I - Two Watersheds
The year 1913 marks a watershed in the history of modern medicine.
Around that year a patient began to have more than a fifty-fifty chance
that a graduate of a medical school would provide him with a specifically
effective treatment (if, of course, he was suffering from one of the
standard diseases recognized by the medical science of the time).
Many shamans and herb doctors familiar with local diseases and remedies
and trusted by their clients had always had equal or better results.
Since then medicine has gone on to define what constitutes disease
and its treatment. The Westernized public learned to demand effective
medical practice as defined by the progress of medical science. For
the first time in history doctors could measure their efficiency against
scales which they themselves had devised. This progress was due to
a new perspective of the origins of some ancient scourges; water could
be purified and infant mortality lowered; rat control could disarm
the plague; treponemas could be made visible under the microscope
and Salvarsan could eliminate them with statistically defined risks
of poisoning the patient; syphilis could be avoided, or recognized
and cured by rather simple procedures; diabetes could be diagnosed
and self-treatment with insulin could prolong the life of the patient.
Paradoxically, the simpler the tools became, the more the medical
profession insisted on a monopoly of their application, the longer
became the training demanded before a medicine man was initiated into
the legitimate use of the simplest tool, and the more the entire population
felt dependent on the doctor.
Hygiene turned from being a virtue into a professionally organized
ritual at the altar of a science.
Infant mortality was lowered, common forms of infection were prevented
or treated, some forms of crisis intervention became quite effective.
The spectacular decline in mortality and morbidity was due to changes
in sanitation, agriculture, marketing, and general attitudes toward
life. But though these changes were sometimes influenced by the attention
that engineers paid to new facts discovered by medical science, they
could only occasionally be ascribed to the intervention of doctors.
Indirectly, industrialization profited from the new effectiveness
attributed to medicine; work attendance was raised, and with it the
claim to efficiency on the job. The destructiveness of new tools was
hidden from public view by new techniques of providing spectacular
treatments for those who fell victims to industrial violence such
as the speed of cars, tension on the job, and poisons in the environment.
The sickening side effects of modern medicine became obvious after
World War II, but doctors needed time to diagnose drug resistant microbes
or genetic damage caused by prenatal X-rays as new epidemics. The
claim made by George Bernard Shaw a generation earlier, that doctors
had ceased to be healers and were assuming control over the patient's
entire life, could still be regarded as a caricature. Only in the
mid-fifties did it become evident that medicine had passed a second
watershed and had itself created new kinds of disease.
Foremost among iatrogenic (doctor-induced) diseases was the pretense
of doctors that they provided their clients with superior health.
First, social planners and doctors became its victims. Soon this epidemic
aberration spread to society at large. Then, during the last fifteen
years, professional medicine became a major threat to health. Huge
amounts of money were spent to stem immeasurable damage caused by
medical treatments. The cost of healing was dwarfed by the cost of
extending sick life; more people survived longer months with their
lives hanging on a plastic tube, imprisoned in iron lungs, or hooked
onto kidney machines. New sickness was defined and institutionalized;
the cost of enabling people to survive in unhealthy cities and in
sickening jobs sky-
rocketed. The monopoly of the medical profession was extended over
an increasing range of everyday occurrences in every man's life.
The exclusion of mothers, aunts, and other nonprofessionals from the
care of their pregnant, abnormal, hurt, sick, or dying relatives and
friends resulted in new demands for medical services at a much faster
rate than the medical establishment could deliver. As the value of
services rose, it became almost impossible for people to care. Simultaneously,
more conditions were defined as needing treatment by creating new
specializations or paraprofessions to keep the tools under the control
of the guild.
At the time of the second watershed, preservation of the sick life
of medically dependent people in an unhealthy environment became the
principal business of the medical profession. Costly prevention and
costly treatment became increasingly the privilege of those individuals
who through previous consumption of medical services had established
a claim to more of it. Access to specialists, prestige hospitals,
and life-machines goes preferentially to those people who live in
large cities, where the cost of basic disease prevention, as of water
treatment and pollution control, is already exceptionally high. The
higher the per capita cost of prevention, the higher, paradoxically,
became the per capita cost of treatment. The prior consumption of
costly prevention and treatment establishes a claim for even more
extraordinary care. Like the modern school system, hospital-based
health care fits the principle that those who have will receive even
more and those who have not will be taken for the little that they
have. In schooling this means that high consumers of education will
get postdoctoral grants, while dropouts learn that they have failed.
In medicine the same principle assures that suffering will increase
with increased medical care; the rich will be given more treatment
for iatrogenic diseases and the poor will just suffer from them.
After this second turning point, the unwanted hygienic by-products
of medicine began to affect entire populations rather than just individual
men. In rich countries medicine began to sustain the middle-aged until
they became decrepit and needed more doctors and increasingly complex
In poor countries, thanks to modern medicine, a larger percentage
of children began to survive into adolescence and more women survived
more pregnancies. Populations increased beyond the capacities of their
environments and the restraints and efficiencies of their
cultures to nurture them. Western doctors abused drugs for the treatment
of diseases with which native populations had learned to live. As
a result they bred new strains of disease with which modern treatment,
natural immunity, and traditional culture could not cope. On a world-wide
scale, but particularly in the U.S.A., medical care concentrated on
breeding a human stock that was fit only for domesticated life within
an increasingly more costly, man-made, scientifically controlled environment.
One of the main speakers at the 1970 AMA convention exhorted her pediatric
colleagues to consider each newborn baby as a patient until the child
could be certified as healthy. Hospital-born, formula-fed, antibiotic-stuffed
children thus grow into adults who can breathe the air, eat the food,
and survive the lifelessness of a modern city, who will breed and
raise at almost any cost a generation even more dependent on medicine.
Bureaucratic medicine spread over the entire world. In 1968, after
twenty years of Mao's regime, the Medical College of Shanghai had
to conclude that it was engaged in the training of "so-called
first-rate doctors ... who ignore five million peasants and serve
only minorities in cities. They create large expenses for routine
laboratory examinations . . . Describe huge amounts of antibiotics
unnecessarily . . . and in the absence of hospital or laboratory facilities
have to limit themselves to explaining the mechanisms of the disease
to people for whom they cannot do anything, and to whom this explanation
is irrelevant." In China this recognition led to a major institutional
inversion. Today, the same college reports that one million health
workers have reached acceptable levels of competence. These health
workers are laymen who in periods of low agricultural manpower needs
have attended short courses, starting with the dissection of pigs,
gone on to the performance of routine lab tests, the study of the
elements of bacteriology, pathology, clinical medicine, hygiene, and
acupuncture, and continued in apprenticeship with doctors or previously