This book was profoundly useful, giving me a set of extraordinarily helpful lenses to better understand both the modern medical/healthcare industry, but also to better understand modernity itself. Although this book is primarily about healthcare, it is also prescient in identifying many of the alienating and atomizing aspects of modern civilization. This book may have been written in the early 1970s, but the author was decades ahead of his time.
One of the foundational concepts of this book is iatrogenesis, which essentially means “harm done by the healer.” I was first exposed to this word thanks to Nassim Taleb in his book Antifragile. In Medical Nemesis, Ivan Illich begins with a discussion of medical iatrogenics in the most basic sense, but then expands the concept into far broader terms, discussing three genres of iatrogenesis: 1) clinical iatrogenesis, 2) social iatrogenesis, and 3) cultural iatrogenesis:
1) Clinical iatrogenesis is the “plain vanilla form” of iatrogenesis: damage done to a patient by a doctor. It can be caused by doctor incompetence, by accident, by a doctor to protect his own legal liability (by ordering tests or procedures that may or may not be necessary to the patient but serve to cover the doctor's legal risk), or by unknown reasons.
2) Social iatrogenesis is a form of damage done when the medical practice or our government encourages or reinforces society to become greater and greater over-consumers of healthcare. This can come from overscreening, overmedicating, from disease-mongering or from labeling people as sick who may not actually be. This includes “breeding” new categories of patients, who can then be encouraged to pay for meds or treatment to “fix” them. Also, we are subject to various grooming practices, even from childhood, to encourage us to tolerate various behaviors: doctors who “use a foreign language” (medical terminology) while they discuss our case right in front of us; doctors who may perform tests or perform actions (even pain-inducing actions) without explanation or apology, etc.
3) Cultural iatrogenesis is when the healthcare industry interferes with people's potential to deal on their own with human weakness and vulnerability. Examples might be: interfering in healthy responses to suffering and impairment. Or, undermining the individual’s ability to face their reality and accept inevitable decline and death. Think of it like a second-order iatrogenesis that sickens and weakens us culturally.
The modern phrase “evidence-based healthcare”--widely used by healthcare evangelists and propagandists--should trigger alarm bells in the mind of any competent critical thinker. Once anyone has even the most basic familiarly with the great crisis of reproducibility, to say nothing of the various other problems suffusing all “studies show” science findings (p-hacking, file drawer effects, statistical gerrymandering, overdependence on Gaussian/normal curve statistical analysis, etc.), one cannot no longer hear the words “evidence-based healthcare” without a sense of bitter irony.
In the modern era we are trained to use money as a solution for everything, including our health. Thus we pay for meds, doctor’s appointments, surgeries, insurance... while we demand more and more government support and funding for “healthcare.” All of this, circularly, simply contributes to the desire to buy our way out of all situations, including buying our way out of reality--and even out of death itself. And of course along the way we have become an enormously overmedicated society.
I also wonder what this author would think--as he laments the upward explosion of healthcare spending from 4% of GDP in the 1960s to 8% in the 1970s--to know that today healthcare costs exceed 20% of GDP (!) as life expectancy and life quality are actually declining.
It is slowly becoming clear to me that iatrogenesis is a feature, not a bug, of modern healthcare--and possibly of modern society in general. It is endemic in many more ways than we realize. And once you can “see” iatrogenics, you can never unsee it.
Update: there is a free online PDF version of this book here. Given the samizdat nature of this book, Medical Nemesis is increasingly hard to find in the real world.