The Escape from Managerialist Medicine

Whether the influence of Big Pharma that profits from sickness, compromised public health agencies controlled by the very industries they are supposed to regulate, a biosecurity state that tends to jump from one declared health emergency to the next, medicine is now in danger of causing more sickness than it heals.

The year I was born, 1976, saw the publication of Ivan Illich’s prophetic book, Medical Nemesis, which opens with the startling claim, “The medical establishment has become a major threat to health.”[i] The book explores the epidemic of iatrogenic disease—that is, illnesses caused by medical interventions—which has only worsened in the nearly half-century since this book was published. Most of the current research literature on iatrogenesis focuses on the problem of medical errors, and how to institute systems that can minimize errors. This is obviously important to address, but medical errors are only part of the story of how medicine is harming us.

Illich’s basic thesis was that some systems, including our healthcare system, improve outcomes only until they expand to a certain industrialized size, monopolized scope, and level of technological power. Once this threshold is reached, without intending to do so, these systems paradoxically cannot help but inflict harm and undermine their stated aims. Illich diagnosed “the disease of medical progress” in its early stages; I believe this disease has now reached its advanced stage.

The problem is political and not merely professional: he argued that “the layman and not the physician has the potential perspective and effective power to stop the current iatrogenic epidemic.”^[ii] Indeed, “among all our contemporary experts, physicians are those trained to the highest level of specialized incompetence for this urgently needed pursuit.”

Organized medicine has always carefully guarded its membership and monopoly on professional privileges, from ordering tests to prescribing medications. “The medical monopoly over health care has expanded without checks and has encroached on our liberty with regard to our own bodies.”^[iii] In my previous book, The New Abnormal: The Rise of the Biomedical Security State, I explore how this tendency manifested during our disastrous response to Covid. But the problem is not limited to that period of recent medical history, and the disastrous public health response was only a symptom of more widespread problems in our healthcare system.

The failed response to medicine’s ills so far has been more managerialism—more top-down control by more so-called “experts”—but this has only worsened the crisis, as I argued in a previous post. Likewise, demands for more medical care will, paradoxically, only exacerbate the problem. As Illich put it:

The self-medication of the medical system cannot but fail. If a public, panicked by gory revelations, were browbeaten into further support for more expert control over experts in health-care production, this would only intensify sickening care. It must now be understood that what has turned health care into a sick-making enterprise is the very intensity of an engineering endeavor that has translated human survival from the performance of organisms into the result of technical manipulation.^[iv]

A professionalized, physician-driven system of healthcare that expands beyond a critical limit causes illness for three reasons. First, an overly expansive healthcare system will tend to inflict clinical damage that eventually outweighs benefits. Second, the system tends to worsen the social conditions that render society unhealthy. Third, it tends to expropriate the power of the individual to heal himself. The solution therefore must involve a political program that facilitates the reappropriation of personal responsibility for health care, with sensible limits to the professional management of our health. To save medicine we must limit medicine. Strange to say, we need less, not more, professionalized health care.

Medicine has developed powerful, self-serving myths, to hide these inconvenient truths. But the epidemic of iatrogenic disease can no longer be hidden; people are waking up to realize that power over their health has been taken from them, and they want to reappropriate what they have given away to an ineffective healthcare system that no longer serves their needs. Physicians have become glorified data-gathering clerks, staring at a computer screen in the consulting room rather than engaging face-to-face with the patient. They ask a series of questions dictated by managers that have little or nothing to do with the patient’s chief complaint. Patients leave these encounters feeling bewildered, unheard, and unhelped.

Medicine now serves industrial, not personal, growth. Its highest aim is not health efficiency—“throughput” is a favorite buzzword of hospital administrators, who copy the people-moving engineering of Disneyland to create a turnstile system that shuffles people through without helping them. Medicine has become about efficiently and predictably controlling bodies more than healing them.

Medicine has long exaggerated its effectiveness, though these myths have been thoroughly documented and debunked by historians of medicine and public health. A few examples will suffice, though these could be multiplied. Although we can now treat it with antibiotics, medicine did not cure tuberculosis: in New York in 1812 the death rate was 700 per 10,000; by the time the offending bacillus was isolated in 1882, the death rate was nearly half that at 370 per 10,000. In 1910 when the first sanitarium was opened it was 180, and following World War II but before antibiotics for TB were developed it was 48.

Other infectious diseases of the last hundred years, from cholera, dysentery, and typhoid to diphtheria, measles, and scarlet fever, likewise peaked and declined apart from medical therapies like antibiotics or vaccines.^[v] This decline was due primarily to improved host resistance due to better nutrition, and secondarily to improvements in housing and other living conditions. In other words, the two main tools of the original Hippocratic physicians, who focused primarily on dietetics and environment and only secondarily on drugs and surgery.

As Illich explained, “The professional practice of physicians cannot be credited with the elimination of old forms of mortality or morbidity, nor should it be blamed for the increased expectancy of life spent in suffering from the new diseases.” Instead, “food, water, and air, in correlation with the level of sociopolitical equality and the cultural mechanisms that make it possible to keep the population stable, play the decisive role in determining how healthy grown-ups feel and at what age adults tend to die.”^[vi] Undernourishment in poor countries and poisons and mutagens in our ultra-processed food in rich ones are the major factors contributing to our current epidemic of chronic illness. Ozempic for everyone cannot cure our metabolic woes.

Health is not a commodity that can be mass-produced on an engineering model. Following the managerialist revolution in medicine, even medical harms are depersonalized and thereby dismissed as minor glitches in an otherwise sound system:

Doctor-inflicted pain and infirmity have always been a part of medical practice. Professional callousness, negligence, and sheer incompetence are age-old forms of malpractice. With the transformation of the doctor from an artisan exercising a skill on personally known individuals into a technician applying scientific rules to classes of patients, malpractice acquired an anonymous, almost respectable status. What had formerly been considered an abuse of confidence and a moral fault can now be rationalized into the occasional breakdown of equipment and operators. In a complex technological hospital, negligence becomes “random human error” or “system breakdown,” callousness becomes “scientific detachment,” and the depersonalization of diagnosis and therapy has changed malpractice from an ethical into a technical problem.^[vii]

But these harms will not be solved by more technical or managerial measures—which will only, by a self-reinforcing feedback loop, exacerbate the problems they created in the first place. The solution can only come from individuals re-appropriating responsibility for their health—what Illich calls “the will to self-care among the laity”—and thereby limiting the expansive industrial scope of malignant medical systems. Perhaps, just to mention one offhand simple example, we should abolish the “note from the doctor.” Why should physicians exercise a monopoly on declaring someone sick? Why should suffering, mourning, or healing outside the medically designated patient role be considered a form of social deviance?

Without a doubt, a limited number of specific medical procedures, and a handful of medications (perhaps a few dozen time-tested drugs), have proven extremely useful. Antibiotics for pneumonia syphilis, malaria, and other serious infectious diseases are effective when used judiciously so as not to breed drug-resistant bugs. Medicine has its tools and we sometimes need them. It’s telling, however, that pharmaceutical companies invest almost nothing in research and development for new antibiotics because a one-time prescription drug is not sufficiently profitable.

They want drugs for chronic conditions that can be mitigated but not cured by medications. The effectiveness of medications for non-infectious diseases has been much less impressive. Some cancer screenings and therapies have improved survival outcomes, but cancer rates continue to rise due to environmental factors.

Some of the most effective drugs are sufficiently safe that they could be made available over the counter or following a simple screening for drug allergies or obvious contraindications. Some of our best medical tools can be deprofessionalized. Organized medicine and medical societies, including the AMA, have strenuously resisted such proposals, as their purpose is to lobby for the maintenance of medical monopolies and the pecuniary interests of physicians. But our investment in medicine—we spend twice as much of our GDP on healthcare as any other nation and get worse outcomes than most developed countries—is enriching physicians but clearly not improving health outcomes.

“The first occupation to monopolize healthcare is that of the physician of the late twentieth century,”^[viii] and he has failed to deliver the goods. It is time to decentralize this monopoly. The necessary “surgery” for our healthcare system will be painful and will meet resistance from entrenched interests. But it’s time for us to make the cut.

Our costly medical bureaucracies stress the delivery of repair and maintenance services for human bodies broken by modern social systems—the human components of our mega-machine.^[ix] Physicians become auto mechanics for cars whose engines are forced to chronically redline, relentlessly pushed beyond their engineered limits. We doctors are told to open the hood and fix them, to get these cars—these broken-down bodies—back on a racetrack they were never designed to drive on. More equitable delivery of these repair and maintenance services will not resolve the underlying problems: the current system is set up to fail.

Medical care has been massively centralized, even in systems like that of the United States that are neither nationalized nor based upon a single government payer. The only way out of this dead-end aporia is decentralization. Give people back sovereignty and responsibility for their own health and give them ways to access healthcare that does not rely entirely on medical gatekeepers. I appreciate MRIs every bit as much as the next doctor, but universally available vitamin D would do more for the nation’s health than all our expensive MRI scanners at a fraction of the cost.

As Illich put it, “The more time, toil, and sacrifice spent by a population in producing medicine as a commodity, the larger will be the by-product, namely, the fallacy that society has a supply of health locked away which can be mined and marketed.”^[x]

Health can be cultivated but cannot be purchased. Health care is something one does, not something one markets or buys. But our current system trains us for healthcare consumption rather than for health-promoting action; indeed, the healthcare system itself constrains our range of autonomous action. Remedies available only on prescription become for many virtually unobtainable for patients and families accustomed to caring for themselves and their loved ones.

Most strategies for medical reform will fail because they focus too much on sickness and too little on changing the environment—the overprocessed food, the toxins, the stress-inducing demands of advanced industrialized societies—that makes people sick in the first place. Public health must attend to these serious problems. However, the cure is neither more environmental engineering nor more human engineering efforts to adapt people to a disease-inducing environment. “A society that values planned teaching above autonomous learning cannot but teach man to keep his engineered place,”^[xi] which will only exacerbate our problems. For humans are not cogs in an engineered machine. The problems of overly industrialized medicine will not be solved by industrialized public health.

Further increases in medical controls are not the answer to our ills, for these will only worsen iatrogenic harms. We cannot allow the whole world to become one vast hospital—a recipe not for health but for dystopian totalitarianism run by an elite cadre of physician-therapists in white coats—where anesthetized patients become solitary, passive, and impotent. Many people today, sadly, already experience this state of helpless unfreedom—what Illich calls “compulsory survival in a planned and engineered hell”^[xii]—where one’s sickness only grows worse.

We must look instead to decentralized, small-scale initiatives that operate autonomously, apart from the managerialized systems of medical power. Self-healing is possible just as self-education is possible, without tossing the undeniable benefits of larger-scale organized medicine or educational institutions—so long as these are kept within due limits. Human nature is not infinitely elastic, contrary to our technocratic fever dreams, but has inherent limits that medicine will never overcome, however powerful our technical tools.

The solution to our health woes will require empowering individuals and small communities with the tools necessary not only to heal, but also to cope with the inevitabilities of pain, impairment, and eventual death. Dependence and addiction to a broken managerialized system will only worsen our health. “The capacity for revolt and for perseverance,” Illich writes, “for stubborn resistance and for resignation, are integral parts of human life and health.”^[xiii]

As the Ancient Greek tragedians knew, hubris brings downfall. Any medicine that does not embrace rational restraint—that does not make the necessary cuts—will end up inflicting more harm than healing. Health is mostly something one does in the context of a supportive family and community, more than something one is granted by external agents. Physicians, and the associated technologies of modern medicine, should play a supportive role in a sane and humane healthcare system, but are not the lead actors in the drama of health and human flourishing.

^[i] Illich, Medical Nemesis: The Expropriation of Health, 3.

^[ii] Ibid., 4.

^[iii] Ibid., 6.

^[iv] Ibid., 7.

^[v] Cf. references in ibid., 16.

^[vi] Ibid., 17-20.

^[vii] Ibid., 29-30.

^[viii] Ibid., 111.

^[ix] For more on Lewis Mumford’s concept of the megamachine, a machine made of human parts, see my summary in Aaron Kheriaty, The New Abnormal : The Rise of the Biomedical Security State (Washington, D.C.: Regnery Publishing, 2022), 18-27.

^[x] Illich, Medical Nemesis : The Expropriation of Health, 62.

^[xi] Ibid., 264.

^[xii] Ibid., 271.

^[xiii] Ibid., 262.

Republished from the author’s Substack