On Ivan Illich and the Limits to Medicine

Reflections on the man and his Medical Nemesis: the Expropriation of Health

Reading Ivan Illich is not easy, though in a different way to reading Continental philosophers or quantum physicists. Illich’s language is demanding and requires a certain suspension of judgement if one is to penetrate the systemic meaning behind his often challenging – if not vehement - rhetoric. But it is worth the effort.

It is difficult to appreciate the nature of Ivan Illich’s critique of Western society and of modernity in general without having some familiarity with his early experiences. He was born in 1926 to a Dalmatian father of landed aristocratic birth and a German mother of Sephardic ancestry whose family had converted to Catholicism. He knew privilege from an early age. Rainer Maria Rilke, Jacques Maritain and Rudolf Steiner were all visitors to his family household.

Illich moved to Vienna in the early 1930s with his mother and his younger twin brothers. They soon came to experience the heaviness of the Nazi regime at close range, particularly after the annexation of Austria in 1938. In order to avoid Nazi persecution, they moved once again in 1941, re-settling in Florence. Those early years taught Illich how suddenly one’s life and cultural circumstance can change. As a child, he had known the steadiness and stability of his father’s ancestral culture, yet within a few short years, he had come to experience the fragility of many of life’s “certainties”

When he was 12 years old, Illich had a foreboding about what was soon to erupt throughout Europe. While walking on the outskirts of Vienna just before the Nazi invasion, he decided that he would never marry because, “certain things will happen which will make it impossible for me to give children to those towers down on the island in Dalmatia where my grandfathers and great-grandfathers made children.” [1]

By the age of 17 years, he had resolved to enter the priesthood. He studied philosophy and theology at the Jesuit-run Gregorian Institute in Rome and concurrently undertook a doctoral thesis at the University of Salzburg based on a study of the ideas of Arnold Toynbee. While in Rome, Illich was drawn into a number of influential circles and developed a personal friendship with his old family friend, Catholic philosopher Jacques Maritain. Through Maritain, he  was introduced to Cardinal Giovanni Montini, who was later to become Pope Paul VI.

Illich completed his studies and was ordained a priest in 1951. His intellectual power had been noted by Montini who wanted him to join the Vatican inner circle. The Cardinal urged him to enrol at the Accademia dei Nobili Ecclesiastici in Rome. Illich, however was more interested in history and planned for a second doctoral degree at Princeton University. [2] He crossed the Atlantic soon after and was appointed parish priest of an impoverished Puerto Rican community in New York.

New York City, ca. 1955

For the next 5 years, Illich was fully immersed in Puerto Rican life and culture. Apart from serving the needs of his own parishioners, he visited Puerto Rico at every opportunity, often travelling on horseback. It was there that he began to regain a sense of the stability and resilience of traditional communities, something that had been shaken by his experiences in Austria. Illich’s time with Puerto Ricans also reinforced a growing distaste for modernity with its wanton destruction of traditional cultures. The themes of cultural integrity and resilience were to be interwoven into his wide-ranging intellectual explorations thereafter.

Illich’s unique qualities were soon recognised. By 1956, he had been appointed Vice-Rector of the Catholic University of Puerto Rico where he established a facility that introduced American priests and religious to the language and the cultural life of Latino communities. He also became deeply interested in the schooling of the local children. It was in Puerto Rico that the ideas for what would eventually find expression in Deschooling Society a decade later began to take form.

In his role as Vice-Rector at the University, Illich managed to cross swords with both of the Catholic bishops of Puerto Rico. His situation had become so untenable that he eventually resigned from his post. On returning to New York in 1960, he was enthusiastically welcomed by the Centre of Intercultural Formation at the Jesuit Fordham University, which was at that time looking to establish a training program for missionaries in Latin America.

Illich was appointed executive director of the new program for a five-year period and given generous funding to set it into motion. He took to the road in search of a suitable base. For the next four months, he ranged throughout Latin America, often travelling by bus or hitch-hiking in order to more fully participate in the life-worlds of local communities.

On arriving in Cuernavaca near Mexico City, he met with Mendez Arceo, a courageous and progressive bishop, “who had a transformative and renewed vision of the Church quite different from official church positions.” [3] They hit it off immediately and Illich there and then decided to establish the Centro de Investigaciones Culturales (CIC) at Cuernavaca. The first missionaries began to arrive in 1961. Bruno-Jofre offers the following reflection:

“Cuernavaca was the right place for Illich. It had been a field of Catholic experimentation before Vatican II, under the leadership of Bishop Mendez Arceo. . . . It was a special place in which the local Church as an institution had attempted to engage with the spirit of the times and with the people themselves, even before Vatican II.” [4] 

Illich soon gathered a group of influential teachers around himself. Under his stewardship, the CIC in Cuernavaca rapidly established itself as a centre of far-ranging intellectual engagement.

Cuernavaca, ca. 1960

Three years later, Illich established a parallel centre in the same premises, the Centro Intercultural de Documentacion (CIDOC), an entity that was completely independent of Church funding. By 1965, CIDOC had virtually subsumed CIC’s role. Through CIDOC, Ivan Illich and his collaborators began to project powerful, independent and controversial ideas that challenged conventional thought in many disciplines.

The establishment of the CIC had been a response to calls from conservative Catholic elements in the U.S. and from Pope John XXIII for the “modernisation” of Latin America through missionary activity. The clerics, religious and volunteers who arrived at the CIC in Cuernavaca found, however, that “something very different was being offered. Instead of teaching words of a new language they learned to be quiet; and instead of basic notions about Latin American culture they [CIC] dissuaded missioners from achieving their goal.” [5]

Catholic support for the Fordham project had been largely motivated by concern over the perceived growth of both Marxism and Protestantism in Latin America. Castro’s success in Cuba prompted John F. Kennedy to launch the “Alliance for Progress”, a ten-year multi-billion dollar aid program on August 17^th 1961. Curiously, that same day, Pope John XXIII formally instructed the North American Catholic hierarchy to send missionaries and lay volunteers in large numbers to Latin America. [6]

Illich was aware that the priests and lay missionaries attending Cuernavaca could, without their knowing it, inadvertently find themselves in the service of imperial power. He strove to sensitise them above all to the culture of the communities within which they would be working. His concerns were later to be made explicit in one of Illich’s more controversial papers, The Seamy Side of Charity published by the Jesuit weekly America Magazine in January 1967. In it, he wrote:

“The men who go to Latin America must humbly accept the possibility that they are useless or even harmful, although they give all they have. They must accept the fact that a limping ecclesiastical assistance program uses them as palliatives to ease the pain of a cancerous structure. . . .

We must acknowledge that missioners can be pawns in  a world ideological struggle and that it is blasphemous to use the gospel to prop up any social or political system.” [7]

Illich was deeply conscious of the movements that were arising spontaneously among the people of Latin American. By the time that Cuernavaca was established, he had spent close to a decade living close to Latinos, firstly in New York, then at the Catholic University in Puerto Rico, and more recently, on the streets and in the barrios of Central and South America. His contact with Bishop Mendez Arceo had affirmed the existence of a strong and engaged Catholicism in Latin America that was beginning to find its own unique expression.

Robert-Fleury, Galileo before the Holy Office, ca. 1847

Not surprisingly, word of Illich’s activities at Cuernavaca began to reach the ears of more conservative members of the Catholic hierarchy, both locally and in the U.S. One of the local bishops even accused him of sorcery. [8] Despite the support of Bishop Arceo in Mexico and Cardinal Spellman in New York, Illich was ordered to present himself before the Vatican’s Congregation for the Doctrine of the Faith in 1967. He arrived in Rome in June 1968 and maintained a dignified reserve in the face of accusatory questions regarding his own activities and those of his religious and academic colleagues in Mexico. In January 1969, the Vatican instructed the Bishop of Cuernavaca that priests and religious were thenceforth to be prohibited from participating in any of the programs or activities at CIDOC.

Illich resigned from his priestly ministry two months later in March 1969. He never, however, lost his connection with the deeper spirit of Catholicism and what he referred to thereafter as Mother Church. He remained celibate and continued to recite the divine office daily for the rest of his life.

Having formally put aside his monsignorial role, Illich immediately embarked upon a highly energised and productive phase of his life, publishing four books – each of which was widely read – between 1970 and 1975. Though thematically different, each of these publications offered radical critiques of the cultural developments that Illich and his colleagues had examined at Cuernavaca. The last of these works was entitled Medical Nemesis. The Expropriation of Health.  It offered a highly individuated and revolutionary critique of the personal, social and cultural influence of Western technological medicine.

Medical Nemesis was a work of deep scholarship, fluid erudition, and fearless rhetoric. It unapologetically laid bare the excesses and the deficiencies of a profession that had over the previous century claimed immense cultural authority for itself. Illich's earlier published books were largely collections of essays. Medical Nemesis however, was a tightly integrated, wide-ranging review of the expropriation of individual and cultural autonomy by the profession of medicine.

Illich clearly understood the magnitude of what he was taking on. Unlike his earlier works, Medical Nemesis was extensively footnoted with sources ranging from The Lancet to The New England Journal of Medicine to the works of Montesquieu and Wittgenstein. By the end of the second chapter of this eight-chapter book, Illich had already referred to the writings of such medical commentators as Rene Dubos, Thomas Szasz, Michael Balint and Maurice Pappworth, sociologists including Eliot Friedson and Howard Becker, and philosophers and cultural historians including Simone de Bouvoir, Michel Foucault, Eric Voegelin and Lewis Mumford.

By documenting the sources of his ideas and insights with such thoroughness, Illich hoped that his non-medical readers would begin to look at what was already out there for themselves. He also wanted to leave a well-signposted audit trail for those within the medical profession who he knew would be incensed by his revelations. Predictably, Medical Nemesis was not welcomed by most within the medical fold. But Illich was no stranger to the consequences of truth-speaking. He had been forced out of his own church by criticising the policies of the Roman curia and of North American prelates in the management of Central and South American “problems”. Ivan Illich had a penchant for rocking the boat. Not surprisingly, he found himself cast adrift.

In Medical Nemesis Ivan Illich identifies and deconstructs many of the unconscious elements that drive the biomedical enterprise. He addresses the complicity of biomedicine in “enabling” people to adapt to inherently sickening social, industrial, environmental and political realities:

“The physician, himself a member of the dominating class, judges that the individual does not fit into an environment that has been engineered and is administered by other professionals, instead of accusing his colleagues of creating environments into which the human organism cannot fit.” (p. 169)

At a more immediate level, Illich brings to light the limitations of biomedicine’s mechanistic and reductionistic view of life and urges a reconsideration of vitalistic and holistic perspectives that encompass more fully the nexus within which both health and sickness arise. He draws strongly from historical and cultural frames of reference that place the individual within meaningful contexts from which the slings and arrows of adverse fates, of human debility and limitation, and the inevitability of suffering and death can be negotiated. Much of his ferocity is directed against the medicalisation of all stages of life, and especially of death:

“For rich and poor, life is turned into a pilgrimage through check-ups and clinics back to the ward where it started. Life is thus reduced to a “span,” to a statistical phenomenon which, for better or for worse, must be institutionally planned and shaped. This life-span is brought into existence with the pre-natal check-up, when the doctor decides if and how the foetus shall be born, and will end with a mark on a chart ordering resuscitation suspended.” (p. 79)

Illich writes at length of iatrogenesis – of the illness or injury caused by medical interventions – but extends the field of inquiry far beyond the domain of personal incidents into the broader theatres of social and cultural influence. Social iatrogenesis is made manifest in the medicalisation of all aspects of life and the consequent loss of individual autonomy and capacity for self-care by citizens who are transformed into “patients.” Of greater concern to Illich is the cultural iatrogenesis reflected in a near-total abandonment in Western societies of the traditional resources, understandings and philosophies that have perennially enabled people to cultivate the art of suffering, and to accept - if not embrace - this inevitable and inescapable dimension of human experience. Philosopher Charles Taylor was moved to reflect further on this aspect of Illich’s thesis:

“So medicalisation alters our phenomenology of lived experience. . . . We don’t see that we are being led to see/feel ourselves in different ways, we just believe naively that this is experience itself; we imagine that people have always imagined themselves this way. And we are baffled by accounts of earlier ages.” [8]

Medical Nemesis is too dense and too difficult a work to be circumscribed by any short review. Yet a few months before Illich’s death in December 2002, Richard Smith, editor of the British Medical Journal reflected on his own re-reading of Illich’s Medical Nemesis, a work that had profoundly influenced him as an undergraduate in the 1970s. He concluded his review with the following remark:

“It’s the ultimate book reviewer’s cliché to say that every doctor and medical student should read this book, but those who haven’t have missed something really important. When sick I want to be cared for by doctors who every day doubt the value and wisdom of what they do – and this book will help make such doctors.” [9]

Illich is to be admired for his principled courage and fearless confrontation of forces he perceived as being inherently noxious and damaging to the individual and the collective psyche. Illich lived as he spoke. Even in the end, he eschewed the ministrations of oncologists in the treatment of a disfiguring facial tumour that seared his latter years, preferring to wear both the pain and the tumour with fortitude and dignity. He remained active until the end and found occasional ease in his latter days by lighting a small piece of opium in the pipe that he carried about with him.

There is more that could be said, but this is sufficient to give some sense of the systemic nature of Illich’s critique. He was not interested in patchwork solutions, but along with his contemporary brothers-in-arms Fritz Schumacher and Leopold Kohr, Ivan Illich sought to alert all who would hear that Western civilisation had entered very dangerous and destructive times.

Endnotes

1.  Cited in James Arraj: “In Search of Ivan Illich.” Viewed at: http://www.innerexplorations.com/chtheomortext/illich.htm

2.  Hartch, Todd (2015): “The Prophet of Cuernavaca. Ivan Illich and the Crisis of the West”, Oxford University Press, p. 6

3.  Bruno-Jofre, Rosa and Zaldiva, Jon Igelmo, (2016), “Monsignor Ivan Illich’s Critique of the Institutional Church, 1960-1966, J. of Ecclesiastical History, vol. 67, No. 3, 568-586

4.  Ibid., p. 577

5.  Zaldivar, Jon Igelmo and Uceda, Patricia Quiroga, (2011), “Ivan Illich and the Conflict with The Vatican (1966-1969”, The International Journal of Illich Studies, Vol. 2, No. 1, 3-12

6.  Bruno-Jofre and Zaldiva, op. cit., p. 574

7.  Illich, Ivan (1967): “The Seamy Side of Charity”, America. The Jesuit Review, Jan.21, 1967. Viewed at: https://www.americamagazine.org/issue/100/seamy-side-charity

8.  Taylor, Charles (2007): “A Secular Age”, The Belknap Press of Harvard University Press, Cambridge, Mass., p. 740 

8.  Smith, Richard (2002)” Book Review, “Limits to Medicine. Medical Nemesis: The Expropriation of Health”, BMJ, 324, 13^th April. Viewed at: http://www.bmj.com/content/324/7342/923.1

Vincent Di Stefano M.H.Sc., D.O., N.D.

Inverloch, September 2017

A PDF copy of the above essay, together with a collation of selected excerpts from his Limits to Medicine. Medical Nemesis: The Expropriation of Health can be  downloaded from:
https://archive.org/details/OnIvanIllichAndTheLimitsOfMedicine

Babette Babich on Ivan Illich:

Life is a Test: Ivan Illich's Medical Nemesis and the "Age of the Show"

A fascinating perspective on the ideas presented by Illich in his Medical Nemesis is offered in the video clip below by Babette Babich, professor of philosophy at Fordham University. This presentation is adapted from a lecture she gave to the International Philosophy of Nursing Society in Quebec, Canada in August 2016. 

Forty years after the publication of Medical Nemesis, Babette Babich wryly reflects on the present state of medicine and its contemporary "cutting edge" aspects.




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