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  1. 1. This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues. Other uses, including reproduction and distribution, or selling or licensing copies, or posting to personal, institutional or third party websites are prohibited. In most cases authors are permitted to post their version of the article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information regarding Elsevier’s archiving and manuscript policies are encouraged to visit:
  2. 2. Author's personal copy Big Ideas Ivan Illich on medical nemesis Illich began his polemic, first published in 1975, with a powerful opening statement ‘The medical establishment has become a major threat to health’ (1990, p.11), and over the next 254 pages he delivered a blistering critique about the limits of Westernised medicine. Described in his obituaryasan ‘archaeologist of ideas’ (Todd and LaCecla, 2002) his stance against the hubris of industrialism, capitalism and bureaucracy spanned not only medicine, but also education (Deschooling Society, Illich, 1970) and the environment (Tools for Conviviality, Illich, 1973). How Illich was ableto take a metaphoricalscalpelto these secular sacred cows may only be understood with reference to some biographical details. Born in 1926 in Vienna to a Jewish mother and Christian father, and expelled from his birthplace by the National Socialist Party in 1941 because of his Jewish ancestry, he moved to Florence where he eventually read Histology and Crystallography at Florence University. He then entered the priesthood, studied theology and philosophy at the Vatican's Gregorian University, and in the post war period worked as a priest with the Puerto Rican community in New York before moving to Puerto Rica as vice rector of the Catholic University, where he founded the Centro Intercultural De Documentacion (CIDOC) at Cuernavaa, Mexico. This institution offered briefings and courses for missionaries arriving from North America and its radicalism attracted many, but it came into conflict with a conservative Vatican which resulted in its eventual disbandment and Illich resigning from active duty as a priest (Todd and La Cecla, 2002). Illich's publications throughout his lifetime were prodigious, the output of a highly educated polymath, who not only spoke and worked in ten languages but was also a seasoned traveller and connected with people at many levels, both as a priest and as global celebrity in the heady counterculture of the 1970s (Wall, 2005). In setting out some of the key concepts from Medical Nemesis I hope to show how this work deserves not only to be in the pantheon of great works and big ideas from the 20th century, but also part of today's curriculum for those studying nursing and medicine in the 21st century. A key concept in Illich's work was his notion that the threat posed by medicine to health had reached epidemic proportions; a state of affairs he referred to as medical iatrogenesis, derived from ‘iatro’ (Gk iatros healer or physician) and ‘genesis’ (Gk: gignesthai to be born or origin of anything). He described the effect of medicine on disease as an illusion and, drawing on past and recent evidence (Chadwick, 1842; McKeown and Record, 1962), rightly identified that the environment was the primary determinant of the general health of any population. Whilst he acknowledged the value of chemotherapy in controlling previously life-threatening infections, and other life-saving procedures such as blood transfusions and surgical techniques, his overriding argument was that the harms caused by medical interventions outweighed the benefits. His defined clinical iatrogenesis as the damage doctors inflicted on patients through malpractice, the side effects of prescribed drugs and hospital acquired injuries and accidents, which he was able to substantiate with due reference to the medical literature. Illich's concept of clinical iatrogenesis is just as relevant today as it was over thirty years ago for, as evidence-based findings show, hospitals continue to cause real harm. For example, in one study of two British hospitals, it was shown that 10% of patients admitted (Vincent et al., 2000) experienced adverse effects leading, in a third of cases, to moderate or greater disability or even death. Indeed, a post Illich version of iatrogenesis, known as ‘E-iatrogenesis’, has now entered the medical lexicon and is used to describe the harms caused to patients by the use (or rather misuse) of electronic patient records and other forms of health information technology (Weiner et al., 2007). From Illich's perspective, medicine had seeped into every facet of people's lives, leading to social iatrogenesis, that is, the medicalisation of all aspects of life. Through a powerful medical bureaucracy and ‘diagnostic imperialism’ doctors now decide who may be excused from work through sickness, become soldiers, practise prostitution, run for vice-presidency of the United States and, of course, those who are dead. As Illich argued, medicine has created another illusion whereby only medicine can control health, disease or postpone our own mortality and, in the process, has medicalised many of the activities and skills that were traditionally part of families and communities. Health care has become a standardised item and the patient has become a consumer, in thrall to an industrialised health care system, controlled by professionals and backed by a pharmaceu- tical industry. Increasing and indeed unstoppable demands for more medicine and health care within the developed and underdeveloped world has not, as Illich was able to show, resulted in better health but has instead disempowered people by creating a medical dependency. Illich's argument remains compelling, given that in 2011 the USA spent 17.4% of their GNP (Gross National Product) on health (private and public), far more than the OECD average of 9.5% and the UK, which spent 9.8% (OECD Health Data, 2011). The USA also spends far more on investigations than any other OECD country, with 34.3 CTs (computed tomography) per million, which is far more than OECD average of 22.1. Likewise, there were 25.9 MRIs (medical resonance imaging) per million in the USA in 2007, which is more than twice the OECD average of 12.0. Nevertheless, despite these vast sums and what may be described as the overuse of technology, infant mortality, a good indicator of the health of any country, was 6.5 per 1000 live births in 2008 which was well above the OECD average of 4.4 (OECD Health Data, 2011). Perhaps Illich's greatest condemnation was reserved for what he termed cultural iatrogenesis, which he believed had led to the medicalisation of death and an inability to accept suffering and death as meaningful aspects of life. For the majority in the developed world, death will take place in hospital despite most of us wanting to die at home in order to avoid what Illich referred to as the exile, loneliness and indignities of hospital life. By the time of Illich's polemic, hospitals had become places where even natural death was resisted at all costs and where, as he stated, ‘mechanical death has destroyed and conquered all other deaths’ (Illich, 1973, p.210). This situation continues today for, as Clark (2002) found, nearly a third of patients admitted to ITU beds in the UK die within six months, whilst in the USA it costs twice as much to die in an intensive care unit as it does to survive (2002). This depersona- lised, technological medicine may, as Barnet (2003) notes, explain the rise in support for assisted suicide by people who feel that dying in a Nurse Education Today 32 (2012) 5–6 0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.08.003 Contents lists available at SciVerse ScienceDirect Nurse Education Today journal homepage:
  3. 3. Author's personal copy medically managed setting is an option they would rather reject. Outside of the heroic efforts by the hospice and palliative care movement to enable a ‘good death’, one which is pain free and dignified (Ellershaw et al., 2003), the use of medical technology aimed at preserving life, however futile, continues, as evidenced by a recent quality of death index. This ranked 40 countries (Economist Intelligence Unit, 2010) according to their End of Life Care (EoLC) provision and highlighted that in most developed countries the focus is still on preventing death rather than helping people achieve this without suffering, pain, discomfort or stress. It should be noted that the UK was ranked first because of its network of hospices and statutory involvement in EoLC, whilst the USA was ranked ninth because of the financial burden it imposes at the end of life. China, Mexico and Brazil ranked at the bottom because, as this report noted, their commitment to stronghospital programmes and the power of medicinemeans that they see little value in hospices. This is a shame and perhaps only identifies the need for today's medical establishment to acquaint themselves with Illich's medical nemesis to understand that minimal medical interven- tion is more likely to result in a ‘good death’ than the current and futile overload of technological wizardry at the end of life stage. ‘Less not more’ in terms of medical interventions is prescribed by Illich throughout his polemic as necessary for a full and healthy life. As he concluded: ‘Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing and dying; they are sustained by a culture than enhances the conscious acceptance of limits to population,of ageing, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die’ (Illich, 1973, 275). I hope that this paper has highlighted some of Illich's big ideas, and will entice a new generation of nurses to explore what I believe to be a masterpiece and help them consider and reflect upon the limits of medicine and its effects upon the human condition. Illich's polemic is not an easy read, some of his arguments are convoluted, and there are strands of philosophy, as well as factual information, which may discombobulate the reader. Illich was a troublesome priest in the best Thomas à Beckett tradition and this comes across in some of his provocative statements. Having heard him speak and defend his position at a conference during the 1990s I can attest that he was as provocative in person as he is on paper. It is also worth noting that, when published, Medical Nemesis earned criticisms from the political left and right for its lack of discussion about the role of capitalism in relation to medicine. This may seem odd given that the driving force behind medical hegemony is capitalism (Scott-Samuel, 2003) but this omission does not detract from its overall power and ability to make one question the status quo. Medical Nemesis has stood the test of time and continues to give us a real insight into the limits of medicine; it is incisive and insightful and bound together with a real understanding and concern for the human condition. References Barnet, R.J., 2003. Ivan Illich and the nemesis of medicine. Medicine, Health Care and Philosophy 6, 273–286. Chadwick, E., 1842. Report of the Poor Law Commissioners to the Secretary of State, on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain, 19, p. 1. Clark, D., 2002. Between hope and acceptance: the medicalisation of dying. British Medical Journal 905–907. Economist Intelligence Unit, 2010. The Quality of Death: Rating End of Life Care across the World. Economic Intelligence Unit. Ellershaw, J., Ward, C., Neuberger, J., 2003. Care of the dying patients: the last hour or days of life. British Medical Journal 326, 30–34. Illich, I., 1970. Deschooling Society. Harper and Row, New York. Illich, I., 1973. Tools for Conviviality. Harper and Row, New York. McKeown, T., Record, R.G., 1962. Reason for the decline in mortality in England and Wales during the nineteenth century. Population Studies 15, 94–122. OECD Health Data, 2011. How Does the United States Compare? dataoecd/46/2/38980580.pdf. Scott-Samuel, A., 2003. Less medicine, more health: a memoir of Ivan Illich. Journal of Epidemiology and Community Health 57 (12), 955. Todd, A., La Cecla, F., 2002. Ivan Illich Obituary The Guardian 9th December 2002. Vincent, C., Neale, G., Woloshyndwych, M., 2000. Adverse events in British Hospitals: preliminary retrospective record reviews. British Medical Journal 322, 517–519. Wall, R., 2005. A Turbulent Priest in the Global Village: Ivan Illich 1926–2002. http:// Weiner, J.P., Kfur, T., Chan, K., Fowles, J.B., 2007. ‘E-Iatrogenesis’: the most critical unintended consequence of CPOE and other HIT. Journal of the American Medical Association 14, 387–388. Ruth Davies College of Human and Health Science, Swansea University, United Kingdom Tel.: +44 1792 602253. E-mail address: 6 Big Ideas