(Installment 2)
First Work — Tools for Convivality, by Ivan Illich
Reading #2 Two Watersheds
Watershed (literal definition): The specific land area that drains water into a river system or other body of water.
KEY CONCEPT ALERT:
Watershed (figurative definition, as used by Illich): A point in the historical process when a particular “tool” creates a quantum shift in society, like the sudden application of gravity feeding water into a terrain basin (literal watershed).
“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.”
With this paragraph, Illich uses “modern medicine,” a human “tool,” as a key example of the watershed phenomenon. This is a somewhat arbitrary point that he picks, a crossover.
What is the crossover?
He then goes on to list a series of accomplishments made by “medicine,” that was quickly on its way to becoming the “medical industry.” And the “industrial mode of production,” now providing a “service product,” began to experience institutional dogwaggery.
What do we mean when we say that?
This industrial monopolization of medicine was part of an historical process that saw the displacement of religion and custom by Science as a kind of Final Authority.
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… 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.
Thought Exercise: What would “medicine,” or sanitation and health care, look like if the “simplest tools” were widely used, without the monopoly of doctors, and without its commodification?
Illich goes on to say, “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.”
KEY CONCEPT ALERT:
Iatrogenesis(eye-uh-tro-GIN-uh-sus): Any adverse mental or physical condition induced in a patient through the effects of treatment by a physician or surgeon. For our purposes, however, we want to introduce this as a more universal idea, as another intellectual tool: Any situation where the “cure” causes more harm than the “cause”. This is a common phenomenon in modern society, but because we have been taught to think about things in discrete little boxes, and not in their relations and interactions, we tend not to see iatrogenesis. Road-building is a good example. The problem is traffic congestion. The cure is to build more roads. But with more roads, new development occurs, which is more spread out, pulling more people into the region where the congestion started, and making them more dependent on more cars. We go from traffic congestion on a small scale, to traffic congestion on a large scale.
Illich does something interesting with language. He uses it directly in unfamiliar ways. The shock of the unfamiliarity causes us to be slightly startled into a state of attention. We normally think of injury associated with machines as something passive, and we tend to subdivide the classes of injury based on circumstances. “Industrial accident” is a term that raises a certain image in our minds. Illich says “industrial violence,” and he then lists three cases of this violence that are not normally associated with each other, as a way of helping us learn what he means by “industrial mode of production”: “speed of cars, tension on the job and poisons in the environment.”
This technique of undermining the episteme is a key tool in the armamentarium of those wishing to effectively deconstruct dominant ideas.
KEY CONCEPT ALERT:
Episteme: While the term comes from the Greek, for “knowledge,” its use in philosophy refers to one assumption in “the body of ideas that determine the knowledge that is intellectually certain at any particular time.” Epistem-OLOGY is the study of “how we know.” This is extremely important, as feminists have pointed out repeatedly, because those assumptions about what is certain are not normally questioned. They are regarded as beyond question. These dominant epistemes, or ideas that determine what is certain, and which are widely shared, continually lead to the same conclusions and restrict consideration of different assumptions and different conclusions.
Changing the term from “accident” to “violence” is an epistemological shift.
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 skyrocketed. The monopoly of the medical profession was extended over an increasing range of everyday occurrences in every man’s life.
This is Illich’s second watershed. Iatrogensis… connected to dogwaggery.
This chapter is called Two Watersheds. It is the first real chapter in his argument. That means that we need to pay particular attention to this notion of two watersheds, which Illich suggests might be a regular feature of industrial processes generally. The action is monopolization. The effects are iatrogeneisis and dogwaggery.
Keep this relation on the desktop of your thinking about Illich here, because this is the basis for everything he will say afterward.
REMINDER: This study is not designed to subject the author to a critique. Determining the validity or lack thereof of his arguments is not the purpose for now. The purpose of this study is to understand what the author meant, and to understand that thoroughly and accurately. Critiques can come afterward, once we are completely familiar with the whole idea.
GREAT QUOTE: “…preservation of the sick life of medically dependent people in an unhealthy environment became the principle business of the medical profession.”
Illich later shifts back to “schooling,” that gerund, that verb becoming a noun. He then looks at another effect of industrialization that many socialists claimed came only from control of the means of production, and not the industrial mode itself: inequality of social power. “In schooling” he says, “high consumers of education (now a commodity - SG, italics mine) will get post-doctoral grants, while dropouts will learn that they have failed.” (italics mine)
What is happening here, when Illich refers to consumers of education, and dropouts learning that they are failures?
Now for a very provocative, episteme-bending statement:
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.
When this was written, Illich, as did many others, had great hope invested in the Chinese Revolution. The actual revolutionary war was conducted in a way that connected in principled ways with masses of rural Chinese, and broke with the Comintern bureaucracy managed by Stalin on key strategic questions. Mao Zedong was still alive, and capitalism had not reasserted itself through the “reforms” of Deng Xiaoping.
SIDEBAR: It is interesting, as an historical sidebar, that scale played a key role in the Maoist vision unraveling. First, there was the sheer size of the Chinese Communist Party, which was larger than the population of many countries. Then, there was the sheer size of China, where various populations were constantly dealing with different issues, drought in one area, floods in another, periodic famines. The scale of the Party led to its need for management. Management led to bureaucratic dogwaggery. Mao attempted to correct this dogwaggery by launching an aggressive social struggle led by young people (the Red Guards) against the bureaucrats in his own party, called the Cultural Revolution. The Cultural Revolution itself was of such a scale that it was not controllable, and the immaturity of many of the youthful Red Guards led to widespread abuses. This political catastrophe set the stage for Deng Xiaoping’s rise to power in the wake of Mao’s death, and with that, capitalist restoration. The dream of “deprofessionalization” of health and other key social needs evaporated. Interestingly enough, the place where it seems to be working more effectively is in Cuba; but the scale is dramatically different… that is, smaller.
Insurgent American holds that the question of scale is a critical object of study and reflection for re-thinking how we organize. There is a point at which, it seems, no matter how good the intentions or formative ideas, increasing scale itself reaches watersheds whereupon the requirement for management fundamentally changes the nature of the organization, and threatens it with dogwaggery. The administrative tail wags the operational dog.
Illich states: “Only the very rich in the United States can now afford what all people in poor countries have: personal attention around the deathbed. An American can now spend in two days of private nursing the median yearly cash income of the world’s population.”
Interesting contrast, no?
Instead of exposing the systemic disorder, however, only the symptoms of “sick” medicine are now publicly indicted in the United States. Spokesmen for the poor object to the capitalist prejudices of the AMA and the income of doctors. Community leaders object to the lack of community control over the delivery systems of professional health maintenance or of sick care, believing that laymen on hospital boards can harness professional medics. Black spokesmen object to the concentration of research grants on the types of disease which tend to strike the white, elderly, overfed foundation official who approves them. They ask for research on sickle-cell anemia, which strikes only the black. The general voter hopes that the end of the war in Vietnam will make more funds available for an increase of medical production. This general concern with symptoms, however, distracts attention from the malignant expansion of institutional health care which is at the root of the rising costs and demands and the decline in well being.
The crisis of medicine lies on a much deeper level than its symptoms reveal and is consistent with the present crisis of all industrial institutions. It results from the development of a professional complex supported and exhorted by society to provide increasingly “better” health, and from the willingness of clients to serve as guinea pigs in this vain experiment. People have lost the right to declare themselves sick; society now accepts their claims to sickness only after certification by medical bureaucrats.
It is not strictly necessary to this argument to accept 1913 and 1955 as the two watershed years in order to understand that early in the century medical practice emerged into an era of scientific verification of its results. And later medical science itself became an alibi for the obvious damage caused by the medical professional. At the first watershed the desirable effects of new scientific discoveries were easily measured and verified. Germ-free water reduced infant mortality related to diarrhea, aspirin reduced the pain of rheumatism, and malaria could be controlled by quinine. Some traditional cures were recognized as quackery, but, more importantly, the use of some simple habits and tools spread widely. People began to understand the relationship between health and a balanced diet, fresh air, calisthenics, pore water and soap. New devices ranging from toothbrushes to Band-Aids and condoms became widely available. The positive contribution of modern medicine to individual health during the early part of the twentieth century can hardly be questioned.
But then medicine began to approach the second watershed. Every year medical science reported a new breakthrough. Practitioners of new specialties rehabilitated some individuals suffering from rare diseases. The practice of medicine became centered on the performance of hospital-based staffs. Trust in miracle cures obliterated good sense and traditional wisdom on healing and health care. The irresponsible use of drugs spread from doctors to the general public. The second watershed was approached when the marginal utility of further professionalization declined, at least insofar as it can be expressed in terms of the physical well-being of the largest number of people. The second watershed was superseded when the marginal disutility increased as further monopoly by the medical establishment became an indicator of more suffering for larger numbers of people. After the passage of this second watershed, medicine still claimed continued progress, as measured by the new landmarks doctors set for them-selves and then reached: both predictable discoveries and costs. For instance, a few patients survived longer with transplants of various organs. On the other hand, the total social cost exacted by medicine ceased to be measurable in conventional terms. Society can have no quantitative standards by which to add up the negative value of illusion, social control, prolonged suffering, loneliness, genetic deterioration, and frustration produced by medical treatment.
Other industrial institutions have passed through the same two watersheds. This is certainly true for the major social agencies that have been reorganized according to scientific criteria during the last 150 years. Education, the mails, social work, transportation, and even civil engineering have followed this evolution. At first, new knowledge is applied to the solution of a clearly stated problem and scientific measuring sticks are applied to account for the new efficiency. But at a second point, the progress demonstrated in a previous achievement is used as a rationale for the exploitation of society as a whole in the service of a value which is determined and constantly revised by an element of society, by one of its self-certifying professional elites.
In the case of transportation it has taken almost a century to pass from an era served by motorized vehicles to the era in which society has been reduced to virtual enslavement to the car. During the American Civil War steam power on wheels became effective. The new economy in transportation enabled many people to travel by rail at the speed of a royal coach, and to do so with a comfort kings had not dared dream of. Gradually, desirable locomotion was associated and finally identified with high vehicular speeds. But when transportation had passed through its second watershed, vehicles had created more distances than they helped to bridge; more time was used by the entire society for the sake of traffic than was “saved.”
It is sufficient to recognize the existence of these two watersheds in order to gain a fresh perspective on our present social crisis. In one decade several major institutions have moved jointly over their second watershed. Schools are losing their claim to be effective tools to provide education; cars have ceased to be effective tools for mass transportation; the assembly line has ceased to be an acceptable mode of production.
The characteristic reaction of the sixties to the growing frustration was further technological and bureaucratic escalation. Self-defeating escalation of power became the core-ritual practiced in highly industrialized nations. In this context the Vietnam war is both revealing and concealing. It makes this ritual visible for the entire world in a narrow theatre of war, yet it also distracts attention from the same ritual being played out in many so-called peaceful arenas. The conduct of the war proves that a convivial army limited to bicycle speeds is served by the opponent’s escalation of anonymous power. And yet many Americans argue that the resources squandered on the war in the Far East could be used effectively to overwhelm poverty at home. Others are anxious to use the $20 billion the war now costs for increasing international development assistance from its present low of $2 billion. They fail to grasp the underlying institutional structure common to a peaceful war on poverty and a bloody war on dissidence. Both escalate what they are meant to eliminate.
While evidence shows that more of the same leads to utter defeat, nothing less than more and more seems worthwhile in a society infected by the growth mania. The desperate plea is not only for more bombs and more police, more medical examinations and more teachers, but also for more information and research. The editor-in-chief of the Bulletin of Atomic Scientists claims that most of our present problems are the result of recently acquired knowledge badly applied, and concludes that the only remedy for the mess created by this information is more of it. It has become fashionable to say that where science and technology have created problems, it is only more scientific understanding and better technology that can carry us past them.
The cure for bad management is more management. The cure for specialized research is more costly interdisciplinary research, just as the cure for polluted rivers is more costly nonpolluting detergents. The pooling of stores of information, the building up of a knowledge stock, the attempt to overwhelm present problems by the introduction of more science is the ultimate attempt to solve a crisis by escalation.
KEY CONCEPTS (cumulative):
(1) Commodificaton. The transformation of anything into a commodity. This can refer to the production and sale of a fire brick, to selling tickets to see a natural cavern. Once it is turned into a thing-for-sale, commodification has occurred.
(2) Dogwaggery (a term invented by De Clarke). When a means becomes a more important end than the original end.
(3) Watershed(figurative definition, as used by Illich): A point in the historical process when a particular “tool” creates a quantum shift in society, like the sudden application of gravity feeding water into a terrain basin (literal watershed).
(4) Iatrogenesis(eye-uh-tro-GIN-uh-sus): Any adverse mental or physical condition induced in a patient through the effects of treatment by a physician or surgeon. For our purposes, however, we want to introduce this as a more universal idea, as another intellectual tool: Any situation where the “cure” causes more harm than the “cause”. This is a common phenomenon in modern society, but because we have been taught to think about things in discrete little boxes, and not in their relations and interactions, we tend not to see iatrogenesis. Road-building is a good example. The problem is traffic congestion. The cure is to build more roads. But with more roads, new development occurs, which is more spread out, pulling more people into the region where the congestion started, and making them more dependent on more cars. We go from traffic congestion on a small scale, to traffic congestion on a large scale.
(5) Episteme: While the term comes from the Greek, for “knowledge,” its use in philosophy refers to one assumption in “the body of ideas that determine the knowledge that is intellectually certain at any particular time.” Epistem-OLOGY is the study of “how we know.” This is extremely important, as feminists have pointed out repeatedly, because those assumptions about what is certain are not normally questioned. They are regarded as beyond question. These dominant epistemes, or ideas that determine what is certain, and which are widely shared, continually lead to the same conclusions and restrict consideration of different assumptions and different conclusions.