Medical Nemesis: The Expropriation of Health

[Includes acknowledgements, introduction and Part1 - Clinical Iatrogenesis]

IVAN ILLICH / Random House

!"#

Ivan Illich, Pantheon Books, A Division of Random House, New York. First American dition. !o"#ri$ht %&'( )# Random House, Inc. All ri$hts reserved under International and Pan*American !o"#ri$ht !onventions. Pu)lished in the +nited ,tates )# Pantheon Books, a division of Random House, Inc., New York. -ri$inall# "u)lished in .reat Britain )# !alder / Bo#ars, 0td., 0ondon. !o"#ri$ht 1 %&'2 )# Ivan Illich. 3anufactured in the +nited ,tates of America. 0i)rar# of !on$ress !atalo$ !ard Num)er4 '2*56%%6 I,BN4 7* 5&8*87992*% Ac$no%led&ments My thinking on medical institutions was shaped over several years in periodic conversations with Roslyn indheim and !ohn Mc"night# Mrs# indheim, Pro$essor o$ %rchitecture at the &niversity o$ Cali$ornia at 'erkeley, is shortly to pu(lish :he Hos"itali;ation of ,"ace, and !ohn Mc"night, )irector o$ &r(an *tudies at +orthwestern &niversity, is working on :he ,erviced ,ociet#. ,ithout the challenge $rom these two $riends, I would not have $ound the courage to develop my last conversations with Paul -oodman into this (ook# *everal others have (een closely connected with the growth o$ this te.t/ !ean Ro(ert and !ean P# )upuy, who illustrated the economic thesis stated in this (ook with e.amples $rom time-polluting and space-distorting transportation systems0 %ndr1 -or2, who has (een my principal tutor in the politics o$ health0 Marion 'oyars, who with admira(le competence pu(lished the dra$t o$ this (ook in ondon and thus ena(led me to (ase my $inal version on a wide spectrum o$ critical reaction# 3o them and to all my critics and helpers, and especially to those who have led me to valua(le reading, I owe deep gratitude# 3his (ook would never have (een written without 4alentina 'orremans# *he has patiently assem(led the documentation on which it is (ased, and re$ined my 5udgment and so(ered my language with her constant v criticism# 3he chapter on the industriali2ation o$ death is a summary o$ the notes she has assem(led $or her own (ook on the history o$ the $ace o$ death# I4%+ I IC6 Cuernavaca, Me.ico !anuary 1789 Contents Introduction :

'ART I( Clinical Iatro&enesis

1. 3he ;pidemics o$ Modern Medicine

1:

Doctors< ffectiveness=an Illusion +seless 3edical :reatment Doctor*Inflicted In>uries Defenseless Patients 'ART II( )ocial Iatro&enesis <# 3he Medicali2ation o$ i$e :7

Political :ransmission of Iatro$enic Disease ,ocial Iatro$enesis 3edical 3ono"ol# ?alue*Free !ure@ 3edicali;ation of the Bud$et :he Pharmaceutical Invasion Dia$nostic Im"erialism Preventive ,ti$ma :erminal !eremonies Black 3a$ic Patient 3a>orities vii 'ART III( Cultural Iatro&enesis Introduction 1<8 :# 3he "illing o$ Pain 1:: =# 3he Invention and ;limination o$ )isease 1>7 ># )eath %gainst )eath 187 Death as !ommodit# :he Devotional Dance of the Dead :he Danse 3aca)re Bour$eois Death !linical Death :rade +nion !laims to a Natural Death Death +nder Intensive !are 'ART IV( The 'olitics of Health 9# *peci$ic Counterproductivity 8# Political Countermeasures <11 <<1

!onsumer Protection for Addicts Aual Access to :orts Pu)lic !ontrols over the Professional 3afia :he ,cientific -r$ani;ation=of 0ife n$ineerin$ for a Plastic Bom) ?# 3he Recovery o$ 6ealth <91

Industriali;ed Nemesis From Inherited 3#th to Res"ectful Procedure :he Ri$ht to Health Health as a ?irtue IndeC 9'& 96& viii Introduction 3he medical esta(lishment has (ecome a ma5or threat to health# 3he disa(ling impact o$ pro$essional control over medicine has reached the proportions o$ an epidemic# Iatro$enesis, the name $or this new epidemic, comes $rom iatros, the -reek word $or @physician,@ and $enesis, meaning @origin#@ )iscussion o$ the disease o$ medical progress has moved up on the agendas o$ medical con$erences, researchers concentrate on the sick-making powers o$ diagnosis and therapy, and reports on parado.ical damage caused (y cures $or sickness take up increasing space in medical dope-sheets# 3he health pro$essions are on the (rink o$ an unprecedented housecleaning campaign# @Clu(s o$ Cos,@ named a$ter the -reek Island o$ )octors, have sprung up here and there, gathering physicians, glori$ied druggists, and their industrial sponsors as the Clu( o$ Rome has gathered @analysts@ under the aegis o$ Aord, Aiat, and 4olkswagen# Purveyors o$ medical services $ollow the e.ample o$ their colleagues in other $ields in adding the stick o$ @limits to growth@ to the carrot o$ ever more desira(le vehicles and therapies# imits to pro$essional health care are a rapidly growing political issue# In whose interest these limits will work will depend to a large e.tent on who takes the initiative in $ormulating the need $or them/ people organi2ed $or political action that challenges status-Buo pro$essional power, or the health : pro$essions intent on e.panding their monopoly even $urther# 3he pu(lic has (een alerted to the perple.ity and uncertainty o$ the (est among its hygienic caretakers# 3he newspapers are $ull o$ reports on volte*face manipulations o$ medical leaders/ the pioneers o$ yesterdayCs so-called (reakthroughs warn their patients against the dangers o$ the miracle cures they have only 5ust invented# Politicians who have proposed the emulation o$ the Russian, *wedish, or ;nglish models o$ sociali2ed medicine are em(arrassed that recent events show their pet systems to (e highly e$$icient in producing the same pathogenicDthat is, sickeningDcures and care that capitalist medicine, al(eit with less eBual access, produces# % crisis o$ con$idence in modern medicine is upon us# Merely to insist on it would (e to contri(ute $urther to a sel$-$ul$illing prophecy, and to possi(le panic# 3his (ook argues that panic is out o$ place# 3hought$ul pu(lic discussion o$ the iatrogenic pandemic, (eginning with an insistence upon demysti$ication o$ all medical matters, will not (e dangerous to the commonweal# Indeed, what is dangerous is a passive pu(lic that has come to rely on super$icial medical housecleanings# 3he crisis in medicine could allow the layman e$$ectively to reclaim his own control over medical perception, classi$ication, and decision-making# 3he laici2ation o$ the %esculapian temple could lead to a delegitimi2ing o$ the (asic religious tenets o$ modern medicine to which industrial societies, $rom the le$t to the right, now su(scri(e#

A)out the Author

My argument is that the layman and not the physician has the potential perspective and e$$ective power to stop the current iatrogenic epidemic# 3his (ook o$$ers the lay reader a conceptual $ramework within which to assess the seamy side o$ progress against its more pu(lici2ed (ene$its# =

It uses a model o$ social assessment o$ technological progress that I have spelled out elsewhereC and applied previously to education< and transportation,: and that I now apply to the criticism o$ the pro$essional monopoly and o$ the scientism in health care that prevail in all nations that have organi2ed $or high levels o$ industriali2ation# In my opinion, the sanitation o$ medicine is part and parcel o$ the socio-economic inversion with which Part I4 o$ this (ook deals# 3he $ootnotes re$lect the nature o$ this te.t# I assert the right to (reak the monopoly that academia has e.ercised over all small print at the (ottom o$ the page# *ome $ootnotes document the in$ormation I have used to ela(orate and to veri$y my own preconceived paradigm $or optimally limited health care, a perspective that did not necessarily have any place within the mind o$ the person who collected the corresponding data# Eccasionally, I Buote my source only as an eyewitness account that is incidentally o$$ered (y the e.pert author, while re$using to accept what he says as e.pert testimon# on the grounds that it is hearsay and there$ore ought not to in$luence the relevant pu(lic decisions# Many more $ootnotes provide the reader with the kind o$ (i(liographical guidance that I would have appreciated when I $irst (egan, as an outsider, to delve into the su(5ect o$ health care and tried to acBuire competence in the political evaluation o$ medicineCs e$$ectiveness# 3hese notes re$er to li(rary tools and re$erence works that I have learned to appreciate in years o$ single-handed e.ploration# 3hey also list readings, $rom technical monographs to novels, that have (een o$ use to me# Ainally, I have used the $ootnotes to deal with my own FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF 1 :ools for !onvivialit# G+ew Hork/ 6arper I Row, 178:J# < Deschoolin$ ,ociet#, Ruth +# %nshen, ed# G+ew Hork/ 6arper I Row, 1781J# : ner$# and Auit# G+ew Hork/ 6arper I Row, 178=J#

parenthetical, supplementary, and tangential suggestions and Buestions, which would have distracted the reader i$ kept in the main te.t# 3he layman in medicine, $or whom this (ook is written, will himsel$ have to acBuire the competence to evaluate the impact o$ medicine on health care# %mong all our contemporary e.perts, physicians are those trained to the highest level o$ speciali2ed incompetence $or this urgently needed pursuit# 3he recovery $rom society-wide iatrogenic disease is a political task, not a pro$essional one# It must (e (ased on a grassroots consensus a(out the (alance (etween the civil li(erty to heal and the civil right to eBuita(le health care# )uring the last generations the medical monopoly over health care has e.panded without checks and has encroached on our li(erty with regard to our own (odies# *ociety has trans$erred to physicians the e.clusive right to determine what constitutes sickness, who is or might (ecome sick, and what shall (e done to such people# )eviance is now @legitimate@ only when it merits and ultimately 5usti$ies medical interpretation and intervention# 3he social commitment to

provide all citi2ens with almost unlimited outputs $rom the medical system threatens to destroy the environmental and cultural conditions needed (y people to live a li$e o$ constant autonomous healing# 3his trend must (e recogni2ed and eventually (e reversed# imits to medicine must (e something other than pro$essional sel$-limitation# I will demonstrate that the insistence o$ the medical guild on its uniBue Buali$ications to cure medicine itsel$ is (ased on an illusion# Pro$essional power is the result o$ a political delegation o$ autonomous authority to the health occupations which was enacted during our century (y other sectors o$ the university-trained (ourgeoisie/ it cannot now (e revoked (y those who conceded it0 it can only (e delegitimi2ed (y popular 9 agreement a(out the malignancy o$ this power# 3he sel$-medication o$ the medical system cannot (ut $ail# I$ a pu(lic, panicked (y gory revelations, were (row(eaten into $urther support $or more e.pert control over e.perts in health-care production, this would only intensi$y sickening care# It must now (e understood that what has turned health care into a sick-making enterprise is the very intensity o$ an engineering endeavor that has translated human survival $rom the per$ormance o$ organisms into the result o$ technical manipulation# @6ealth,@ a$ter all, is simply an everyday word that is used to designate the intensity with which individuals cope with their internal states and their environmental conditions# In Homo sa"iens, @healthy@ is an ad5ective that Buali$ies ethical and political actions# In part at least, the health o$ a population depends on the way in which political actions condition the milieu and create those circumstances that $avor sel$-reliance, autonomy, and dignity $or all, particularly the weaker# In conseBuence, health levels will (e at their optimum when the environ-ment (rings out autonomous personal, responsi(le coping a(ility# 6ealth levels can only decline when survival comes to depend (eyond a certain point on the heteronomous Gother-directedJ regulation o$ the organismCs homeostasis# 'eyond a critical level o$ intensity, institutional health careDno matter i$ it takes the $orm o$ cure, prevention, or environmental engineeringDis eBuivalent to systematic health denial# 3he threat which current medicine represents to the health o$ populations is analogous to the threat which the volume and intensity o$ tra$$ic represent to mo(ility, the threat which education and the media represent to learning, and the threat which ur(ani2ation represents to competence in homemaking# In each case a ma5or institutional endeavor has turned counterproductive# 3ime-con8 suming acceleration in tra$$ic, noisy and con$using communications, education that trains ever more people $or ever higher levels o$ technical competence and speciali2ed $orms o$ generali2ed incompetence/ these are all phenomena parallel to the production (y medicine o$ iatrogenic disease# In each case a ma5or institutional sector has removed society $rom the speci$ic purpose $or which that sector was created and technically instrumented# Iatrogenesis cannot (e understood unless it is seen as the speci$ically medical mani$estation o$ s"ecfic counter"roductivit#. *peci$ic or parado.ical counterproductivity is a negative social indicator $or a diseconomy which remains locked within the system that produces it# It is a measure o$ the con$usion delivered (y the news media, the incompetence $ostered (y educators, or the time-loss represented (y a more power$ul car# *peci$ic counterproductivity is an unwanted side-e$$ect o$ increasing institutional outputs that remains internal to the system which itsel$ originated the speci$ic value# It is

a social measure $or o(5ective $rustration# 3his study o$ pathogenic medicine was undertaken in order to illustrate in the health-care $ield the various aspects o$ counterproductivity that can (e o(served in all ma5or sectors o$ industrial society in its present stage# % similar analysis could (e undertaken in other $ields o$ industrial production, (ut the urgency in the $ield o$ medicine, a traditionally revered and sel$congratulatory service pro$ession, is particularly great# 'uilt-in iatrogenesis now a$$ects all social relations# It is the result o$ internali2ed coloni2ation o$ li(erty (y a$$luence# In rich countries medical coloni2ation has reached sickening proportions0 poor countries are Buickly $ollowing suit# G3he siren o$ one am(ulance can destroy *amaritan attitudes in a whole Chilean town#J 3his process, which I shall call the @medicali2ation o$ li$e,@ deserves articulate political recognition# Medicine could ? (ecome a prime target $or political action that aims at an inversion o$ industrial society# Enly people who have recovered the a(ility $or mutual sel$-care and have learned to com(ine it with dependence on the application o$ contemporary technology will (e ready to limit the industrial mode o$ production in other ma5or areas as well# % pro$essional and physician-(ased health-care system that has grown (eyond critical (ounds is sickening $or three reasons/ it must produce clinical damage that outweighs its potential (ene$its0 it cannot (ut enhance even as it o(scures the political conditions that render society unhealthy0 and it tends to mysti$y and to e.propriate the power o$ the individual to heal himsel$ and to shape his or her environment# Contemporary medical systems have outgrown these tolera(le (ounds# 3he medical and paramedical monopoly over hygienic methodology and technology is a glaring e.ample o$ the political misuse o$ scienti$ic achievement to strengthen industrial rather than personal growth# *uch medicine is (ut a device to convince those who are sick and tired o$ society that it is they who are ill, impotent, and in need o$ technical repair# I will deal with these three levels o$ sickening medical impact in the $irst three parts o$ this (ook# 3he (alance sheet o$ achievement in medical technology will (e drawn up in the $irst chapter# Many people are already apprehensive a(out doctors, hospitals, and the drug industry and only need data to su(stantiate their misgivings# )octors already $ind it necessary to (olster their credi(ility (y demanding that many treatments now common (e $ormally outlawed# Restrictions on medical per$ormance which pro$essionals have come to consider mandatory are o$ten so radical that they are not accept-a(le to the ma5ority o$ politicians# 3he lack o$ e$$ectiveness o$ costly and high-risk medicine is a now widely discussed $act $rom which I start, not a key issue I want to dwell on# 7 Part II deals with the directly health-denying e$$ects o$ medicineCs social organi2ation, and Part III with the disa(ling impact o$ medical ideology on personal stamina/ under three separate headings I descri(e the trans$ormation o$ pain, impairment, and death $rom a personal challenge into a technical pro(lem# Part I4 interprets health-denying medicine as typical o$ the counterproductivity o$ overindustriali2ed civili2ation and analy2es $ive types o$ political response which constitute tactically use$ul remedies that are all strategically $utile# It distinguishes (etween two modes in which the person relates and adapts to his environment/ autonomous Gi#e#, sel$-governingJ coping and heteronomous Gi#e#, ad-ministeredJ maintenance and management# It concludes (y demonstrating that only a political program aimed at the limitation o$ pro$essional management o$ health will ena(le people

to recover their powers $or health care, and that such a program is integral to a societywide criticism and restraint o$ the industrial mode o$ production# 1K

'ART I

Clinical Iatro&enesis

The Epidemics of Modern Medicine )uring the past three generations the diseases a$$licting ,estern societies have undergone dramatic changes#C Polio, diphtheria, and tu(erculosis are vanishing0 one shot o$ an anti(iotic o$ten cures pneumonia or syphilis0 and so many mass killers have come under control that two-thirds o$ all deaths are now associated with the diseases o$ old age# 3hose who die young are more o$ten than not victims o$ accidents, violence, or suicide#< 3hese changes in health status are generally eBuated with a decrease in su$$ering and attri(uted to more or to (etter medical care# %lthough almost everyone (elieves that at least one o$ his $riends would not (e alive and well e.cept $or the skill o$ a doctor, there is in $act no evidence o$ any direct relationship (etween this mutation o$ sickness and the so-called progress o$ medicine#: 3he changes are 1: dependent varia(les o$ political and technological trans-$ormations, which in turn are re$lected in what doctors do and say0 they are not signi$icantly related to the activities that reBuire the preparation, status, and costly eBuipment in which the health pro$essions take pride#= In addition, an e.panding proportion o$ the new (urden o$ disease o$ the last $i$teen years is itsel$ the result o$ medical intervention in $avor o$ people who are or might (ecome sick# It is doctor-made, or iatro$enic.2 %$ter a century o$ pursuit o$ medical utopia,9 and contrary to current conventional wisdom,8 medical services 1= have not (een important in producing the changes in li$e e.pectancy that have occurred# % vast amount o$ contemporary clinical care is incidental to the curing o$ disease, (ut the damage done (y medicine to the health o$ individuals and populations is very signi$icant# 3hese $acts are o(vious, well documented, and well repressed#

*octors+ Effecti,eness-An Illusion

3he study o$ the evolution o$ disease patterns provides evidence that during the last century doctors have a$$ected epidemics no more pro$oundly than did priests during earlier times# ;pidemics came and went, imprecated (y (oth (ut touched (y neither# 3hey are not modi$ied any more decisively (y the rituals per$ormed in medical clinics than (y those customary at religious shrines#? )iscussion o$ the $uture o$ health care might use$ully (egin with the recognition o$ this $act# 3he in$ections that prevailed at the outset o$ the industrial age illustrate how medicine came (y its reputation#7 3u(erculosis, $or instance, reached a peak over two generations# In +ew Hork in 1?1<, the death rate was estimated to (e higher than 8KK per 1K,KKK0 (y 1??<, when "och $irst isolated and cultured the (acillus, it had already declined to :8K per 1K,KKK# 3he rate was down to 1?K when the $irst sanatorium was opened in 171K, even though @consumption@ still held second place in the mortality ta(les#1K %$ter ,orld ,ar II, (ut (e$ore anti(i1> otics (ecame routine, it had slipped into eleventh place with a rate o$ =?# Cholera,@ dysentery,1< and typhoid similarly peaked and dwindled outside the physicianCs control# 'y the time their etiology was understood and their therapy had (ecome speci$ic, these diseases had lost much o$ their virulence and hence their social importance# 3he com(ined death rate $rom scarlet $ever, diphtheria, whooping cough, and measles among children up to $i$teen shows that nearly 7K percent o$ the total decline in mortality (etween 1?9K and 179> had occurred (e$ore the introduction o$ anti(iotics and widespread immuni2ation#1: In part this recession may (e attri(uted to improved housing and to a decrease in the virulence o$ micro-organisms, (ut (y $ar the most important $actor was a higher host-resistance due to (etter nutrition# In poor countries today, diarrhea and upper-respiratory-tract in$ections occur more $reBuently, last longer, and lead to higher mortality where nutrition is poor, no matter how much or how little medical care is availa(le#1= In ;ngland, (y the middle o$ the nineteenth century, in$ectious epidemics had (een replaced (y ma5or malnutrition syndromes, such as rickets and pellagra# 3hese in turn peaked and vanished, to (e replaced (y the diseases o$ early childhood and, somewhat later, (y an increase in duodenal ulcers in 19 young men# ,hen these declined, the modern epidemics took over/ coronary heart disease, emphysema, (ronchitis, o(esity, hypertension, cancer Gespecially o$ the lungsJ, arthritis, dia(etes, and so-called mental disorders# )espite intensive research, we have no complete e.planation $or the genesis o$ these changes#1> 'ut two things are certain/ the pro$essional practice o$ physicians cannot (e credited with the elimination o$ old $orms o$ mortality or mor(idity, nor should it (e (lamed $or the increased e.pectancy o$ li$e spent in su$$ering $rom the new diseases# Aor more than a century, analysis o$ disease trends has shown that the environment is the primary determinant o$ the state o$ general health o$ any population#19 Medical geography,18 18 the history o$ diseases,1? medical anthropology,17 and the social history o$ attitudes towards illness<K have shown that $ood,<1 water,<< and air,<: in correlation with the level o$

sociopolitical eBuality<= and the cultural mechanisms that make it possi(le to keep the population sta(le,<> play the

17 decisive role in determining how healthy grown-ups $eel and at what age adults tend to die# %s the older causes o$ disease recede, a new kind o$ malnutrition is (ecoming the most rapidly e.panding modern epidemic#<9 Ene-third o$ humanity survives on a level o$ undernourishment which would $ormerly have (een lethal, while more and more rich people a(sor( ever greater amounts o$ poisons and mutagens in their $ood#<8 *ome modern techniBues, o$ten developed with the help o$ doctors, and optimally e$$ective when they (ecome part o$ the culture and environment or when they are applied independently o$ pro$essional delivery, have also e$$ected changes in general health, (ut to a lesser degree# %mong these can (e included contraception, smallpo. vaccination o$ in$ants, and such nonmedical health measures as the treatment o$ water and sewage, the use o$ soap and scissors (y midwives, and some anti(acterial and insecticidal procedures# 3he importance o$ many o$ these practices was $irst recogni2ed and stated (y doctorsDo$ten courageous dissidents who su$$ered $or their recommendations<? <K D(ut this does not consign soap, pincers, vaccination needles, delousing preparations, or condoms to the category o$ @medical eBuipment#@ 3he most recent shi$ts in mortality $rom younger to older groups can (e e.plained (y the incorporation o$ these procedures and devices into the laymanCs culture# In contrast to environmental improvements and modern nonpro$essional health measures, the speci$ically medical treatment o$ people is never signi$icantly related to a decline in the compound disease (urden or to a rise in li$e e.pectancy#<7 +either the proportion o$ doctors in a population nor the clinical tools at their disposal nor the num(er o$ hospital (eds is a causal $actor in the striking changes in over-all patterns o$ disease# 3he new techniBues $or recogni2ing and treating such conditions as pernicious anemia and hypertension, or $or correcting congenital mal$ormations (y surgical intervention, re-de$ine (ut do not reduce mor(idity# 3he $act that the doctor population is higher where certain diseases have (ecome rare has little to do with the doctorsC a(ility to control or eliminate them#:K It simply means that doctors <1 deploy themselves as they like, more so than other pro$essionals, and that they tend to gather where the climate is healthy, where the water is clean, and where people are employed and can pay $or their services#:1

.seless Medical Treatment %we-inspiring medical technology has com(ined with egalitarian rhetoric to create the impression that contemporary medicine is highly e$$ective# &ndou(tedly, during the last generation, a limited num(er o$ speci$ic procedures have (ecome e.tremely use$ul# 'ut where they are not monopoli2ed (y pro$essionals as tools o$ their trade, those which are applica(le to widespread diseases are usually very ine.pensive and reBuire a minimum o$ personal skills, materials, and custodial services $rom hospitals# In contrast, most o$ todayCs skyrocketing medical e.penditures are destined $or theFF kindF o$ diagnosis and treatment whose e$$ectiveness at (est dou(t$ul#:< 3o make this point I will distinguish (etween in$ectious and nonin$ectious diseases#

In the case o$ in$ectious diseases, chemotherapy has played a signi$icant role in the control o$ pneumonia, gonorrhea, and syphilis# )eath $rom pneumonia, once the @old manCs $riend,@ declined yearly (y > to ? percent a$ter sulphonamides and anti(iotics came on the market# *yphilis, yaws, and many cases o$ malaria and typhoid can (e cured Buickly and easily# 3he rising rate o$ venereal << disease is due to new mores, not to ine$$ectual medicine# 3he reappearance o$ malaria is due to the development o$ pesticide-resistant mosBuitoes and not to any lack o$ new antimalarial drugs#:: Immuni2ation has almost wiped out paralytic poliomyelitis, a disease o$ developed countries, and vaccines have certainly contri(uted to the decline o$ whooping cough and measles,:= thus seeming to con$irm the popular (elie$ in @medical progress#@ :> 'ut $or most other in$ections, medicine can show no compara(le results# )rug treatment has helped to reduce mortality $rom tu(erculosis, tetanus, diphtheria, and scarlet $ever, (ut in the total decline o$ mortality or mor(idity $rom these diseases, chemotherapy played a minor and possi(ly insigni$icant role#:9 Malaria, leishmaniasis, and sleeping sickness indeed receded $or a time under the onslaught o$ chemical attack, (ut are now on the rise again#:8 <: 3he e$$ectiveness o$ medical intervention in com(atting nonin$ectious diseases is even more Buestiona(le# In some situations and $or some conditions, e$$ective progress has indeed (een demonstrated/ the partial prevention o$ caries through $luoridation o$ water is possi(le, though at a cost not $ully understood#:? Replacement therapy lessens the direct impact o$ dia(etes, though only in the short run#:7 3hrough intravenous $eeding, (lood trans$usions, and surgical techniBues, more o$ those who get to the hospital survive trauma, (ut survival rates $or the most common types o$ cancerDthose which make up 7K percent o$ the casesDhave remained virtually unchanged over the last twenty-$ive years# 3his $act has consistently (een clouded (y announcements $rom the %merican Cancer *ociety reminiscent o$ -eneral ,estmorelandCs proclamations $rom 4ietnam# En the other hand, the diagnostic value o$ the Papanicolaou vaginal smear test has (een proved/ i$ the tests are given $our times a year, early intervention $or cervical cancer demonstra(ly increases the $ive-year survival rate# *ome skin-cancer treatment is highly e$$ective# 'ut there is little evidence o$ e$$ective treatment o$ most other cancers#=K 3he $ive-year survival rate in (reast-can<= cer cases is >K percent, regardless o$ the $reBuency o$ medical check-ups and regardless o$ the treatment used#=1 +or is there evidence that the rate di$$ers $rom that among untreated women# %lthough practicing doctors and the pu(licists o$ the medical esta(lishment stress the importance o$ early detection and treatment o$ this and several other types o$ cancer, epidemiologists have (egun to dou(t that early intervention can alter the rate o$ survival#=< *urgery and chemotherapy $or rare congenital and rheumatic heart disease have increased the chances $or an active li$e $or some o$ those who su$$er $rom degenerative conditions#=: 3he medical treatment o$ common cardiovascular disease== and the intensive treatment o$ heart <> disease,=> however, are e$$ective only when rather e.ceptional circumstances com(ine that are outside the physicianCs control# 3he drug treatment o$ high (lood pressure is e$$ective and warrants the risk o$ side-e$$ects in the $ew in whom it is a malignant condition0 it represents a considera(le risk o$ serious harm, $ar outweighing any proven

(ene$it, $or the 1K to <K million %mericans on whom rash artery-plum(ers are trying to $oist it#=9

*octor/Inflicted In0uries &n$ortunately, $utile (ut otherwise harmless medical care is the least important o$ the damages a proli$erating medical enterprise in$licts on contemporary society# 3he pain, dys$unction, disa(ility, and anguish resulting $rom technical medical intervention now rival the mor(idity due to tra$$ic and industrial accidents and even war-related activities, and make the impact o$ medicine one o$ the most rapidly spreading epidemics o$ our time# %mong murderous institutional torts, only modern malnutrition in5ures more people than iatrogenic disease in its various mani$estations#=8 In the most narrow sense, iatrogenic disease includes only illnesses that would not have come <9 a(out i$ sound and pro$essionally recommended treatment had not (een applied#=? ,ithin this de$inition, a patient could sue his therapist i$ the latter, in the course o$ his management, $ailed to apply a recommended treatment that, in the physicianCs opinion, would have risked making him sick# In a more general and more widely accepted sense, clinical iatrogenic disease comprises all clinical conditions $or which remedies, physicians, or hospitals are the pathogens, or @sickening@ agents# I will call this plethora o$ therapeutic side-e$$ects clinical iatro$enesis. 3hey are as old as medicine itsel$,=7 and have always (een a su(5ect o$ medical studies#>K Medicines have always (een potentially poisonous, (ut their unwanted side-e$$ects have increased with their power>1 and widespread use#>< ;very twenty-$our to thirty<8 si. hours, $rom >K to ?K percent o$ adults in the &nited *tates and the &nited "ingdom swallow a medically prescri(ed chemical# *ome take the wrong drug0 others get an old or a contaminated (atch, and others a counter$eit0>: others take several drugs in dangerous com(inations0>= and still others receive in5ections with improperly sterili2ed syringes#>> *ome drugs are addictive, others mutilating, and others mutagenic, although perhaps only in com(ination with $ood coloring or insecticides# In some patients, anti(iotics alter the normal (acterial $lora and induce a superin$ection, permitting more resistant organisms to proli$erate and invade the host# Ether drugs contri(ute to the (reeding o$ drug-resistant strains o$ (acteria#>9 *u(tle kinds o$ poisoning thus have spread even $aster than the (ewildering variety and u(iBuity o$ nostrums#>8 &nnecessary surgery is a standard procedure#>? Disa)lin$ nondiseases <? result $rom the medical treatment o$ none.istent diseases and are on the increase/>7 the num(er o$ children disa(led in Massachusetts through the treatment o$ cardiac nondisease e.ceeds the num(er o$ children under e$$ective treatment $or real cardiac disease#9K )octor-in$licted pain and in$irmity have always (een a part o$ medical practice#91 Pro$essional callousness, negli<7

gence, and sheer incompetence are age-old $orms o$ malpractice#9< ,ith the trans$ormation o$ the doctor $rom an artisan e.ercising a skill on personally known individuals into a technician applying scienti$ic rules to classes o$ patients, malpractice acBuired an anonymous, almost respecta(le status#9: ,hat had $ormerly (een considered an a(use o$ con$idence and a moral $ault can now (e rationali2ed into the occasional (reakdown o$ eBuipment and operators# In a comple. technological hospital, negligence (ecomes @random human error@ or @system (reak-down,@ callousness (ecomes @scienti$ic detachment,@ and incompetence (ecomes @a lack o$ speciali2ed eBuipment#@ 3he depersonali2ation o$ diagnosis and therapy has changed malpractice $rom an ethical into a technical pro(lem#9= loss o$ the masterCs income during his protracted sickness# Citi2ens were not covered (y these statutes, (ut could avenge malpractice on their own initiative# :K In 1781, (etween 1<,KKK and 1>,KKK malpractice suits were lodged in &nited *tates courts# ess than hal$ o$ all malpractice claims were settled in less than eighteen months, and more than 1K percent o$ such claims remain unsettled $or over si. years# 'etween si.teen and twenty percent o$ every dollar paid in malpractice insurance went to compensate the victim0 the rest was paid to lawyers and medical e.perts#9> In such cases, doctors are vulnera(le only to the charge o$ having acted against the medical code, o$ the incompetent per$ormance o$ prescri(ed treatment, or o$ dereliction out o$ greed or la2iness# 3he pro(lem, however, is that most o$ the damage in$licted (y the modern doctor does not $all into any o$ these categories#99 It occurs in the ordinary practice o$ well-trained men and women who have learned to (ow to prevailing pro$essional 5udgment and procedure, even though they know Gor could and should knowJ what damage they do# 3he &nited *tates )epartment o$ 6ealth, ;ducation, and ,el$are calculates that 8 percent o$ all patients su$$er compensa(le in5uries while hospitali2ed, though $ew o$ them do anything a(out it# Moreover, the $reBuency o$ reported accidents in hospitals is higher than in all industries (ut mines and high-rise construction# %ccidents are the ma5or cause o$ death in %merican children# In :1 proportion to the time spent there, these accidents seem to occur more o$ten in hospitals than in any other kind o$ place# Ene in $i$ty children admitted to a hospital su$$ers an accident which reBuires speci$ic treatment#98 &niversity hospitals are relatively more pathogenic, or, in (lunt language, more sickening# It has also (een esta(lished that one out o$ every $ive patients admitted to a typical research hospital acBuires an iatrogenic disease, sometimes trivial, usually reBuiring special treatment, and in one case in thirty leading to death# 6al$ o$ these episodes result $rom complications o$ drug therapy0 ama2ingly, one in ten comes $rom diagnostic procedures#9? )espite good intentions and claims to pu(lic service, a military o$$icer with a similar record o$ per$ormance would (e relieved o$ his command, and a restaurant or amusement center would (e closed (y the police# +o wonder that the health industry tries to shi$t the (lame $or the damage caused onto the victim, and that the dope-sheet o$ a multinational pharmaceutical concern tells its readers that @iatrogenic disease is almost always o$ neurotic origin#@ 97

*efenseless 'atients

3he undesira(le side-e$$ects o$ approved, mistaken, callous, or contraindicated technical contacts with the medical system represent 5ust the $irst level o$ pathogenic medicine# *uch clinical iatro$enesis includes not only the damage that doctors in$lict with the intent o$ curing or o$ e.ploiting the patient, (ut also those other torts that result $rom the doctorCs attempt to protect himsel$ against the :< possi(ility o$ a suit $or malpractice# *uch attempts to avoid litigation and prosecution may now do more damage than any other iatrogenic stimulus# En a second level,8K medical practice sponsors sickness (y rein$orcing a mor(id society that encourages people to (ecome consumers o$ curative, preventive, industrial, and environmental medicine# En the one hand de$ectives survive in increasing num(ers and are $it only $or li$e under institutional care, while on the other hand, medically certi$ied symptoms e.empt people $rom industrial work and there(y remove them $rom the scene o$ political struggle to reshape the society that has made them sick# *econd-level iatrogenesis $inds its e.pression in various symptoms o$ social overmedicali2ation that amount to what I shall call the e.propriation o$ health# 3his second-level impact o$ medicine I designate as social iatro$enesis, and I shall discuss it in Part II# En a third level, the so-called health pro$essions have an even deeper, culturally healthdenying e$$ect inso$ar as they destroy the potential o$ people to deal with their human weakness, vulnera(ility, and uniBueness in a personal and autonomous way# 3he patient in the grip o$ contemporary medicine is (ut one instance o$ mankind in the grip o$ its pernicious techniBues#81 3his cultural iatro$en* :: esis, which I shall discuss in Part III, is the ultimate (acklash o$ hygienic progress and consists in the paralysis o$ healthy responses to su$$ering, 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 i$ it were a commodity, something called @ (etter health#@ 3his inevita(ly results in the managed maintenance o$ li$e on high levels o$ su(lethal illness# 3his ultimate evil o$ medical @progress@ must (e clearly distinguished $rom (oth clinical and social iatrogenesis# I hope to show that on each o$ its three levels iatrogenesis has (ecome medically irreversi(le/ a $eature (uilt right into the medical endeavor# 3he unwanted physiological, social, and psychological (y-products o$ diagnostic and therapeutic progress have (ecome resistant to medical remedies# +ew devices, approaches, and organi2ational arrangements, which are conceived as remedies $or clinical and social iatrogenesis, themselves tend to (ecome pathogens contri(uting to the new epidemic# 3echnical and managerial measures taken on any level to avoid damaging the patient (y his treatment tend to engender a sel$-rein$orcing iatrogenic loop analogous to the escalating destruction generated (y the polluting procedures used as antipollution devices#8< I will designate this sel$-rein$orcing loop o$ negative institutional $eed(ack (y its classical -reek eBuivalent and call it medical nemesis. 3he -reeks saw gods in the $orces o$ nature# Aor them, nemesis represented divine vengeance := visited upon mortals who in$ringe on those prerogatives the gods enviously guard $or themselves# +emesis was the inevita(le punishment $or attempts to (e a hero rather than a human (eing# ike most a(stract -reek nouns, +emesis took the shape o$ a

divinity# *he represented natureCs response to hubris: to the individualCs presumption in seeking to acBuire the attri(utes o$ a god# Eur contemporary hygienic hu(ris has led to the new syndrome o$ medical nemesis#8: 'y using the -reek term I want to emphasi2e that the corresponding phenomenon does not $it within the e.planatory paradigm now o$$ered (y (ureaucrats, therapists, and ideologues $or the snow(alling diseconomies and disutilities that, lacking all intuition, they have engineered and that they tend to call the @counterintuitive (ehavior o$ large systems#@ 'y invoking myths and ancestral gods I should make it clear that my $ramework $or analysis o$ the current (reakdown o$ medicine is $oreign to the industrially determined logic and ethos# I (elieve that the reversal of nemesis can come only $rom within man and not $rom yet another managed GheteronomousJ source depending once again on presumptious e.pertise and su(seBuent mysti$ication# Medical nemesis is resistant to medical remedies# It can (e reversed only through a recovery o$ the will to sel$-care among the laity, and through the legal, political, and institutional recognition o$ the right to care, which imposes limits upon the pro$essional monopoly o$ physicians# My $inal chapter proposes guidelines $or stemming medical nemesis and provides criteria (y which the medical enterprise can (e kept within healthy (ounds# I do not suggest any speci$ic $orms o$ health care or :> sick-care, and I do not advocate any new medical philosophy any more than I recommend remedies $or medical techniBue, doctrine, or organi2ation# 6owever, I do propose an alternative approach to the use o$ medical organi2ation and technology together with the allied (ureaucracies and illusions# :9 Footnotes 1 ;rwin 6# %ckerknecht, Histor# and .eo$ra"h# of the 3ost Im"ortant Diseases G+ew Hork/ 6a$ner, 179>J# < Edin ,# %nderson and Monroe erner, 3easurin$ Health 0evels in the +nited ,tates, %&77* %&26, 6ealth In$ormation Aoundation Research *eries no# 11 G+ew Hork/ Aoundation, 179KJ# Marc alonde, A New Pers"ective on the Health of !anadians4 A Borkin$ Document GEttawa/ -overnment o$ Canada, %pril 178=J# 3his courageous Arench-;nglish report (y the Canadian Aederal *ecretary $or 6ealth contains a multicolored center$old documenting the change in mortality $or Canada in a series o$ graphs# : Ren1 )u(os, :he 3ira$e of Health4 +to"ian Pro$ress and Biolo$ical !han$e G+ew Hork/ %nchor 'ooks, 17>7J, was the $irst to e$$ectively e.pose the delusion o$ producing @(etter health@ as a dangerous and in$ectious medically sponsored disease# 3homas Mc"eown and -ordon Mc achlan, eds#, 3edical Histor# and 3edical !are4 A ,#m"osium of Pers"ectives G+ew Hork/ E.$ord &niv# Press, 1781J, introduce the sociology o$ medical pseudo-progress# !ohn Powles, @En the imitations o$ Modern Medicine,@ in ,cience, 3edicine and 3an G ondon/ Pergamon, 178:J, 1/1-:K, gives a critical selection o$ recent ;nglish-language literature on this su(5ect# Aor the &#*# situation consult Rick Carlson, :he nd of 3edicine G+ew Hork/ ,iley Interscience, 178>J# 6is essay is @an empirically (ased (rie$, theoretical in nature#@ Aor his indictment o$ %merican medicine he has chosen those dimensions $or which he had complete evidence o$ a nature he could handle# !ean-Claude Polack, 0a 3Ddecine du ca"ital GParis/ Maspero, 178KJ# % critiBue o$ the political trends that seek to endow medical technology with an e$$ective impact on health levels (y a @democrati2ation o$ medical consumer products#@ 3he author discovers

that these products themselves are shaped (y a repressive and alienating (ourgeois class structure# 3o use medicine $or political li(eration it will (e necessary to @$ind in sickness, even when it is distorted (y medical intervention, a protest against the e.isting social order#@ = )aniel -reen(erg, @3he L,ar on CancerC/ E$$icial Aiction and 6arsh Aacts,@ ,cience and .overnment Re"ort, vol# = G)ecem(er 1, 178=J# 3his well-researched report to the layman su(stantiates the view that %merican Cancer *ociety proclamations that cancer is cura(le and progress has (een made are @reminiscent o$ 4ietnam optimism prior to the deluge#@ > Dorland<s Illustrated 3edical Dictionar#, <>th ed# GPhiladelphia/ *aunders, 178=J/ @Iatrogenic Eiatro=.r. physician, gennanD-r# to produceJ# Resulting $rom the activity o$ physicians# Eriginally applied to disorders induced in the patient (y autosuggestion (ased on the physicianCs e.amination, manner, or discussion, the term is now applied to any adverse condition in a patient occurring as the result o$ treatment (y a physician or surgeon#@ 9 6einrich *chipperges, +to"ien der 3edi;in4 .eschichte und Fritik der Grt;tlichen Ideolo$ie des %&. Hh. G*al2(urg/ Muller, 1799J# % use$ul guide to the historical literature is Richard M# 'urke, %n Historical !hronolo$# of :u)erculosis, <nd ed# G*pring$ield, Ill#/ 3homas, 17>>J# 8 Aor an analysis o$ the agents and patterns that determine the epidemic spread o$ modern misin$ormation throughout a scienti$ic community, see )erek !# de *olla Price, 0ittle ,cience, Bi$ ,cience G+ew Hork/ Colum(ia &niv# Press, 179:J# ? En the clerical nature o$ medical practice, see @Cl1ricalisme de la $onction m1dicaleM M1decine et politiBue# e L*acerdoceC m1dical# a Relation th1rapeutiBue# Psychanalyse et christianisme,@ 0e ,emeur, suppl# < G1799-98J# 7 !# +# ,eis$ert, @)as Pro(lem des *chwindsuchtskranken in )rama und Roman,@ Deutscher Hournalistens"ie$el 5 G17<8J/ >87-?<# % guide to tu(erculosis as a literary motive in 17th-century drama and novel# ;# ;(stein, @)ie ungenschwindsucht in der ,eltliteratur,@ Ieitschrift fJr BJcherfreunde 2 G171:J# 1K RenN and !ean )u(os, :he Bhite Pla$ue4 :u)erculosis, 3an and ,ociet# G'oston/ ittle, 'rown, 17>:J# En the social, literary, and scienti$ic aspects o$ 17th-century tu(erculosis0 an analysis o$ its incidence# 11 Charles ;# Rosen(erg, :he !holera Years4 :he +nited ,tates in %659, %68&, and %6(( GChicago/ &niv# o$ Chicago Press, 179<J# 3he +ew Hork epidemic o$ 1?:< was a moral dilemma $rom which deliverance was sought in $asting and prayer# 'y the time o$ the epidemics o$ 1?99, the culture that had produced +ew Hork slums had as well produced chloride o$ lime# 1< ,# !# van Oi5l, @*tudies on )iarrheal )isease in *even Countries,@ Bulletin of the Borld Health -r$ani;ation :> G1799J/ <=7-91# Reduction in diarrheal diseases is (rought a(out (y a (etter water supply and sanitation, never (y curative intervention# 1: R# R# Porter, :he !ontri)ution of the Biolo$ical and 3edical ,ciences to Human Belfare, Presidential %ddress to the 'ritish %ssociation $or the %dvancement o$ *cience, *wansea Meeting, 1781 G ondon/ the %ssociation, 178<J, p# 7>#

1= +# *# *crimshaw, C# ;# 3aylor, and !ohn ;# -ordon, Interactions of Nutrition and Infection G-eneva/ ,orld 6ealth Ergani2ation, 179?J# 1> !ohn Cassel, @Physical Illness in Response to *tress,@ %ntologPa %8, mimeographed GCuernavaca/ CI)EC GCentro Intercultural de )ocumentaciQnJ, 1781J# 19 Ene o$ the clearest early statements on the paramount importance o$ the environment is !# P# Arank, Akademische Rede vom ?olkselend als der 3utter der Frankheiten GPavia, 187K0 reprint ed#, eip2ig/ 'arth, 179KJ# 3homas Mc"eown and R# -# Record, @Reasons $or the )ecline in Mortality in ;ngland and ,ales )uring the +ineteenth Century,@ Po"ulation ,tudies 19 G179<J/ 7=R1<<# ;dwin Chadwick, Re"ort on the ,anitar# !ondition of the 0a)ourin$ Po"ulation of .reat Britain, %689, ed# M# ,# Alinn GChicago/ %ldine, 179>J, concluded a century and a hal$ ago that @the primary and most important measures and at the same time the most practical, and within the recogni2ed providence o$ pu(lic administration, are drainage, the removal o$ all re$use $rom ha(itations, streets, and roads, and the improvement o$ the supplies o$ water#@ Ma. von Petterko$er, :he ?alue of Health to a !it#4 :wo 0ectures Delivered in %6'5, trans# 6enry ;# *igerist G'altimore/ !ohns 6opkins, 17=1J, calculated a century ago the cost o$ health to the city o$ Munich in terms o$ average wages lost and medical costs created# Pu(lic services, especially (etter water and sewage disposal, he argued, would lower the death rate, mor(idity, and a(senteeism and this would pay $or itsel$# ;pidemiological research has entirely con$irmed these humanistic convictions/ )elpit-Morando, Radenac, and 4ilain, Dis"aritDs rD$ionales en matiKre de santD, 'ulletin de *tatistiBue du MinistNre de la *ant1 et de la *1curit1 *ociale +o# :, 178:0 ,arren ,inkelstein, !r#, @;pidemiological Considerations &nderlying the %llocation o$ 6ealth and )isease Care Resources,@ International Hournal of "idemiolo$# 1, no# 1 G178<J/ 97R8=0 A# Aagnani, ,antD, consommation mDdicate et environnement4 Pro)lKmes et mDthodes GParis/ Mouton, 178:J# 18 +# )# Mc-lashan, ed#, 3edical .eo$ra"h#4 :echniAues and Field ,tudies G+ew Hork/ 'arnes I +o(le, 178:J# !acBues May and )onna Mc elland, eds#, ,tudies in 3edical .eo$ra"h#, 1K vols# G+ew Hork/ 6a$ner, 1791R81J# )aniel +oin, 0a .Do$ra"hie dDmo$ra"hiAue de la France GParis/ P&A, 178:J# !# 4allin, 0a 3ortalite en France "ar tranches de"uis %6&& EParis4 P+F, %&'5L. 0. D. ,tam", :he .eo$ra"h# of 0ife and Death EIthaca, N.Y.4 !ornell +niv. Press, %&(2L. . Rodenwaldt et al., Beltseuchenatlas EHam)ur$, %&2(L. Hohn 3elton Hunter, :he .eo$ra"h# of Health and Disease, ,tudies in .eo$ra"h# no. ( E!ha"el Hill4 +niv. of North !arolina Press, %&'8L. 1? ;rwin 6# %ckerknecht, :hera"eutics4 From the Primitives to the :wentieth !entur# G+ew Hork/ 6a$ner, 178:J# % simple overview# !# A# )# *hrews(ury, A Histor# of the Bu)onic Pla$ue in the British Isles GCam(ridge/ Cam(ridge &niv# Press, 178KJ# %n outstanding e.ample o$ history written (y a (acteriologist and epidemiologist# 17 Aor an introduction to the literature, see *teven Polgar, @6ealth and 6uman 'ehaviour/ %reas o$ Interest Common to the *ocial and Medical *ciences,@ !urrent Anthro"olo$# 5 G%pril 179<J/ 1>7-<K># Polgar gives a critical evaluation o$ each item and the responses o$ a large num(er o$ colleagues to his evaluation# *ee also *teven Polgar, @6ealth,@ in International nc#clo"edia of the ,ocial ,ciences G179?J, 9/::K-90 ;liot Areidson, @3he *ociology o$ Medicine/ % 3rend Report and 'i(liography,@ !urrent ,ociolo$#, %&(%*(9, nos# 1K-11, pp# 1<:-7<# <K Paul *lack, @)isease and the *ocial 6istorian,@ :imes iterary *upplement, March ?, 178=, pp# <::-=# % critical review article# Catherine Rollet and %gnNs *ouriac,, @;pid1mics et mentalit1s/ e Chol1ra de 1?:< en *eine-et-Eise,@ Annales conomies, ,ociDtDs, !ivilisations, 178=, no# =, pp# 7:>-9>#

<1 %lan 'erg, :he Nutrition Factor4 Its Role in National Develo"ment G,ashington, )#C#/ 'rookings Institution, 178:J# 6ans !# 3eute(erg and -Snter ,iegelmann, Der Bandel der Nahrnn$s$ewohnheiten unter dem influss der Industrialisierun$ G-Tttingen/ 4andenhoeck I Ruprecht, 178<J, deal with the impact o$ industriali2ation on the Buantity, Buality, and distri(ution o$ $ood in 17th-century ;urope# ,ith the transition $rom su(sistence on limited staples to either managed or chosen menus, the traditional regional cultures o$ eating, $asting, and surviving hunger were destroyed# % (adly organi2ed rich mine o$ (i(liographic in$ormation# In the wake o$ Marc 'loch and ucien Ae(vre, some o$ the most valua(le research on the signi$icance o$ $ood to power structures and health levels was done# Aor an orientation on the method used, consult -uy 3huillier, @+ote sur les sources de lChistoire r1gionale de lCalimentation au UIUe siNcle,@ Annales conomies, ,ociDtDs, !ivilisations, 179?, no# 9, pp# 1:K1-170 -uy 3huillier, @%u UIUe siNcle/ C%limentation en +ivernais,@ Annales, %&(2, no# 9, pp# 119:?=# Aor a masterpiece consult Arancois e(run, 0es Hommes et la mort en Mn>ou au %'e et %6e siKcles4 ssai de dDmo$ra"hie et "s#cholo$ie historiAues GParis/ Mouton, 1781J0 %# Poitrineau, @ C%limentation populaire en %uvergne au U4IIIC siNcle,@ in nAuites, pp# :<:-:1# Ewsei 3emkin, +utrition $rom Classical %ntiBuity to the 'aroBue, Human Nutrition 3ono$ra"h 5, +ew Hork, 179<# Aor the trans$ormation o$ (read into a su(stance machines can produce, see *ieg$ried--iedion, 3echani;ation :akes !ommand4 A !ontri)ution to Anon#mous Histor# G+ew Hork/ +orton, 1797J, especially pts# =/<, =/: Gon meatJ# %lso Aernand 'raudel, @ e *uper$lu et lCordinaire/ +ourriture et (oissons,@ in !ivilisation matDrielle et ca"italisme GParis/ Colin, 1798J, pp# 1:=-7?# << I# )# Carruthers, Im"act and conomics of !ommunit# Bater ,u""l#4 A ,tud# of Rural Bater Investment in Fen#a, ,ye College, %sh$ord, "ent, 178:0 on the impact o$ water supply on health# En the improvement o$ rural water supplies during the 17th century/ -uy 3huillier, @Pour une histoire r1gionale de lCeau en +ivernais au UIUe si1cle,@ Annales conomies, ,ociDtDs, !ivilisations, 179?, no# 1, pp# =7 i$# 3he improvement o$ water supplies changed peopleCs attitude towards their own (odies/ -uy 3huillier, @Pour une histoire de lChygiNne corporelle# &n e.emple r1gional/ le +ivernais,@ Revue d<histoire DconomiAue et sociale =9, no# < G179?J/ <:<->:0 awrence ,right, !lean and Decent :he Fascinatin$ Histor# of the Bathroom and the Bater !loset and of ,undr# Ha)its, Fashions and Accessories of the :oilet, Princi"all# in .reat Britain, France and America G3oronto/ &niv# o$ 3oronto Press, 1798J# +ew patterns $or laundry developed/ -uy 3huillier, @Pour une histoire de la lessive au UIUe siNcle,@ Annales, 1797, no# <, pp# :>>7K# <: ester '# ave and ;ugene P# *eskin, @%ir Pollution and 6uman 6ealth,@ ,cience 197 G178KJ/ 8<:-::# !ean-Paul )essaive et al#, 3Ddecins, climat et D"idDmies d la fin du N?IIIe siKcle GParis/ Mouton, 178<J# <= % synthetic, well-documented argument to this point is ;manuel de "adt, @IneBuality and 6ealth,@ &niv# o$ *usse., !anuary 178># 3he original and longer version o$ this paper was written in 178< as the introductory chapter o$ a (ook, ,alud # )ienestar, which should have (een pu(lished in *antiago, Chile, in 178:# !ohn Powles, @6ealth and Industrialisation in 'ritain/ 3he Interaction o$ *u(stantive and Ideological Change,@ prepared $or a ColloBuium on the %dapta(ility o$ Man to &r(an i$e, Airst ,orld Congress on ;nvironmental Medicine and 'iology, Paris, !uly 1->, 178=# C# Aerrero, @6ealth and evels o$ iving in atin %merica,@ 3il)ank 3emorial Fund Ouarterl# =: GEcto(er 179>J/ <?1-7># % decline in mortality is not to (e anticipated $rom more e.penditures on health care (ut $rom a di$$erent allocation o$ $unds within the health sector com(ined with social change# <> ;mily R# Coleman, @ CIn$anticide dans le haut moyen Vge,@ trans# %# Chamou., Annales conomies, ,ociDtDs, !ivilisations, 178=, no# <, pp# :1>-:># *uggests that in$anticide in the Middle %ges was demographically signi$icant# %nsley !# Coale, @3he )ecline o$ Aertility in ;urope $rom the Arench Revolution to ,orld ,ar II,@ in *# !# 'ehrman et al#, Fertilit#

and Famil# Plannin$ G%nn %r(or/ &niv# o$ Michigan Press, 178KJ# Marital $ertility declined everywhere (e$ore the proportion o$ the population who married increased# )iscrimination against the illegitimate com(ined with restricted access to marriage may have served to control population# 3his hypothesis is rein$orced in !#- # Alandrin, @Contraception, mariage et relations amoureuses dans lCEccident chrNtien,@ Annales, 1797, no# 9, pp# 1:8K-7K# )emographic data suggest no contraception within marriage $or 18th and 1?th-century Arance, (ut very low rates o$ illegitimacy# Contraception in marriage was near heresy, conception outside marriage a scandal# Alandrin suggests that during the 17th century se.ual (ehavior (etween spouses (egan to (e modeled on traditional (ehavior outside marriage# Contraception seems to have (ecome accepta(le $irst among peasant $amilies rich enough to keep in$ant mortality low/ see M# eridon, @A1condit1 et mortalit1 in$antile dans trois villages (avarois/ &ne %nalyse de donn1es individualis1es du UIUe siNcle,@ Po"ulation 2 G1797J/ 778-1KK<# %lthough physicians in ;ngland opposed its spread, they seemingly applied it e$$ectively in their own lives/ !# %# 'anks, @Aamily Planning and 'irth Control in 4ictorian 3imes,@ paper read at the *econd %nnual Con$erence, o$ the *ociety $or the 6istory o$ Medicine, eicester &niv#, 178<# 3he Catholic Church seems to have made contraception an issue only inso$ar as it a$$ected the industrial middle classes/ see !ohn 3homas +oonan, !ontrace"tion4 A Histor# of Its :reatment )# the !atholic :heolo$ians and !anonists GCam(ridge/ 6arvard &niv# Press, 179>J# Philippe %riNs, @ es 3echniBues de la mort,@ in Histoire des "o"ulations franPaises et de leurs attitudes devant la vie de"uis le N?IIIe siKcle GParis/ *poil, 1781J, p# :8:# <9 *o $ar, world hunger and world malnutrition have increased with industrial development# @Ene third to one hal$ o$ humanity are said to (e going to (ed hungry every night# In the *tone %ge the $raction must have (een much smaller# 3his is the era o$ unprecedented hunger# +ow, in the time o$ the greatest technical power, starvation is an institution#@ Marshall *ahlins, ,tone A$e conomics GChicago/ %ldine, 178<J, p# <:# <8 !# ;# )avies and ,# A# ;dmundson, "idemiolo$# of DD: GMount "isco, +#H#/ Auture, 178<J# % good e.ample o$ parado.ical disease control $rom 'orneo/ Insecticides used in villages to control malaria vectors also accumulated in cockroaches, most o$ which are resistant# -eckoes $ed on these, (ecame lethargic, and $ell prey to cats# 3he cats died, rats multiplied, and with rats came the threat o$ epidemic (u(onic plague# 3he army had to parachute cats into the 5ungle village E!onservation News, !uly 178:J# <? % good e.ample o$ medical persecution o$ innovators is given (y -# -ortvay and I# Ooltan, I. ,emmelweis, His 0ife and Bork G'udapest/ %kademiai "iado, 179?J, a critical (iography o$ the $irst gynecologist to use antiseptic procedures in his wards# In 1?=? he reduced mortality $rom puerperal $ever (y a $actor o$ 1> and was thereupon dismissed and ostraci2ed (y his colleagues, who were o$$ended at the idea that physicians could (e carriers o$ death# Morton 3hompsonCs novel :he !r# and the !ovenant G+ew Hork/ +ew %merican i(rary, 178:J makes *emmelweis come alive# <7 Charles 3# *tewart, !r#, @%llocation o$ Resources to 6ealth,@ Hournal of Human Resources 9, no# 1 G1781J/ 1K:-<1# *tewart classi$ies resources devoted to health as treatment, prevention, in$ormation, and research# In all nations o$ the ,estern 6emisphere, prevention Ge#g#, pota(le waterJ and education are signi$icantly related to li$e e.pectancy, (ut none o$ the @treatment varia(les@ are so related# :K Reuel %# *tallones, in nvironment, colo$#, and "idemiolo$#, Pan-%merican 6ealth Ergani2ation *cienti$ic Pu(lication no# <:1 G,ashington, *eptem(er :K, 1781J, shows there is a strong positive correlation in the &#*#%# (etween a high proportion o$ doctors in the general population and a high rate o$ coronary disease, while the correlation is strongly negative $or cere(ral vascular disease# *tallones points out that this says nothing a(out a possi(le in$luence o$ doctors on either# Mor(idity and mortality are an

integral part o$ the human environment and unrelated to the e$$orts made to control any speci$ic disease# :1 %lain etourmy and Arancois -i(ert, ,antD, environnement, consommations mDdicales4 +n 3odKle et son estimation Q "artir des donnDes de mortalitDR Ra""ort "rinci"al GParis/ CWRX'; GCentre de Recherche sur le 'ien-YtreJ, !une 178=J# Compares mortality rates in di$$erent regions o$ Arance0 they are unrelated to medical density, highly related to the $at content o$ the sauces typical o$ each region, and somewhat less to alcohol consumption# :< 3he model study on this matter at present seems to (e %# # Cochrane, ffectiveness and fficienc#4 Random Reflections on Health ,ervices, +u$$ield Provincial 6ospitals 3rust, 178<# *ee also British 3edical Hournal, 178=, =/># %# Zuerido, fficienc# of 3edical !are G+ew Hork/ International Pu(lications, 179:J# :: !acBues M# May, @In$luence o$ ;nvironmental 3rans$ormation in Changing the Map o$ )isease,@ in M# 3aghi Aarvar and !ohn P# Milton, eds#, :he !areless :echnolo$# G-arden City, +#H#/ +atural 6istory Press, 178<J, pp# 17-:=# May warns that mosBuito resistance to insecticides on the one hand and parasite resistance to chemotherapeutic agents on the other may have created an unanswera(le challenge to human adaptation# := 6enry !# Parish, % Histor# of Immuni;ation G;din(urgh/ ivingstone, 179>J# Consult historical introduction $or literature# 3he e$$ectiveness o$ prevention in relation to any speci$ic disease must (e distinguished $rom its contri(ution to the volume o$ disease/ !# 6# %lston, % New 0ook at Infectious Disease G ondon/ Pitman, 1798J, shows how in$ections are replaced (y new ones, without reduction in over-all volume# "eith Mellan(y, Pesticides and Pollution G+ew Hork/ Collins, 1798J, in an easily understanda(le way demonstrates how the engineering mechanisms designed to reduce one in$ection $oster others# :> Repu(lica de Cu(a, Ministerio de la *alud P[(lica, !u)a4 -r$ani;atiSn de los servicios # nivel de salud G6avana, 178=J, introduction (y Aidel Castro# %n impressive demonstration o$ the shi$t in mortality and mor(idity patterns over one decade, during which ma5or in$ections on the whole island were signi$icantly a$$ected (y a pu(lic-health campaign# +guyen "hac 4ien, @<> %nn1es dCactivit1s m1dico-sanitaires,@ tudes vietnamiennes G6anoiJ, no# <>, 178K# :9 -# E# *o$oluwe, @Promotive Medicine/ % 'oost to the ;conomy o$ )eveloping Countries,@ :ro"ical and .eo$ra"hical 3edicine << G!une 178KJ/ <>K-=# )uring the :K years (etween 17:> and 179?, most curative measures used $or parasitic diseases and in$ections o$ the skin and respiratory organs and $or diarrhea have le$t @the pattern o$ mor(idity on the whole unchanged#@ :8 In Aarvar and Milton, eds#, :he !areless :echnolo$#, several authors make this point speci$ically $or malaria, 'ancro$tian $ilariasis G6amonJ, schistosomiasis Gvan der *chalieJ, and genito-urinary in$ections GAarvarJ# :? 'ruce Mitchel, Fluoridation Bi)lio$ra"h#, Council o$ Planning i(rarians ;.change 'i(liography no# <9?, G,aterloo, Ent#, March 178<J# Covers the de(ate and especially the social scientistCs perception o$ peopleCs (ehavior regarding $luoridation in Canada# :7 C# # Meinert et al#, @% *tudy o$ the ;$$ects o$ 6ypoglycemic %gents on 4ascular Complications in Patients with %dult-Enset )ia(etes# II# Mortality Results, 178K,@ Dia)etes 17, suppl# < G178KJ/ 8?7-?:K# -# # "natterud et al#, @;$$ects o$ 6ypoglycemic %gents on 4ascular Complications in Patients with %dult-Enset )ia(etes,@ Hournal of the American 3edical Association <18 G1781J/ 888-?=# Cochrane, ffectiveness and fficac#,

comments on the last two# 3hey suggest that giving tol(utamide and phen$ormin is de$initely disadvantageous in the treatment o$ mature dia(etes and that there is no advantage in giving insulin rather than a diet# =K 6# Eeser, Fre)s)ekGm"fun$4 Hoffnun$ und RealitGt G*tuttgart/ 3hieme, 178=J# 3his is so $ar, to my knowledge, the most use$ul introduction $or the general physician or layman to a critical evaluation o$ world literature on the e$$ectiveness o$ cancer treatment# *ee also +# ;# Mc"innon, @3he ;$$ects o$ Control Programs on Cancer Mortality,@ !anadian 3edical Association Hournal ?< G179KJ/ 1:K?-1<# "# 3# ;vans, @'reast Cancer *ymposium/ Points in the Practical Management o$ 'reast Cancer# %re Physical Methods o$ )iagnosis o$ 4alueM@ British Hournal of ,ur$er# >9 G1797J/ 8?=-9# =1 ;dwin A# ewison, @%n %ppraisal o$ ong-3erm Results in *urgical 3reatment o$ 'reast Cancer,@ Hournal of the American 3edical Association 1?9 G179:J/ 78>-?# @3he most impressive $eature o$ the surgical treatment o$ (reast cancer is the striking similarity and surprising uni$ormity o$ long-term end results despite widely di$$ering therapeutic techniBues as reported $rom this country and a(road#@ 3he same can (e said today# =< Ro(ert *utherland, !ancer4 :he ,i$nificance of Dela# G ondon/ 'utterworth, 179KJ, pp# 179-<K<# %lso 6edley %tkins et al#, @3reatment o$ ;arly 'reast Cancer/ % Report a$ter 3en Hears o$ Clinical 3rial,@ British 3edical Hournal, 178<, </=<:-70 also p# =18# )# P# 'yar and 4eterans %dministration Cooperative &rological Research -roup, @*urvival o$ Patients with Incidentally Aound Microscopic Cancer o$ the Prostate/ Results o$ Clinical 3rial o$ Conservative 3reatment,@ Hournal of +rolo$# 1K? G)ecem(er 178<J/ 7K?-1:# Random comparison o$ $our treatments Gplace(o, estrogen, place(o and orchiectomy, and estrogen and orchiectomyJ reveals no signi$icant di$$erences among them, nor in comparison with radical prostatectomy# Aor a (road survey o$ analogous research on cancer in various sites, see note =K a(ove# =: %nn -# "utner, @Current *tatus o$ *teroid 3herapy in Rheumatic Aever,@ American Heart Hournal '7 G%ugust 179>J/ 1=8-7# Rheumatic Aever ,orking Party o$ the Medical Research Council o$ -reat 'ritain and *u(committee o$ Principal Investigators o$ the %merican Council on Rheumatic Aever and Congenital 6eart )isease, %merican 6eart %ssociation, @3reatment o$ %cute Rheumatic Aever in Children/ % Cooperative Clinical 3rial o$ %C36, Cortisone and %spirin,@ British 3edical Hournal, 17>>, 1/>>>-8=# == %l(ert +# 'rest, @3reatment o$ Coronary Ecclusive )isease/ Critical Review,@ Diseases of the !hest 82 G!anuary 179=J/ =K-=># Malcolm I# indsay and Ralph ;# *piekerman, @Reevaluation o$ 3herapy o$ %cute Myocardial In$arction,@ American Heart Hournal 98 G%pril 179=J/ >>7-9=# 6arvey )# Cain et al#, @Current 3herapy o$ Cardiovascular )isease,@ .eriatrics 1? G!uly 179:J/ >K8-1?# => 6# -# Mather et al#, @%cute Myocardial In$arction/ 6ome and 6ospital 3reatment,@ British 3edical Hournal, 1781, :/::=-?# =9 Com(ined *ta$$ Clinic, @Recent %dvances in 6ypertension,@ American Hournal of 3edicine :7 GEcto(er 179>J/ 9:=-?# =8 Aor some o$ the standard te.t(ooks see Ro(ert 6# Moser, :he Disease of 3edical Pro$ress4 A ,tud# of Iatro$enic Disease, :rd ed# G*pring$ield, Ill#/ 3homas, 1797J# )avid M# *pain, :he !om"lications of 3odern 3edical Practices G+ew Hork/ -rune I *tratton, 179:J# 6# P# "Smmerle and +# -oossens, Flinik und :hera"ie der Ne)enwirkun$en G*tuttgart/ 3hieme, 178: [lst ed#, 179K]J# R# 6eint2, rkrankun$en durch Ar;neimittel4 Dia$nostik, Flinik, Patho$enese, :hera"ie G*tuttgart/ 3hieme, 1799J# -uy )uchesnay, 0e RisAue thDra"eutiAue GParis/ )oin, 17>=J# P# A# )C%rcy and !# P# -ri$$in, Iatro$enic Disease G+ew Hork/ E.$ord &niv# Press, 178<J#

=? Aor the evolution o$ 5urisprudence related to this kind o$ torts see M# +# Oald, @3he *ocial Control o$ -eneral 6ospitals,@ in '# *# -eorgopoulos, ed#, -r$ani;ation Research on Health Institutions G%nn %r(or/ &niv# o$ Michigan, Institute $or *ocial Research, 178<J# *ee also %ngela 6older, 3edical 3al"ractice 0aw G+ew Hork/ ,iley, 178=J# =7 *uch side-e$$ects were studied (y the %ra(s# %l-Ra2i G%#)# ?9>-7<>J, the medical chie$ o$ the hospital o$ 'aghdad, was concerned with the medical study o$ iatrogenesis, according to %l-+adim in the Fihrist, chap# 8, sec# :# %t the time o$ %l-+adim G%#)# 7:>J, three (ooks and one letter o$ %l-Ra2i on the su(5ect were still availa(le/ :he 3istakes in the Pur"ose of Ph#siciansR -n Pur$in$ Fever Patients Before the :ime Is Ri"eR :he Reason Bh# the I$norant Ph#sicians, the !ommon Peo"le, and the Bomen in !ities Are 3ore ,uccessful :han 3en of ,cience in :reatin$ !ertain Diseases and the Ccuses Bhich Ph#sicians 3ake for :hisR and the letter/ @,hy a Clever Physician )oes +ot 6ave the Power to 6eal %ll )iseases, $or 3hat Is +ot ,ithin the Realm o$ the Possi(le#@ >K *ee also ;rwin 6# %ckerknecht, @Our -eschichte der iatrogenen "rankheiten,@ .esnerus 9' G178KJ/ >8-9:# 6e distinguishes three waves, or periods, since 18>K when the study o$ iatrogenesis was considered important (y the medical esta(lishment# ;rwin 6# %ckerknecht, @Our -eschichte der iatrogenen ;rkrankungen des +ervensystems,@ :hera"eutische +mschauTRevue thDra"eutiAue 9', no# 9 G178KJ/ :=>-9# % short survey o$ medical awareness o$ the side-e$$ects o$ drugs on the central nervous system, starting with %vicenna G7?K-1K:8J on mercury# >1 # Meyler, ,ide ffects of Dru$s G'altimore/ ,illiams I ,ilkins, 178<J# Adverse Reactions :itles, a monthly (i(liography o$ titles $rom appro.imately :,=KK (iomedical 5ournals pu(lished throughout the world0 pu(lished in %msterdam since 1799# Aller$# Information Bulletin, %llergy In$ormation %ssociation, ,eston, Entario# >< P# ;# *artwell, @Iatrogenic )isease/ %n ;pidemiological Perspective,@ International Hournal of Health ,ervices 8 Gwinter 178=J/ ?7-7:# >: Pharmaceutical *ociety o$ -reat 'ritain, Indentification of Dru$s and Poisons G ondon/ the *ociety, 179>J# Reports on drug adulteration and analysis# Margaret "reig, Black 3arket 3edicine G;nglewood Cli$$s, +#!#/ Prentice-6all, 1798J, reports that an increasing percentage o$ articles sold (y legitimate pro$essional pharmacies are inert counter$eit drugs indistinguisha(le in packaging and presentation $rom the trademarked product# >= Morton Mint2, B# Prescri"tion -nl#, <nd ed# G'oston/ 'eacon Press, 1798J# GAor a $uller description o$ this (ook, see (elow, note 7?, p# 98#J *olomon -ar(, +ndesira)le Dru$ Interactions, %&'8*'2, rev# ed# G+ew Hork/ *pringer, 178>J# Includes in$ormation on inactivation, incompati(ility, potentiation, and plasma (inding, as well as on inter$erence with elimination, digestion, and test procedures# >> '# Epit2 and 6# 6orn, @4erhStung iatrogener In$ektionen (ei *chut2imp$ungen,@ Deutsches .esundheitswesen <8\<= G178<J/ 11:1-9# En in$ections associated with immuni2ation procedures# >9 6arry +# 'eaty and Ro(ert -# Petersdor$, @Iatrogenic Aactors in In$ectious )isease,@ Annals of Internal 3edicine 9> GEcto(er 1799J/ 9=1->9# >8 ;very year a million peopleDthat is, : to > percent o$ all hospital admissionsDare admitted primarily (ecause o$ a negative reaction to drugs# +icholas ,ade, @)rug Regulation/ A)% Replies to Charges (y ;conomists and Industry,@ ,cience 187 G178:J/ 88>-8#

>? ;ugene 4ayda, @% Comparison o$ *urgical Rates #in Canada and in ;ngland and ,ales,@ New n$land Hournal of 3edicine <?7 G178:J/ 1<<=-7, shows that surgical rates in Canada in 179? were 1#? times greater $or men and 1#9 times greater $or women than in ;ngland# )iscretionary operations such as tonsillectomy and adenoidectomy, hemorroidectomy, and inguinal herniorrhaphy were two or more times higher# Cholecystectomy rates were more than $ive times greater# 3he main determinants may (e di$$erences in payment o$ health services and availa(le hospital (eds and surgeons# Charles ;# ewis, @4ariations in the Incidence o$ *urgery,@ New n$land Hournal of 3edicine <?1 G1797J/ ??K-=, $inds three- to $our$old variations in regional rates $or si. common surgical procedures in the &#*#%# 3he num(er o$ surgeons availa(le was $ound to (e the signi$icant predictor in the incidence o$ surgery# *ee also !ames C# )oyle, @&nnecessary 6ysterectomies/ *tudy o$ 9,<=? Eperations in 3hirty-$ive 6ospitals )uring 17=?,@ Hournal of the American 3edical Association 1>1 G17>:J/ :9K-># !ames C# )oyle, @&nnecessary Evariectomies/ *tudy 'ased on the Removal o$ 8K= +ormal Evaries $rom >=9 Patients,@ Hournal of the American 3edical Association 1=? G17><J/ 11K>-11# 3homas 6# ,eller, @Pediatric Perceptions/ 3he Pediatrician and Iatric In$ectious )isease,@ Pediatrics >1 G%pril 178:J/ >7>-9K<# >7 Cli$ton Meador, @3he %rt and *cience o$ +ondisease,@ New n$land Hournal of 3edicine <8< G179>J/ 7<-># Aor the physician accustomed to dealing only with pathologic entities, terms such as @nondisease entity@ or @nondisease@ are $oreign and di$$icult to comprehend# 3his paper presents, with tongue in cheek, a classi$ication o$ nondisease and the important therapeutic principles (ased on this concept# Iatrogenic disease pro(a(ly arises as o$ten $rom treatment o$ nondisease as $rom treatment o$ disease# 9K %(raham '# 'ergman and *tanley !# *tamm, @3he Mor(idity o$ Cardiac +ondisease in *chool Children,@ New n$land Hournal of 3edicine 9'( G1798J/ 1KK?-1:# -ives one particular e.ample $rom the @lim(o where people either perceive themselves or are perceived (y others to have a none.istent disease# 3he ill e$$ects accompanying some nondiseases are as e.treme as those accompanying their counterpart diseases # # # the amount o$ disa(ility $rom cardiac nondisease in children is estimated to (e greater than that due to actual heart disease#@ *ee also !# %ndriola, @% +ote on Possi(le Iatrogenesis o$ *uicide,@ Ps#chiatr# :9 G178:J/ <1:-1?# 91 Clinical iatrogenesis has a long history# Plinius *ecundus, Naturalis Historia <7#17/ @3o protect us against doctors there is no law against ignorance, no e.ample o$ capital punishment# )octors learn at our risk, they e.periment and kill with sovereign impunity, in $act the doctor is the only one who may kill# 3hey go $urther and make the patient responsi(le/ they (lame him who has succum(ed#@ In $act, Roman law already contained some provisions against medically in$licted torts, @damnum in5uria datum per modicum#@ !urisprudence in Rome made the doctor legally accounta(le not only $or ignorance and recklessness (ut $or (um(ling# % doctor who operated on a slave (ut did not properly $ollow up his convalescence had to pay the price o$ the slave and the 9< MontesBuieu, De l<es"rit des lois, (k# <7, chap# 1=, ( GParis/ Pl1iade, 17>1J# 3he Roman laws ordained that physicians should (e punished $or neglect or lack o$ skill Gthe Cornelian laws, De ,icariis, inst# iv# tit# :, de lege %Buila 8J# I$ the physician was a person o$ any $ortune or rank, he was only condemned to deportation, (ut i$ he was o$ low condition he was put to death# In our institutions it is otherwise# 3he Roman laws were not made under the same circumstances as ours/ in Rome every ignorant pretender meddled with physic, (ut our physicians are o(liged to go through a regular course o$ study and to take degrees, $or which reason they are supposed to understand their pro$ession# In this passage the 18th-century philosopher demonstrates an entirely modern optimism a(out medical education#

9: Aor -erman internists, the time the patient can spend $ace-to-$ace with his doctor has now (een reduced to 1#8 minutes per visit# 6einrich ;rdmann, 6ein2--unther Everrath, and ,ol$gang and 3hure &.kull, @Erganisationspro(leme der Vr2tlichen "rankenversorgung/ )argestellt am 'eispiel einer medi2inischen &niversitVtsklinik,@ Deutsches Mr;te)latt*Mr;tliche 3itteilun$en 81 G178=J/ :=<1-9# In general practice, this time was Gin 179:J a(out : minutes# *ee 3# -eyer, ?erschwUrun$ G6ilchen(ach/ Medi2inpolitischer 4erlag, 1781J, p# :K# 9= Aor the (roader issue o$ genetic rather than individual damage, see !ohn ,# -o$$man and %rthur R# 3amplin, @;pidemiological *tudies o$ Carcinogenesis (y Ioni2ing Radiation,@ in Proceedin$s of the ,iCth Berkele# ,#m"osium on 3athematical ,tatistics and Pro)a)ilit#, &niv# o$ Cali$ornia, !uly 178K, pp# <:>-88# 3he presumption is all too common that where uncertainty e.ists a(out the magnitude o$ carcinogenic e$$ects, it is appropriate to continue the e.posure o$ humans to the risk# 3he authors show that it is neither appropriate nor good pu(lic-health practice to demand human epidemiological evidence (e$ore stopping e.posure# 3he argument against ioni2ing radiation $rom nuclear generation o$ electrical energy can (e applied to all medical treatment in which there is uncertainty a(out genetic impact# 3he competence o$ physicians to esta(lish levels o$ tolerance $or entire populations must (e Buestioned on theoretical grounds# 9> Aor data and $urther (i(liography see &#*# 6ouse o$ Representatives, Committee on Interstate and Aoreign Commerce, An -verview of 3edical 3al"ractice, 7=th Cong#, lst *ess#, March 18, 178># 99 3he maltreatment o$ patients has (ecome an accepted routine0 see Charles 'utterworth, @Iatrogenic Malnutrition,@ Nutrition :oda#, March-%pril 178=# Ene o$ the largest pockets o$ unrecogni2ed malnutrition in %merica and Canada e.ists, not in rural slums or ur(an ghettos, (ut in the private rooms and wards o$ (ig-city hospitals# !# Mayer, @Iatrogenic Malnutrition,@ New n$land Hournal of 3edicine <?= G1781J/ 1<1?# 98 -eorge 6# owrey, @3he Pro(lem o$ 6ospital %ccidents to Children,@ Pediatrics 59 G)ecem(er 179:J/ 1K9=-?# 97 !# 3# Mc am( and R# R# 6untley, @3he 6a2ards o$ 6ospitali2ation,@ ,outhern 3edical Hournal (7 GMay 1798J/ 8(&*'9. 97 @ a maladie iatrogNne est presBue tou5ours ] (ase n1vrotiBue@/ # Israel, @ a Maladie iatrogene,@ in Documenta ,ando;, n#d# 8K 3he distinction o$ several levels o$ iatrogenesis was made (y Ralph %udy, @Man-made Maladies and Medicine,@ !alifornia 3edicine, +ovem(er 178K, pp# 86*25. 6e recogni2es that iatrogenic @diseases@ are only one type o$ man-made malady# %ccording to their etiology, they $all into several categories/ those resulting $rom diagnosis and treatment, those relating to social and psychological attitudes and situations, and those resulting $rom man-made programs $or the control and eradication o$ disease# 'esides iatrogenic clinical entities, he recogni2es other maladies that have a medical etiology# 81 @)as *chicksal des "ranken verkTrpert als *ym(ol das *chicksal der Menschheit im *tadium einer technischen ,eltentwicklung@/ ,ol$gang !aco(, Der kranke 3ensch in der technischen Belt, IU# Internationaler Aort(ildungskurs $Sr praktische und wissenscha$tliche Pharma2ie der 'undesapothekerkammer in Meran GArank$urt am Main/ ,er(e- und 4ertrie(sgesellscha$t )eutscher %potheker, 1781J# 8< !ames '# Zuinn, @+e.t 'ig Industry/ ;nvironmental Improvement,@ Harvard Business Review 8& G*eptem(er-Ecto(er 1781J/ 1<K-:K# 6e (elieves that environmental improvement is (ecoming a dynamic and pro$ita(le series o$ markets $or industry that

pay $or themselves and in the end will represent an important addition to income and -+P# Implicitly the same argument is (eing made $or the health-care $ield (y the proponents o$ no-$ault malpractice insurance# 8: 3he term was used (y 6onor1 )aumier G1?1K-87J# *ee reproduction o$ his drawing @+emesis m1dicale@ in ,erner 'lock, Der Art;t und der :od in Bildern aus sechs Hahrhunderten G*tuttgart/ ;nke, 1799J#