Medical Nemesis

6

Specific Counterproductivity

 

   Iatrogenesis will be controlled only if it is understood as but one aspect of the destructive dominance of industry over society, as but one instance of that paradoxical counterproductivity which is now surfacing in all major industrial sectors. Like time-consuming acceleration, stupefying education, self-destructive military defense, disorienting information, or unsettling housing projects, pathogenic medicine is the result of industrial overproduction that paralyzes autonomous action. In order to focus on this specific counterproductivity of contemporary industry, frustrating overproduction must be clearly distinguished from two other categories of economic burdens with which it is generally confused, namely, declining marginal utility and negative externality. Without this distinction of the specific frustration that constitutes counterproductivity from rising prices and oppressive social costs, the social assessment of any technical enterprise, be it medicine, transportation, the media, or education, will remain limited to an accounting of cost-efficiency and not even approach a radical critique of the instrumental effectiveness of these various sectors.

   Direct costs reflect rental charges, payments made for labor, materials, and other considerations. The production cost of a passenger-mile includes the payments made to build and operate the vehicle and the road, as well as the profit that accrues to those who have obtained control over transportation: the interest charged by the capitalists who own the tools of production, and the perquisites claimed by the bureaucrats who monopolize the stock of knowledge that is applied in the process. The price is the sum of these various rentals, no matter whether it is paid by the consumer out of his own pocket or by a tax-supported social agency that purchases on his behalf.

   Negative externality is the name of the social costs that are not included in the monetary price; it is the common designation for the burdens, privations, nuisances, and injuries that I impose on others by each passenger-mile I travel. The dirt, the noise, and the ugliness my car adds to the city; the harm caused by collisions and pollution; the degradation of the total environment by the oxygen I burn and the poisons I scatter; the increasing costliness of the police department; and also the traffic-related discrimination against the poor: all are negative externalities associated with each passenger-mile. Some can easily be internalized in the purchase price, as for instance the damages done by collisions, which are paid for by insurance. Other externalities that do not now show up in the market price could be internalized in the same way: the cost of therapy for cancer caused by exhaust fumes could be added to each gallon of fuel, to be spent for cancer detection and surgery or for cancer prevention through antipollution devices and gas masks. But most externalities cannot be quantified and internalized: if gasoline prices are raised to reduce depletion of oil stocks and of atmospheric oxygen, each passenger-mile becomes more costly and more of a privilege; environmental damage is lessened but social injustice is increased. Beyond a certain level of intensity of industrial production, externalities cannot be reduced but only shifted around.

   Counterproductivity is something other than either an individual or a social cost; it is distinct from the declining utility obtained for a unit of currency and from all forms of external disservice. It exists whenever the use of an institution paradoxically takes away from society those things the institution was designed to provide. It is a form of built-in social frustration. The price of a commodity or a service measures what the purchaser is willing to spend for whatever he gets; externalities indicate what society will tolerate to allow for this consumption; counterproductivity gauges the degree of prevalent cognitive dissonance resulting from the transaction: it is a social indicator for the built-in counterpurposive functioning of an economic sector. The iatrogenic intensity of our medical enterprise is only a particularly painful example of how frustrating overproduction appears in equal measure as time-consuming acceleration of traffic, static in communications, training for well-rounded incompetence in education, uprooting as a result of housing development, and destructive overfeeding. This specific counterproductivity constitutes an unwanted side-effect of industrial production which cannot be externalized from the particular economic sector that produces it. Fundamentally it is due neither to technical mistakes nor to class exploitation but to industrially generated destruction of those environmental, social, and psychological conditions needed for the development of nonindustrial or nonprofessional use-values. Counterproductivity is the result of an industrially induced paralysis of practical self-governing activity.

   The industrial distortion of our shared perception of reality has rendered us blind to the counterpurposive level of our enterprise. We live in an epoch in which learning is planned, residence standardized, traffic motorized, and communication programmed, and in which, for the first time, a large part of all foodstuffs consumed by humanity passes through interregional markets. In such an intensely industrialized society, people are conditioned to get things rather than to do them; they are trained to value what can be purchased rather than what they themselves can create. They want to be taught, moved, treated, or guided rather than to learn, to heal, and to find their own way. Impersonal institutions are assigned personal functions. Healing ceases to be considered a task for the sick. It first becomes the duty of the individual body repairmen, and then soon changes from a personal service into the output of an anonymous agency. In the process, society is rearranged for the sake of the health-care system, and it becomes increasingly difficult to care for one's own health. Goods and services litter the domains of freedom.

   Schools produce education, motor vehicles produce locomotion, and medicine produces health care. These outputs are staples that have all the characteristics of commodities. Their production costs can be added to or subtracted from the GNP, their scarcity can be measured in terms of marginal value, and their costs can be established in currency equivalents. By their very nature these staples create a market. Like school education and motor transportation, clinical care is the result of a capital-intensive commodity production; the services produced are designed for others, not with others nor for the producer.

   Owing to the industrialization of our world-view, it is often overlooked that each of these commodities still competes with a nonmarketable use-value that people freely produce, each on his own. People learn by seeing and doing, they move on their feet, they heal, they take care of their health, and they contribute to the health of others. These activities have use-values that resist marketing. Most valuable learning, body movement, and healing do not show up on the GNP. People learn their mother tongue, move around, produce their children and bring them up, recover the use of broken bones, and prepare the local diet, and do these things with more or less competence and enjoyment. These are all valuable activities which most of the time will not and cannot be undertaken for money, but which can be devalued if too much money is around.

   The achievement of a concrete social goal cannot be measured in terms of industrial outputs, neither in their amount nor in the curve that represents their distribution and their social costs. The effectiveness of each industrial sector is determined by the correlation between the production of commodities by society and the autonomous production of corresponding use-values. How effective a society is in producing high levels of mobility, housing, or nutrition depends on the meshing of marketed staples with inalienable, spontaneous action.

   When most needs of most people are satisfied in a domestic or community mode of production, the gap between expectation and gratification tends to be narrow and stable. Learning, locomotion, or sick-care are the results of highly decentralized initiatives, of autonomous inputs and self-limiting total outputs. Under the conditions of a subsistence economy, the tools used in production determine the needs that the application of these same tools can fulfill. For instance, people know what they can expect when they get sick. Somebody in the village or the nearby town will know all the remedies that have worked in the past, and beyond this lies the unpredictable realm of the miracle. Until late in the nineteenth century, most families, even in Western countries, provided most of the therapy that was known. Most learning, locomotion, or healing was performed by each man on his own, and the tools needed were produced in his family or village setting.

   Autonomous production can, of course, be supplemented by industrial outputs that will have to be designed and often manufactured beyond direct community control. Autonomous activity can be rendered both more effective and more decentralized by using such industrially made tools as bicycles, printing presses, recorders, or X-ray equipment. But it can also be hampered, devalued, and blocked by an arrangement of society that is totally in favor of industry. The synergy between the autonomous and the heteronomous modes of production then takes on a negative cast. The arrangement of society in favor of managed commodity production has two ultimately destructive aspects: people are trained for consumption rather than for action, and at the same time their range of action is narrowed. The tool separates the workman from his labor. Habitual bicycle commuters are pushed off the road by intolerable levels of traffic, and patients accustomed to taking care of their own ailments find yesterday's remedies available only on prescription and hence largely unobtainable. Wage labor and client relationships expand while autonomous production and gift relationships wither.

   Effectively achieving social objectives depends on the degree to which the two fundamental modes of production supplement or hamper each other. Effectively coming to know and to control a given physical and social environment depends on people's formal education and on their opportunity and motivation to learn in a nonprogrammed way. Effective traffic depends on the ability of people to get where they must go quickly and conveniently. Effective sick-care depends on the degree to which pain and dysfunction are made tolerable and recovery is enhanced. The effective satisfaction of these needs must be clearly distinguished from the efficiency with which industrial products are made and marketed, from the number of certificates, passenger-miles, housing units, or medical interventions performed. Beyond a certain threshold, these outputs will all be needed only as remedies; they will substitute for personal activities that previous industrial outputs have paralyzed. The social criteria by which effective need-satisfaction can be evaluated do not match the measurements used to evaluate the production and marketing of industrial goods.

   Since measurements disregard the contributions made by the autonomous mode towards the total effectiveness with which any major social goal may be achieved, they cannot indicate if this total effectiveness is increasing or decreasing. The number of graduates, for instance, might be inversely related to general competence. Much less can technical measurements indicate who are the beneficiaries and who are the losers from industrial growth, who are the few that get more and can do more, and who fall into the majority whose marginal access to industrial products is compounded by their loss of autonomous effectiveness. Only political judgment can assess the balance.

   The persons most hurt by counterproductive institutionalization are usually not the poorest in monetary terms. The typical victims of the depersonalization of values are the powerless in a milieu made for the industrially enriched. Among the powerless may be people who are relatively affluent within their society or those who are inmates of benevolent total institutions. Disabling dependence reduces them to modernized poverty. Policies meant to remedy the new sense of privation will not only be futile but will aggravate the damage. By promising more staples rather than protecting autonomy, they will intensify disabling dependence.

   The poor in Bengal or Peru still survive with occasional employment and an occasional dip into the market economy: they live by the timeless art of making do. They still can stretch out provisions, alternate between fat and lean periods, knit gift relationships whereby they barter or otherwise exchange goods and services neither made for nor accounted for by the market. In the country, in the absence of television, they enjoy living in homes built on traditional models. Drawn or pushed into town, they squat on the margins of the steel-and-petroleum sector, where they build a provisional economy with scraps of waste that can serve as building blocks for self-made shacks. Their exposure to extreme famine grows with their dependence on marketed food.

   Given sufficient generations, during its entire evolution Homo sapiens has shown high competence in developing a great variety of cultural forms, each meant to keep the total population of a region within the limits of resources that could be shared or formally exchanged in its limited milieu. The worldwide and homogeneous disabling of the communal coping ability of local populations has developed with imperialism and its contemporary variants of industrial development and compassionate chic.

   The invasion of the underdeveloped countries by new instruments of production organized for financial efficiency rather than local effectiveness and for professional rather than lay control inevitably disqualifies tradition and autonomous learning and creates the need for therapy from teachers, doctors, and social workers. While road and radio mold the lives of those whom they reach to industrial standards, they degrade their handicrafts, housing, or health care much faster than they crush the skills they replace. Aztec massage gives relief to many who would no longer admit it because they believe it outdated. The common family bed becomes disreputable much faster than its occupants become aware of discomfort. Where development plans have worked, they have often succeeded because of the unforeseen resilience of the adobe-cum-oildrum sector. The continued ability to produce foods on marginal land and in city backyards has saved productivity campaigns from the Ukraine to Venezuela. The ability to care for the sick, the old, and the insane without nurses or wardens has buffered the majority against the rising specific disutilities which symbolic enrichment has brought. Poverty in the subsistence sector, even when this subsistence is retrenched by considerable market dependence, does not crush autonomy. People remain motivated to squat on thoroughfares, to nibble at professional monopolies, or to circumvent the bureaucrats.

   When perception of personal needs is the result of professional diagnosis, dependence turns into painful disability. The aged in the United States can again serve as the paradigm. They have been trained to experience urgent needs that no level of relative privilege can possibly satisfy. The more tax money that is spent to bolster their frailty, the keener is their awareness of decay. At the same time, their ability to take care of themselves has withered, as social arrangements allowing them to exercise autonomy have practically disappeared. The aged are an example of the specialization of poverty which the over-specialization of services can bring forth. The elderly in the United States are only one extreme example of suffering promoted by high-cost deprivation. Having learned to consider old age akin to disease, they have developed unlimited economic needs in order to pay for interminable therapies, which are usually ineffective, are frequently demeaning and painful, and call more often than not for reclusion in a special milieu.

   Five faces of industrially modernized poverty appear caricatured in the pampered ghettos of rich men's retirement: the incidence of chronic disease increases as fewer people die in their youth; more people suffer clinical damage from health measures; medical services grow more slowly than the spread and urgency of demand; people find fewer resources in their environment and culture to help them come to terms with their suffering, and thus are forced to depend on medical services for a wider range of trivia; people lose the ability to live with impairment or pain and become dependent on the management of every discomfort by specialized service personnel. The cumulative result of overexpansion in the health-care industry has thwarted the power of people to respond to challenges and to cope with changes in their bodies or in their environment.

   The destructive power of medical overexpansion does not, of course, mean that sanitation, inoculation, and vector control, well-distributed health education, healthy architecture, and safe machinery, general competence in first aid, equally distributed access to dental and primary medical care, as well as judiciously selected complex services, could not all fit into a truly modern culture that fostered self-care and autonomy. As long as engineered intervention in the relationship between individuals and environment remains below a certain intensity, relative to the range of the individual's freedom of action, such intervention could enhance the organism's competence in coping and creating its own future. But beyond a certain level, the heteronomous management of life will inevitably first restrict, then cripple, and finally paralyze the organism's nontrivial responses, and what was meant to constitute health care will turn into a specific form of health denial.1

   1 About pathogenic role-assignment, particularly in contemporary industrial society, see H. P. Dreitzel, Die gesellschaftlichen Leiden und das Leiden an der Gesellschaft: Vorstudien zu einer Pathologie des Rollenverhaltens (Stuttgart: Enke, 1972).