XVIII. Read the text and define the literary genre it belongs to. Support your opinion with details and facts.

THE MEDICAL ESTABLISHMENT IS
A MAJOR THREAT TO HEALTH

The quotation “the medical establishment is a major threat to health” was one devised by Illich in Medical Nemesis (1976 p11) where he attempted to explain the detrimental effects medical professionals and their procedures can have on the health of individuals. In order to discuss the effects of the medical establishment it is necessary to evaluate its performance including the critiques of modern medicine. The concepts of iatrogenesis and medicalisation will be explored and case studies given as an example.

The medical profession has claimed responsibility for the eradication of the infectious diseases that plagued the population in the eighteenth and nineteenth centuries. Vaccination, chemical cures and advancements in medical understanding of the biological mechanisms of the human body were the means by which the medical establishment claimed this victory. McKeown argues that “medicine only played a minor role” (Davey, et. al., 1995) and that nearly 90% of the decline in mortality rates between 1860 and 1965 occurred before chemical treatments were available (Illich, 1976). Cochrane indicates that medical technology has never been evaluated. In fact, in a study observing differences between heart disease patients nursed at home and in coronary care units, the results showed that hospitalisation did not provide any advantage (Bilton et. al., 1996). According to McKeown, social, environmental measures were most effective in the control of infectious disease and the medical establishment should not be credited with the power they now possess.

In modern society the emphasis of illness has changed from infectious diseases to new epidemics in the form of heart disease, cancer and accidents. There is: “no evidence of any direct relationship between the mutation of sickness and the so-called progress of disease” (Davey et. al., 1995 p237).

In fact, all of these illnesses have no effective medical cure. An ageing population has to suffer the degenerative diseases that are inherent of modern societies with no hope for a cure, only insinuations of their ‘wasting’ of scarce resources for the largely ineffective alleviation of their discomfort. It would appear that the successes of the medical establishment have been greatly over stated.

Iatrogenesis is a concept devised by Illich (1976) to describe the “disabling impact of professional control over medicine” (Illich 1976) and how this effects individuals’ health. Meaning literally doctor-induced disease, iatrogenesis describes the influence of medical intervention. The damage inflicted on people in the name of medicine is apparently reaching epidemic proportions: “the pain, dysfunction, disability and anguish resulting from medical intervention now rivals the morbidity due to traffic and industrial accidents and even war-related activities. Only modern malnutrition injures more people than iatrogenic disease in its various manifestations” (Illich, 1976 cited in Davey et. al., 1995 pp239-240).

Illich differentiates between three types of iatrogenesis.

Clinical iatrogenesis involves health professionals acting pathogenically towards their patients by administering “clinically damaging and irrelevant” treatment (Scambler, 1991 p180). Damaging medicines, intrusive treatments and unnecessary surgery often in the name of defensive medicine are all common practices of a profession sworn to care for the population. Only high rise construction and mining have more accidents than hospitals (Davey et. al., 1995).

The over prescribing of often unnecessary and harmful medicines is one element of clinical iatrogenesis. “Every twenty-four to thirty-six hours from 50 to 80% of adults in the United States and the United Kingdom swallow a medically prescribed chemical” (Illich, 1976 p36).

The side-effects are some drugs are perhaps still unknown and emerging day by day, others, such as Thalidomide (Bilton et. al., 1996) are well documented. Dependency on addictive drugs and lethal combinations are also associated with this problematic scenario. Increasingly, many prescribed chemicals are ineffective due to the rise in mutations of resistant bacteria and the prevalence of viruses.

Pain and disability are also often the result of medical intervention. Procedures that fail or have devastating side effects are common. It is assumed that litigation ‘forces’ doctors to perform unnecessary operations and treatments as part of ‘defensive medicine’: “the doctor’s attempt to protect himself against the possibility of a suit for malpractice” (Illich, 1976 p41).

Fear of legal reprisals has not improved the care received but appears to merely increase the number of perhaps unnecessary interventions.

The second aspect of this doctor-made disease is social iatrogenesis. Industrialisation, by taking away people’s inherent need to be producers, encourages individuals to become consumers. Navarro (1975) argued that people are perceived in terms of the possessions they have and this need to consume is reflected in the uptake of health services (Taylor and Field, 1997). The “blind belief in medical progress” (Jones, 1994 p456) reinforces this attitude, creating a dependence on the medical profession and they services they offer. Illich believed that “liberal health service provision” encourages the over-use of these services, “this dependence is itself a form of sickness which undermines the good health of autonomous humans” (Armstrong, 1989 p116).

Thus, people feel less healthy and consume more. Also due to industrialisation, according to Durkheim, is the decline of social institutions such as the family and religion. A decrease in social support is the natural progression of this individualism thus people turn to doctors in times of personal crisis. (Taylor and Field, 1997).

The medicalisation of many aspects of life is seen rather than being beneficial, as detrimental to health. Many areas which cannot be cured by medical intervention are still subjected to the medical ‘gaze’, for instance ageing, death, and mental illness. Szasz (1964) believed that treatment of the mentally ill by drugs and electroconvulsive therapy was not only unnecessary but a violation of human rights (Scambler, 1991). Social problems such as child abuse, violence and alcoholism become redefined as medical areas. Halmos argues that the medicalisation of such areas is a more effective way of controlling such deviance than legal punishment (Scambler, 1991).Whatever the reason, it is obvious that the social control the medical establishment possesses is further expanded in the process, and medical imperialism is reinforced. The concept of medicalisation of natural areas of life is part of social iatrogenesis: it “is at best unnecessary and at worst does great damage to human independence and dignity” (Horrobin, 1976 p15).

Medicalisation is defined as a: “process of increased medical intervention and control into areas that hitherto would have been outside the medical domain” (Bilton et. al., 1996 p422).

As an illustration of this concept, feminist sociologists have provided case studies of pregnancy, menstruation, and especially childbirth. Since the eighteenth and nineteenth centuries there has been a change in the management of childbirth from lay women in the community who supervised home births to the male dominated specialities of obstetrics and gynaecology and the establishment of ‘lying-in hospitals’ (Oakley, 1987). Not only has this ‘natural’ process come under the scrutiny of male professionals but interventions are also increasing with time. “In 1927 85% of all children were born at home but by 1980 this proportion had fallen to just over 1%. In 1953 2.2% of children were born by caesarean sections but by 1984 this figure had risen to 10%. In 1953 3.7 % of children were delivered by forceps or vacuum extraction, but by 1984 this figure had risen to 15%” (Macfarlane and Mugford, 1984 cited in Aggleton, 1995 p125).

It may appear that the medicalisation of childbirth is beneficial. However, to begin with the intervention of doctors endangered the mother and child (Bilton et. al., 1996), and more recently critics argue that there has been no evaluation of antenatal care (Oakley, 1987) thus its efficiency is debatable. According to Oakley (1970) medicalisation has “caused women to be massively alienated from their reproductive function” (Aggleton, 1995 p126). Expectant mothers are seen as ‘walking wombs’ with little control over the interventions imposed upon them, they experience a feeling of helplessness. They are controlled by the predominantly male doctors thus reinforcing medical imperialism. “Gynaecology and family planning were similarly seen as having been taken over by medical men with questionable motives” (Sailly, 1980 cited in Cunningham - Burley et. al., 1990 p184).

Contraceptive methods are example of medicalisation. Doctors still defend their right to control the most effective methods of birth control despite arguments that prescriptions for the pill are unnecessary (Cunningham - Burley et. al., 1990). Medical professionals view reproduction as potentially pathological in need of clinical intervention (Cunningham - Burley et. al., 1990).

Structural or cultural iatrogenesis is the third aspect. This is the: “stripping away from human culture of ways of coping with pain, birth and death and their replacement by a sanitised technological medical intervention against which individuals and society are unable to fight back” (Jones, 1994 p456).

Zola (1972) maintains that this causes loss of autonomy, creating passive patients who conform to whatever the medical profession dictate (Armstrong, 1989). There is increasingly a feeling of loss of control over one’s life created by medical imperialism. This is damaging because ‘not only is the process masked as a technical, scientific, objective one, but one done for our own good’ (Jones, 1994 p456).

Individuals are encouraged to feel grateful for the treatment they have received. Informed consent is largely a myth as patients assume the medical professionals ‘know best’. The medical establishment has monopolised all aspects of health purely for selfish reasons (Hart 1985), they are ‘sponsoring sickness’ (Taylor and Field, 1997).

In reply to Illich’s theories, Horrobin (1978, Medical Hubris) argues the case of iatrogenesis has been over stated. He maintains that the causes of, and cures for, the modern epidemics threatening the health of society will never be discovered “without the probing of doctors using modern research techniques” (Horrobin, 1978). The increase in medical negligence litigation were also given as evidence of the ineffective and damaging procedures of the medical profession, part of the concept of clinical iatrogenesis. However, only 40 % of the claims in the United Kingdom receive compensation (Mongomery, 1997). Horobin (1978) also believes that to: “return medical care to the people by removing controls and allowing lay individuals to supply and to accept medical care freely would lead to total disaster”.

It cannot be denied that the medical establishment certainly has had its successes in interventions although perhaps as cures rather than prevention. Dissatisfaction in medical imperialism is increasing as individuals attempt to re-establish autonomy. This dissatisfaction can be seen in the increase of the popularity of alternative medicine and the increasing number of medical negligence claims. The medicalisation of many areas of social life (illustrated by the medicalisation of childbirth) is evidence of the power the medical profession hold and are unwilling to relinquish. Iatrogenesis, in its many forms, is certainly a way in which the medical establishment can be seen as damaging to health. However, Horrobin (1978) believes that Illich’s critiques of the medical profession are exaggerated and the threat imposed by them affects only the minority. It would appear that the evidence suggested by Illich and his supporters is more convincing than Horrobin’s but it would not be fair to dismiss all medical practitioners as they are still vital in the control and care of many areas of disease and ill health

1. Answer the questions to the text:

a) To what problems of the modern health care system does the author attract the reader’s attention?

b) What impact does the modern medical treatment have on individuals and the whole society?

c) How does the author manage to show in the text mutual influence of medical and social issues?

d) Is the tone of the text impartial? By what means is this effect achieved?