Little, Brown, 1953). On the social, literary, and
scientific aspects of 19th-century tuberculosis; an analysis of its
incidence.

11 Charles E. Rosenberg, The Cholera Years: The United States in 1832,
1849, and 1866 (Chicago: Univ. of Chicago Press, 1962). The New York
epidemic of 1832 was a moral dilemma from which deliverance was sought
in fasting and prayer. By the time of the epidemics of 1866, the
culture that had produced New York slums had as well produced chloride
of lime.

12 W. J. van Zijl, "Studies on Diarrheal Disease in Seven Countries,"
Bulletin of the World Health Organization 35 (1966): 249-61. Reduction
in diarrheal diseases is brought about by a better water supply and
sanitation, never by curative intervention.

13 R. R. Porter, The Contribution of the Biological and Medical
Sciences to Human Welfare, Presidential Address to the British
Association for the Advancement of Science, Swansea Meeting, 1971
(London: the Association, 1972), p. 95.

14 N. S. Scrimshaw, C. E. Taylor, and John E. Gordon, Interactions of
Nutrition and Infection (Geneva: World Health Organization, 1968).

15 John Cassel, "Physical Illness in Response to Stress," Antología
A7, mimeographed (Cuernavaca: CIDOC (Centro Intercultural de
Documentación), 1971).

16 One of the clearest early statements on the paramount importance of
the environment is J. P. Frank, Akademische Rede vom Volkselend als
der Mutter der Krankheiten (Pavia, 1790; reprint ed., Leipzig: Barth,
1960). Thomas McKeown and R. G. Record, "Reasons for the Decline in
Mortality in England and Wales During the Nineteenth Century,"
Population Studies 16 (1962): 94–122. Edwin Chadwick, Report on the
Sanitary Condition of the Labouring Population of Great Britain, 1842,
ed. M. W. Flinn (Chicago: Aldine, 1965), concluded a century and a
half ago that "the primary and most important measures and at the same
time the most practical, and within the recognized providence of
public administration, are drainage, the removal of all refuse from
habitations, streets, and roads, and the improvement of the supplies
of water." Max von Petterkofer, The Value of Health to a City: Two
Lectures Delivered in 1873, trans. Henry E. Sigerist (Baltimore: Johns
Hopkins, 1941), calculated a century ago the cost of health to the
city of Munich in terms of average wages lost and medical costs
created. Public services, especially better water and sewage disposal,
he argued, would lower the death rate, morbidity, and absenteeism and
this would pay for itself. Epidemiological research has entirely
confirmed these humanistic convictions: Delpit-Morando, Radenac, and
Vilain, Disparités régionales en matière de santé, Bulletin de
Statistique du Ministère de la Santé et de la Sécurité Sociale
No.
3,
1973; Warren Winkelstein, Jr., "Epidemiological Considerations
Underlying the Allocation of Health and Disease Care Resources,"
International Journal of Epidemiology 1, no. 1 (1972): 69–74; F.
Fagnani, Santé, consommation médicate et environnement: Problèmes et
méthodes (Paris: Mouton, 1973).

17 N. D. McGlashan, ed., Medical Geography: Techniques and Field
Studies (New York: Barnes & Noble, 1973). Jacques May and Donna
McLelland, eds., Studies in Medical Geography, 10 vols. (New York:
Hafner, 1961–71). Daniel Noin, La Géographie démographique de la
France (Paris: PUF, 1973). J. Vallin, La Mortalite en France par
tranches depuis 1899 (Paris: PUF, 1973). L. D. Stamp, The Geography of
Life and Death (Ithaca, N.Y.: Cornell Univ. Press, 1965). E.
Rodenwaldt et al., Weltseuchenatlas (Hamburg, 1956). John Melton
Hunter, The Geography of Health and Disease, Studies in Geography no.
6 (Chapel Hill: Univ. of North Carolina Press, 1974).

18 Erwin H. Ackerknecht, Therapeutics: From the Primitives to the
Twentieth Century (New York: Hafner, 1973). A simple overview. J. F.
D. Shrewsbury, A History of the Bubonic Plague in the British Isles
(Cambridge: Cambridge Univ. Press, 1970). An outstanding example of
history written by a bacteriologist and epidemiologist.

19 For an introduction to the literature, see Steven Polgar, "Health
and Human Behaviour: Areas of Interest Common to the Social and
Medical Sciences," Current Anthropology 3 (April 1962): 159-205.
Polgar gives a critical evaluation of each item and the responses of a
large number of colleagues to his evaluation. See also Steven Polgar,
"Health," in International Encyclopedia of the Social Sciences (1968),
6:330-6; Eliot Freidson, "The Sociology of Medicine: A Trend Report
and Bibliography," Current Sociology, 1961-62, nos. 10-11, pp. 123-92.

20 Paul Slack, "Disease and the Social Historian," Times Literary
Supplement, March 8, 1974, pp. 233-4. A critical review article.
Catherine Rollet and Agnès Souriac,, "Epidémics et mentalités:
Le
Choléra de 1832 en Seine-et-Oise," Annales Economies, Sociétés,
Civilisations, 1974, no. 4, pp. 935-65.

21 Alan Berg, The Nutrition Factor: Its Role in National Development
(Washington, D.C.: Brookings Institution, 1973). Hans J. Teuteberg and
Günter Wiegelmann, Der Wandel der Nahrnngsgewohnheiten unter dem
Einfluss der Industrialisierung (Göttingen: Vandenhoeck & Ruprecht,
1972), deal with the impact of industrialization on the quantity,
quality, and distribution of food in 19th-century Europe. With the
transition from subsistence on limited staples to either managed or
chosen menus, the traditional regional cultures of eating, fasting,
and surviving hunger were destroyed. A badly organized rich mine of
bibliographic information. In the wake of Marc Bloch and Lucien
Febvre, some of the most valuable research on the significance of food
to power structures and health levels was done. For an orientation on
the method used, consult Guy Thuillier, "Note sur les sources de
l'histoire régionale de l'alimentation au XIXe siècle," Annales
Economies, Sociétés, Civilisations, 1968, no. 6, pp. 1301-19; Guy
Thuillier, "Au XIXe siècle: L'Alimentation en Nivernais," Annales,
1965, no. 6, pp. 1163-84. For a masterpiece consult Francois Lebrun,
Les Hommes et la mort en Änjou au 17e et 18e siècles: Essai de
démographie et psychologie historiques (Paris: Mouton, 1971); A.
Poitrineau, "L'Alimentation populaire en Auvergne au XVIII' siècle,"
in Enquites, pp. 323-31. Owsei Temkin, Nutrition from Classical
Antiquity to the Baroque, Human Nutrition Monograph 3, New York, 1962.
For the transformation of bread into a substance machines can produce,
see Siegfried-Giedion, Mechanization Takes Command: A Contribution to
Anonymous History (New York: Norton, 1969), especially pts. 4:2, 4:3
(on meat). Also Fernand Braudel, "Le Superflu et l'ordinaire:
Nourriture et boissons," in Civilisation matérielle et capitalisme
(Paris: Colin, 1967), pp. 134-98.

22 I. D. Carruthers, Impact and Economics of Community Water Supply: A
Study of Rural Water Investment in Kenya, Wye College, Ashford, Kent,
1973; on the impact of water supply on health. On the improvement of
rural water supplies during the 19th century: Guy Thuillier, "Pour une
histoire régionale de l'eau en Nivernais au XIXe siécle," Annales
Economies, Sociétés, Civilisations, 1968, no. 1, pp. 49 if. The
improvement of water supplies changed people's attitude towards their
own bodies: Guy Thuillier, "Pour une histoire de l'hygiène corporelle.
Un exemple régional: le Nivernais," Revue d'histoire économique et
sociale 46, no. 2 (1968): 232-53; Lawrence Wright, Clean and Decent
The Fascinating History of the Bathroom and the Water Closet and of
Sundry Habits, Fashions and Accessories of the Toilet, Principally in
Great Britain, France and America (Toronto: Univ. of Toronto Press,
1967). New patterns for laundry developed: Guy Thuillier, "Pour une
histoire de la lessive au XIXe siècle," Annales, 1969, no. 2, pp.
355-90.

23 Lester B. Lave and Eugene P. Seskin, "Air Pollution and Human
Health," Science 169 (1970): 723-33. Jean-Paul Dessaive et al.,
Médecins, climat et épidémies d la fin du XVIIIe siècle
(Paris:
Mouton, 1972).

24 A synthetic, well-documented argument to this point is Emanuel de
Kadt, "Inequality and Health," Univ. of Sussex, January 1975. The
original and longer version of this paper was written in 1972 as the
introductory chapter of a book, Salud y bienestar, which should have
been published in Santiago, Chile, in 1973. John Powles, "Health and
Industrialisation in Britain: The Interaction of Substantive and
Ideological Change," prepared for a Colloquium on the Adaptability of
Man to Urban Life, First World Congress on Environmental Medicine and
Biology, Paris, July 1-5, 1974. C. Ferrero, "Health and Levels of
Living in Latin America," Milbank Memorial Fund Quarterly 43 (October
1965): 281-95. A decline in mortality is not to be anticipated from
more expenditures on health care but from a different allocation of
funds within the health sector combined with social change.

25 Emily R. Coleman, "L'Infanticide dans le haut moyen äge," trans. A.
Chamoux, Annales Economies, Sociétés, Civilisations, 1974, no. 2, pp.
315-35. Suggests that infanticide in the Middle Ages was
demographically significant. Ansley J. Coale, "The Decline of
Fertility in Europe from the French Revolution to World War II," in S.
J. Behrman et al., Fertility and Family Planning (Ann Arbor: Univ. of
Michigan Press, 1970). Marital fertility declined everywhere before
the proportion of the population who married increased. Discrimination
against the illegitimate combined with restricted access to marriage
may have served to control population. This hypothesis is reinforced
in J.-L. Flandrin, "Contraception, mariage et relations amoureuses
dans l'Occident chrètien," Annales, 1969, no. 6, pp. 1370-90.
Demographic data suggest no contraception within marriage for 17th and
18th-century France, but very low rates of illegitimacy. Contraception
in marriage was near heresy, conception outside marriage a scandal.
Flandrin suggests that during the 19th century sexual behavior between
spouses began to be modeled on traditional behavior outside marriage.
Contraception seems to have become acceptable first among peasant
families rich enough to keep infant mortality low: see M. Leridon,
"Fécondité et mortalité infantile dans trois villages bavarois:
Une
Analyse de données individualisées du XIXe siècle," Population 5
(1969): 997-1002. Although physicians in England opposed its spread,
they seemingly applied it effectively in their own lives: J. A. Banks,
"Family Planning and Birth Control in Victorian Times," paper read at
the Second Annual Conference, of the Society for the History of
Medicine, Leicester Univ., 1972. The Catholic Church seems to have
made contraception an issue only insofar as it affected the industrial
middle classes: see John Thomas Noonan, Contraception: A History of
Its Treatment by the Catholic Theologians and Canonists (Cambridge:
Harvard Univ. Press, 1965). Philippe Ariès, "Les Techniques de la
mort," in Histoire des populations françaises et de leurs attitudes
devant la vie depuis le XVIIIe siècle (Paris: Spoil, 1971), p. 373.

26 So far, world hunger and world malnutrition have increased with
industrial development. "One third to one half of humanity are said to
be going to bed hungry every night. In the Stone Age the fraction must
have been much smaller. This is the era of unprecedented hunger. Now,
in the time of the greatest technical power, starvation is an
institution." Marshall Sahlins, Stone Age Economics (Chicago: Aldine,
1972), p. 23.

27 J. E. Davies and W. F. Edmundson, Epidemiology of DDT (Mount Kisco,
N.Y.: Future, 1972). A good example of paradoxical disease control
from Borneo: Insecticides used in villages to control malaria vectors
also accumulated in cockroaches, most of which are resistant. Geckoes
fed on these, became lethargic, and fell prey to cats. The cats died,
rats multiplied, and with rats came the threat of epidemic bubonic
plague. The army had to parachute cats into the jungle village
(Conservation News, July 1973).

28 A good example of medical persecution of innovators is given by G.
Gortvay and I. Zoltan, I. Semmelweis, His Life and Work (Budapest:
Akademiai Kiado, 1968), a critical biography of the first gynecologist
to use antiseptic procedures in his wards. In 1848 he reduced
mortality from puerperal fever by a factor of 15 and was thereupon
dismissed and ostracized by his colleagues, who were offended at the
idea that physicians could be carriers of death. Morton Thompson's
novel The Cry and the Covenant (New York: New American Library, 1973)
makes Semmelweis come alive.

29 Charles T. Stewart, Jr., "Allocation of Resources to Health,"
Journal of Human Resources 6, no. 1 (1971): 103-21. Stewart classifies
resources devoted to health as treatment, prevention, information, and
research. In all nations of the Western Hemisphere, prevention (e.g.,
potable water) and education are significantly related to life
expectancy, but none of the "treatment variables" are so related.

30 Reuel A. Stallones, in Environment, Ecology, and Epidemiology, Pan-
American Health Organization Scientific Publication no. 231
(Washington, September 30, 1971), shows there is a strong positive
correlation in the U.S.A. between a high proportion of doctors in the
general population and a high rate of coronary disease, while the
correlation is strongly negative for cerebral vascular disease.
Stallones points out that this says nothing about a possible influence
of doctors on either. Morbidity and mortality are an integral part of
the human environment and unrelated to the efforts made to control any
specific disease.

31 Alain Letourmy and Francois Gibert, Santé, environnement,
consommations médicales: Un Modèle et son estimation à partir des
données de mortalité; Rapport principal (Paris: CÉRÈBE (Centre
de
Recherche sur le Bien-être), June 1974). Compares mortality rates in
different regions of France; they are unrelated to medical density,
highly related to the fat content of the sauces typical of each
region, and somewhat less to alcohol consumption.

32 The model study on this matter at present seems to be A. L.
Cochrane, Effectiveness and Efficiency: Random Reflections on Health
Services, Nuffield Provincial Hospitals Trust, 1972. See also British
Medical Journal, 1974, 4:5. A. Querido, Efficiency of Medical Care
(New York: International Publications, 1963).

33 Jacques M. May, "Influence of Environmental Transformation in
Changing the Map of Disease," in M. Taghi Farvar and John P. Milton,
eds., The Careless Technology (Garden City, N.Y.: Natural History
Press, 1972), pp. 19-34. May warns that mosquito resistance to
insecticides on the one hand and parasite resistance to
chemotherapeutic agents on the other may have created an unanswerable
challenge to human adaptation.

34 Henry J. Parish, A History of Immunization (Edinburgh: Livingstone,
1965). Consult historical introduction for literature. The
effectiveness of prevention in relation to any specific disease must
be distinguished from its contribution to the volume of disease: J. H.
Alston, A New Look at Infectious Disease (London: Pitman, 1967), shows
how infections are replaced by new ones, without reduction in over-all
volume. Keith Mellanby, Pesticides and Pollution (New York: Collins,
1967), in an easily understandable way demonstrates how the
engineering mechanisms designed to reduce one infection foster others.

35 Republica de Cuba, Ministerio de la Salud Pública, Cuba:
Organizatión de los servicios y nivel de salud (Havana, 1974),
introduction by Fidel Castro. An impressive demonstration of the shift
in mortality and morbidity patterns over one decade, during which
major infections on the whole island were significantly affected by a
public-health campaign. Nguyen Khac Vien, "25 Années d'activités
médico-sanitaires," Etudes vietnamiennes (Hanoi), no. 25, 1970.

36 G. O. Sofoluwe, "Promotive Medicine: A Boost to the Economy of
Developing Countries," Tropical and Geographical Medicine 22 (June
1970): 250-4. During the 30 years between 1935 and 1968, most curative
measures used for parasitic diseases and infections of the skin and
respiratory organs and for diarrhea have left "the pattern of
morbidity on the whole unchanged."

37 In Farvar and Milton, eds., The Careless Technology, several
authors make this point specifically for malaria, Bancroftian
filariasis (Hamon), schistosomiasis (van der Schalie), and genito-
urinary infections (Farvar).

38 Bruce Mitchel, Fluoridation Bibliography, Council of Planning
Librarians Exchange Bibliography no. 268, (Waterloo, Ont., March
1972). Covers the debate and especially the social scientist's
perception of people's behavior regarding fluoridation in Canada.

39 C.L. Meinert et al., "A Study of the Effects of Hypoglycemic Agents
on Vascular Complications in Patients with Adult-Onset Diabetes. II.
Mortality Results, 1970," Diabetes 19, suppl. 2 (1970): 789-830. G.L.
Knatterud et al., "Effects of Hypoglycemic Agents on Vascular
Complications in Patients with Adult-Onset Diabetes," Journal of the
American Medical Association 217 (1971): 777-84. Cochrane,
Effectiveness and Efficacy, comments on the last two. They suggest
that giving tolbutamide and phenformin is definitely disadvantageous
in the treatment of mature diabetes and that there is no advantage in
giving insulin rather than a diet.

40 H. Oeser, Krebsbekämpfung: Hoffnung und Realität (Stuttgart:
Thieme, 1974). This is so far, to my knowledge, the most useful
introduction for the general physician or layman to a critical
evaluation of world literature on the effectiveness of cancer
treatment. See also N. E. McKinnon, "The Effects of Control Programs
on Cancer Mortality," Canadian Medical Association Journal 82 (1960):
1308-12. K. T. Evans, "Breast Cancer Symposium: Points in the
Practical Management of Breast Cancer. Are Physical Methods of
Diagnosis of Value?" British Journal of Surgery 56 (1969): 784-6.

41 Edwin F. Lewison, "An Appraisal of Long-Term Results in Surgical
Treatment of Breast Cancer," Journal of the American Medical
Association 186 (1963): 975-8. "The most impressive feature of the
surgical treatment of breast cancer is the striking similarity and
surprising uniformity of long-term end results despite widely
differing therapeutic techniques as reported from this country and
abroad." The same can be said today.

42 Robert Sutherland, Cancer: The Significance of Delay (London:
Butterworth, 1960), pp. 196-202. Also Hedley Atkins et al., "Treatment
of Early Breast Cancer: A Report after Ten Years of Clinical Trial,"
British Medical Journal, 1972, 2:423-9; also p. 417. D. P. Byar and
Veterans Administration Cooperative Urological Research Group,
"Survival of Patients with Incidentally Found Microscopic Cancer of
the Prostate: Results of Clinical Trial of Conservative Treatment,"
Journal of Urology 108 (December 1972): 908-13. Random comparison of
four treatments (placebo, estrogen, placebo and orchiectomy, and
estrogen and orchiectomy) reveals no significant differences among
them, nor in comparison with radical prostatectomy. For a broad survey
of analogous research on cancer in various sites, see note 40 above.

43 Ann G. Kutner, "Current Status of Steroid Therapy in Rheumatic
Fever," American Heart Journal 70 (August 1965): 147-9. Rheumatic
Fever Working Party of the Medical Research Council of Great Britain
and Subcommittee of Principal Investigators of the American Council on
Rheumatic Fever and Congenital Heart Disease, American Heart
Association, "Treatment of Acute Rheumatic Fever in Children: A
Cooperative Clinical Trial of ACTH, Cortisone and Aspirin," British
Medical Journal, 1955, 1:555-74.

44 Albert N. Brest, "Treatment of Coronary Occlusive Disease: Critical
Review," Diseases of the Chest 45 (January 1964): 40-45. Malcolm I.
Lindsay and Ralph E. Spiekerman, "Re-evaluation of Therapy of Acute
Myocardial Infarction," American Heart Journal 67 (April 1964):
559-64. Harvey D. Cain et al., "Current Therapy of Cardiovascular
Disease," Geriatrics 18 (July 1963): 507-18.

45 H. G. Mather et al., "Acute Myocardial Infarction: Home and
Hospital Treatment," British Medical Journal, 1971, 3:334-8.

46 Combined Staff Clinic, "Recent Advances in Hypertension," American
Journal of Medicine 39 (October 1965): 634-8.

47 For some of the standard textbooks see Robert H. Moser, The Disease
of Medical Progress: A Study of Iatrogenic Disease, 3rd ed.
(Springfield, Ill.: Thomas, 1969). David M. Spain, The Complications
of Modern Medical Practices (New York: Grune & Stratton, 1963). H. P.
Kümmerle and N. Goossens, Klinik und Therapie der Nebenwirkungen
(Stuttgart: Thieme, 1973 [lst ed., 1960]). R. Heintz, Erkrankungen
durch Arzneimittel: Diagnostik, Klinik, Pathogenese, Therapie
(Stuttgart: Thieme, 1966). Guy Duchesnay, Le Risque thérapeutique
(Paris: Doin, 1954). P. F. D'Arcy and J. P. Griffin, Iatrogenic
Disease (New York: Oxford Univ. Press, 1972).

48 For the evolution of jurisprudence related to this kind of torts
see M. N. Zald, "The Social Control of General Hospitals," in B. S.
Georgopoulos, ed., Organization Research on Health Institutions (Ann
Arbor: Univ. of Michigan, Institute for Social Research, 1972). See
also Angela Holder, Medical Malpractice Law (New York: Wiley, 1974).

49 Such side-effects were studied by the Arabs. Al-Razi (A.D.
865-925), the medical chief of the hospital of Baghdad, was concerned
with the medical study of iatrogenesis, according to Al-Nadim in the
Fihrist, chap. 7, sec. 3. At the time of Al-Nadim (A.D. 935), three
books and one letter of Al-Razi on the subject were still available:
The Mistakes in the Purpose of Physicians; On Purging Fever Patients
Before the Time Is Ripe; The Reason Why the Ignorant Physicians, the
Common People, and the Women in Cities Are More Successful Than Men of
Science in Treating Certain Diseases and the Excuses Which Physicians
Make for This; and the letter: "Why a Clever Physician Does Not Have
the Power to Heal All Diseases, for That Is Not Within the Realm of
the Possible."

50 See also Erwin H. Ackerknecht, "Zur Geschichte der iatrogenen
Krankheiten," Gesnerus 27 (1970): 57-63. He distinguishes three waves,
or periods, since 1750 when the study of iatrogenesis was considered
important by the medical establishment. Erwin H. Ackerknecht, "Zur
Geschichte der iatrogenen Erkrankungen des Nervensystems,"
Therapeutische Umschau/Revue thérapeutique 27, no. 6 (1970): 345-6. A
short survey of medical awareness of the side-effects of drugs on the
central nervous system, starting with Avicenna (980-1037) on mercury.

51 L. Meyler, Side Effects of Drugs (Baltimore: Williams & Wilkins,
1972). Adverse Reactions Titles, a monthly bibliography of titles from
approximately 3,400 biomedical journals published throughout the
world; published in Amsterdam since 1966. Allergy Information
Bulletin, Allergy Information Association, Weston, Ontario.

52 P. E. Sartwell, "Iatrogenic Disease: An Epidemiological
Perspective," International Journal of Health Services 4 (winter
1974): 89-93.

53 Pharmaceutical Society of Great Britain, Indentification of Drugs
and Poisons (London: the Society, 1965). Reports on drug adulteration
and analysis. Margaret Kreig, Black Market Medicine (Englewood Cliffs,
N.J.: Prentice-Hall, 1967), reports that an increasing percentage of
articles sold by legitimate professional pharmacies are inert
counterfeit drugs indistinguishable in packaging and presentation from
the trademarked product.

54 Morton Mintz, By Prescription Only, 2nd ed. (Boston: Beacon Press,
1967). (For a fuller description of this book, see below, note 98, p.
67.) Solomon Garb, Undesirable Drug Interactions, 1974-75, rev. ed.
(New York: Springer, 1975). Includes information on inactivation,
incompatibility, potentiation, and plasma binding, as well as on
interference with elimination, digestion, and test procedures.

55 B. Opitz and H. Horn, "Verhütung iatrogener Infektionen bei
Schutzimpfungen," Deutsches Gesundheitswesen 27/24 (1972): 1131-6. On
infections associated with immunization procedures.

56 Harry N. Beaty and Robert G. Petersdorf, "Iatrogenic Factors in
Infectious Disease," Annals of Internal Medicine 65 (October 1966):
641-56.

57 Every year a million people—that is, 3 to 5 percent of all hospital
admissions—are admitted primarily because of a negative reaction to
drugs. Nicholas Wade, "Drug Regulation: FDA Replies to Charges by
Economists and Industry," Science 179 (1973): 775-7.

58 Eugene Vayda, "A Comparison of Surgical Rates .in Canada and in
England and Wales," New England Journal of Medicine 289 (1973):
1224-9, shows that surgical rates in Canada in 1968 were 1.8 times
greater for men and 1.6 times greater for women than in England.
Discretionary operations such as tonsillectomy and adenoidectomy,
hemorroidectomy, and inguinal herniorrhaphy were two or more times
higher. Cholecystectomy rates were more than five times greater. The
main determinants may be differences in payment of health services and
available hospital beds and surgeons. Charles E. Lewis, "Variations in
the Incidence of Surgery," New England Journal of Medicine 281 (1969):
880-4, finds three- to fourfold variations in regional rates for six
common surgical procedures in the U.S.A. The number of surgeons
available was found to be the significant predictor in the incidence
of surgery. See also James C. Doyle, "Unnecessary Hysterectomies:
Study of 6,248 Operations in Thirty-five Hospitals During 1948,"
Journal of the American Medical Association 151 (1953): 360-5. James
C. Doyle, "Unnecessary Ovariectomies: Study Based on the Removal of
704 Normal Ovaries from 546 Patients," Journal of the American Medical
Association 148 (1952): 1105-11. Thomas H. Weller, "Pediatric
Perceptions: The Pediatrician and Iatric Infectious Disease,"
Pediatrics 51 (April 1973): 595-602.

59 Clifton Meador, "The Art and Science of Nondisease," New England
Journal of Medicine 272 (1965): 92-5. For the physician accustomed to
dealing only with pathologic entities, terms such as "nondisease
entity" or "nondisease" are foreign and difficult to comprehend. This
paper presents, with tongue in cheek, a classification of nondisease
and the important therapeutic principles based on this concept.
Iatrogenic disease probably arises as often from treatment of
nondisease as from treatment of disease.

60 Abraham B. Bergman and Stanley J. Stamm, "The Morbidity of Cardiac
Nondisease in School Children," New England Journal of Medicine 276
(1967): 1008-13. Gives one particular example from the "limbo where
people either perceive themselves or are perceived by others to have a
nonexistent disease. The ill effects accompanying some nondiseases are
as extreme as those accompanying their counterpart diseases . . . the
amount of disability from cardiac nondisease in children is estimated
to be greater than that due to actual heart disease." See also J.
Andriola, "A Note on Possible Iatrogenesis of Suicide," Psychiatry 36
(1973): 213-18.

61 Clinical iatrogenesis has a long history. Plinius Secundus,
Naturalis Historia 29.19: "To protect us against doctors there is no
law against ignorance, no example of capital punishment. Doctors learn
at our risk, they experiment and kill with sovereign impunity, in fact
the doctor is the only one who may kill. They go further and make the
patient responsible: they blame him who has succumbed." In fact, Roman
law already contained some provisions against medically inflicted
torts, "damnum injuria datum per modicum." Jurisprudence in Rome made
the doctor legally accountable not only for ignorance and recklessness
but for bumbling. A doctor who operated on a slave but did not
properly follow up his convalescence had to pay the price of the slave
and the

62 Montesquieu, De l'esprit des lois, bk. 29, chap. 14, b (Paris:
Pléiade, 1951). The Roman laws ordained that physicians should be
punished for neglect or lack of skill (the Cornelian laws, De
Sicariis, inst. iv. tit. 3, de lege Aquila 7). If the physician was a
person of any fortune or rank, he was only condemned to deportation,
but if he was of low condition he was put to death. In our
institutions it is otherwise. The Roman laws were not made under the
same circumstances as ours: in Rome every ignorant pretender meddled
with physic, but our physicians are obliged to go through a regular
course of study and to take degrees, for which reason they are
supposed to understand their profession. In this passage the 17th-
century philosopher demonstrates an entirely modern optimism about
medical education.

63 For German internists, the time the patient can spend face-to-face
with his doctor has now been reduced to 1.7 minutes per visit.
Heinrich Erdmann, Heinz-Gunther Overrath, and Wolfgang and Thure
Uxkull, "Organisationsprobleme der ärztlichen Krankenversorgung:
Dargestellt am Beispiel einer medizinischen Universitätsklinik,"
Deutsches Ärzteblatt-Ärztliche Mitteilungen 71 (1974): 3421-6. In
general practice, this time was (in 1963) about 3 minutes. See T.
Geyer, Verschwörung (Hilchenbach: Medizinpolitischer Verlag, 1971), p.
30.

64 For the broader issue of genetic rather than individual damage, see
John W. Goffman and Arthur R. Tamplin, "Epidemiological Studies of
Carcinogenesis by Ionizing Radiation," in Proceedings of the Sixth
Berkeley Symposium on Mathematical Statistics and Probability, Univ.
of California, July 1970, pp. 235-77. The presumption is all too
common that where uncertainty exists about the magnitude of
carcinogenic effects, it is appropriate to continue the exposure of
humans to the risk. The authors show that it is neither appropriate
nor good public-health practice to demand human epidemiological
evidence before stopping exposure. The argument against ionizing
radiation from nuclear generation of electrical energy can be applied
to all medical treatment in which there is uncertainty about genetic
impact. The competence of physicians to establish levels of tolerance
for entire populations must be questioned on theoretical grounds.

65 For data and further bibliography see U.S. House of
Representatives, Committee on Interstate and Foreign Commerce, An
Overview of Medical Malpractice, 94th Cong., lst Sess., March 17,
1975.

66 The maltreatment of patients has become an accepted routine; see
Charles Butterworth, "Iatrogenic Malnutrition," Nutrition Today, March-
April 1974. One of the largest pockets of unrecognized malnutrition in
America and Canada exists, not in rural slums or urban ghettos, but in
the private rooms and wards of big-city hospitals. J. Mayer,
"Iatrogenic Malnutrition," New England Journal of Medicine 284 (1971):
1218.

67 George H. Lowrey, "The Problem of Hospital Accidents to Children,"
Pediatrics 32 (December 1963): 1064-8.

69 J. T. McLamb and R. R. Huntley, "The Hazards of Hospitalization,"
Southern Medical Journal 60 (May 1967): 469-72.

69 "La maladie iatrogène est presque toujours à base
névrotique": L.
Israel, "La Maladie iatrogene," in Documenta Sandoz, n.d.

70 The distinction of several levels of iatrogenesis was made by Ralph
Audy, "Man-made Maladies and Medicine," California Medicine, November
1970, pp. 48-53. He recognizes that iatrogenic "diseases" are only one
type of man-made malady. According to their etiology, they fall into
several categories: those resulting from diagnosis and treatment,
those relating to social and psychological attitudes and situations,
and those resulting from man-made programs for the control and
eradication of disease. Besides iatrogenic clinical entities, he
recognizes other maladies that have a medical etiology.

71 "Das Schicksal des Kranken verkörpert als Symbol das Schicksal der
Menschheit im Stadium einer technischen Weltentwicklung": Wolfgang
Jacob, Der kranke Mensch in der technischen Welt, IX. Internationaler
Fortbildungskurs für praktische und wissenschaftliche Pharmazie der
Bundesapothekerkammer in Meran (Frankfurt am Main: Werbe- und
Vertriebsgesellschaft Deutscher Apotheker, 1971).

72 James B. Quinn, "Next Big Industry: Environmental Improvement,"
Harvard Business Review 49 (September-October 1971): 120-30. He
believes that environmental improvement is becoming a dynamic and
profitable series of markets for industry that pay for themselves and
in the end will represent an important addition to income and GNP.
Implicitly the same argument is being made for the health-care field
by the proponents of no-fault malpractice insurance.

73 The term was used by Honoré Daumier (1810-79). See reproduction of
his drawing "Nemesis médicale" in Werner Block, Der Artzt und der Tod
in Bildern aus sechs Jahrhunderten (Stuttgart: Enke, 1966).

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