COMMUNITY HEALTH STUDIES VOLUME II, NUMBER 1 , 1 9 78

R E VIEW ARTICLE

AVOIDING THE DOCTOR Jim Ward*

Medicine is under seige; more than at any time in its recent history its legitimacy is being questioned from all quarters. It is accused of being over-specialised, elitist, irrelevant, harmful and outrageously expensive. Anyone involved in medicine cannot afford to ignore any of these criticisms but those which we can least afford to igqore come from Ivan Illich and Vicente Navarro. The purpose of this short article is to highlight some of the basic contrasts inherent in the approaches of these two highly vocal and highly readable critics and to convince the reader that their criticisms as well as those of others must be taken seriously by those in the medical profession. The article does not pretend to be a detailed analysis of the point of view of the critics but simply an introduction to their work.

Illich believes there is too much medicine in the world, that it has taken over and sapped our vital energies, our ability to ‘do for ourselves’, in fact it makes us sick. Navarro believes that medicine is what Althusser refers to as an ‘ideological state apparatus12 - its major task that of reproducing the conditions of the capitalist system. It is irrelevant, if not harmful, t o the needs of working class people, its better services being available only to the upper class who needs them least. For Navarro the problem is not one of too much medicine but of unequal distribution. Given that each of the critics sees the problem of medicine in different ways each also proposes different solutions. Illich suggests disestablishment of the medical system and a return to greater self-sufficiency, whilst Navarro suggests an increase of worker control.

This paper discusses the two critiques in the light of the process of medicalisation of society, access to and ability to resist the medical system, and the validity of the solutions each critique proposes.

The Medicalisation of Society

Medicalisation of society refers to that process whereby the institution of medicine becomes even more involved in ever wider

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spheres of our lives. The notion plays a particularly important part in Illich’s critique. He notes that:

. . . the severe limits of effective medical treatment apply not only to conditions that have long been recognised as sickness , . , but even more drastically to those that have only recently generated demands for medical care.3

He goes on to demonstrate that old age has, in recent times, been ‘put under doctor’s orders’.

The movement of various types of behaviour (such as illicit drug use and heavy alcohol use) from ‘simply deviant’ into the medical sphere is a further example of the process. The recent hints by the Premier of New South Wales that marijuana users in that State should be recommended for treatment are a case of the former and the movement from cells to wards for chronic drunkenness offenders is an example of the latter.4 A more extreme example of medicalisation is the recent suggestion by a medical authority in Sydney to consider the condition of homelessness as an illness.

In the above cases it is the relatively powerless who are most vulnerable to the medicalisation process: the aged, the adolescent, the poor. But the relatively powerful middle class is also vulnerable particular1 through the growth of multi-phasic screening.? In some cases it may be necessary to go through such a procedure to become eligible for employment or insurance; in other cases it may simply be a suggestion on the part of those operating the service to become involved in what is often portrayed as a ‘breakthrough’ in medicine - the move from a curative to a preventative emphasis.

From Illich’s point of view, however, so-called preventative medicine is just another example of medicalisation. By such an approach individuals are ‘taken over’ by the medical system without even being sick. There is no ‘escape! * Those who see the preventative

* The writer recently received an invitation in the mail to attend a preventive health clinic. The purpose

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approach as an answer to the irrelevance and high cost of medicine are portrayed as naive by Illich because they are unable to recognise the growth imperative of institutions. McKnight, an Illich follower, claims the major dynamic behind the growth of such professional institutions is the provision of jobs and income for those within such institutions.6 As the physical and human resources of the medical system grow in size and complexity there is an increasing need to expand into new areas to put such resources to use. What better way than having the entire population as clients? Thus it is the institution that needs the client rather than the reverse. Hence the importance of the preventative medicine ideology. Not only is the individual unable to care for himself when sick - he also has this power taken from him when well.

Access to the Medical System

Although the threat of medicalisation looms large in Illich’s critique, it is of little importance to Navarro who is more concerned with unequal access to the system than with avoiding it. Largely because of his ‘class blind- ness’ Illich pays little attention to the dif- ferential effects of medicine according to social class. For Navarro, however, this is a central concern of the critique. He focusses his studies of. Latin America and the United States on the maldistribution of health resources, using the holistic perspective of political economy to show that under capitalism the unequal distribution of health resources is a reflection of the unequal distribution of power and material wealth. (To any Marxist this is patently obvious, to bourgeois medicine it is a revelation!)

Working class people therefore have both greater health problems and greater difficulty in gaining access to suitable health care. The greater health problems stem from reduced life chances and the difficulty in receiving health care follows from their lack of power reflected in their lack of control of the medical system. Poorer rural areas within nations are poorly served by medical care not because of their lack of resources but because their rich resources are exploited by the urban based capitalists. Their poverty and ill health is not related to their lack of resources but to their lack of control over those resources.

Although, according to Navarro, the working class is the largest class in America it

of the clinic is stated a8 ‘. . . the early detection of disease, the identification and management of persons at high risk for later develo ment of disease and, finally, the encouragement o f positive attitudes to health’.

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has no control whatever within the medical system.’ Thus its access to the system is difficult and the system tends to be irreIevant to its needs.

Tudor Hart’s study of access to medical care in Britain reaches similar conclusions.6 His notion of the ‘inverse care law’ refers to the situation wherein:

‘. . . the availability of good medical care tends to vary inversely with the need of the population served.’ Tudor Hart points out that health

problems in Britain are not simply due to difficulty of access to good medical care but are also greatly affected by environmental conditions. Paradoxically, those who have to suffer the worst environmental conditions also have least access to good medical facilities. With Navarro, Tudor Hart recognises the holistic nature of health problems. For the former the Appalachian mining towns are the location of greatest exploitation and the poorest health care, for the latter it is South Wales. Here in Australia it may be the resource-rich aboriginal reserves. The recognition that the medical system cannot be understood in isolation from the world in which it exists is central to the Marxist critique. As Navarro writes:

“The system of medicine is determined primarily - although not exclusively - by the same forces that determine the overall socid formation, society.”9 Navarro is thus vitally concerned with

inequality of access to health care facilities. The harm that may be caused by easier access plays no part in his analyses - in contrast to Illich’s statement that

“Less access to the present health system would, contrary to political rhetoric, benefit the poor.”’

The Medical System as a Threat to Health and Freedom

Illich sees the medical system as a threat to health, others such as Szasz, Kittrie and Cardner see it as a threat to freedom.’ Illich’s argument is based on the assertion that virtually all the major improvements in health have been achieved through sewerage, housing, food, etcetera, and that the medical system has unjustifiably taken the credit for these improvements. Not only is the medical system not responsible for the historical improvement in health conditions it is not responsible for maintaining good health today - in fact it creates ill health. Those falling into the grips of the medical s stem are likely to suffer clinical iatrogenesis.’ Not only does the individual taken into the system suffer from such threats to his health but the whole society, through its

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dependence on professional medicine and inability to care for itself, suffers social and cultural iatrogenesis. Thus, contrary to Navarro who argues for more equal access to the medical system, Illich would see such access in terms of a wider distribution of the various iatrogeneses. From this standpoint any segment of the population that has poorer access to the medical system is likely to be healthier!

An increasing number of critics (for example, Szasz, Kittrie and Gardner) are becoming concerned over the inability of many to resist access to an authoritarian medical system.13 Insofar as they emphasise the inequities of too much, rather than too little, access to the medical system their critiques are closer to those of Illich than Navarro’s. They are concerned with the increased medicalisation of society that leads to certain behaviours being labelled as ‘sick’ and the confinement of ‘sufferers’ in therapeutic institutions. Their point is that the labelling process is arbitrary but is made to stick because it receives its legitimacy through a highly prestigious professional institution - that of medicine. Not only is it possible for virtually anyone to be so labelled and put away in a treatment centre for his or her ‘own good‘ but the iatrogenesis thus suffered is often extreme. The medical system is empowered to create ‘illness’ and take away freedoms. In such cases access to the system is something to be avoided at all costs. We might ask can some resist more effectively than others?

Medicine as a Threat to Freedom: Authoritarian and Negotiating Systems

In the literature concerned with health care help-seeking behaviour, there is little agreement on wh particular individuals become patient^.?^ However, these otherwise disparate studies do agree that it is better to seek professional health care than not t o do so. Such an assumption is obviously at odds with Illich’s approach, since to seek professional health care is to voluntarily expose oneself to iatrogenesis in all its forms.

Some studies have indicated that class is an important variable in affecting health care help-seeking behaviour. Strauss has noted that previous negative experiences of the health care system on the part of working class people - who then have seen the system as being irrelevant to their needs - have deterred them from further involvement.’ Waitzkin and Waterman use Bernstein’s notions of restricted and elaborated language codes to mount a Marxist argument on the communication barriers between middle class physicians and working class patients.’ They attempt to show that the doctor-patient relationship in such

situations is highly asymmetrical, the doctor being more interested in maintaining his distance and preserving the mystique of the profession. Given this kind of argument one would expect working class people to be most ‘put off‘ by the system and thus least vulnerable to medicalisation, seeking help only in times of crisis. Despite, or perhaps because of, this state of affairs working class people are most vulnerable to “freedom threatening” or authoritarian medicine. It may be useful here to develop the notion of two medical systems: the authoritarian and the negotiating. The negotiating system is experienced by middle class individuals who come from a s$ilar location in the social structure to those w om they contact in the health care system. Middle class people ‘speak the same language’ as the providers so they can negotiate an appropriate pathway through the system. Their class has some say in the control of the system.

The authoritarian system is formed when working class people come into contact with medicine. They are told what to do. The response may be acceptance or rejection of the unilateral ‘advice’. but the contact experience itself tends to be negative, so that future voluntary contacts will be avoided. However, the same individuals have less ability - because they do not deal with the negotiating system of medicine - to resist medical labelling and are thus most likely to come into contact with the authoritarian system on an involuntary basis. For this reason working class people form by far the greater proportion of individuals in therapeutic programmes. Such a situation cannot be understood outside the class structure of society as a whole. Thus although Illich and others are concerned with the threat to freedom represented by modern medicine their class blindness causes them to see it as something that threatens all in society equally. There can be little doubt that there is an urgent need for Marxist analyses in this area.

The Hobo and the Authoritarian System

Hobos are amongst the most powerless of groups in capitalist industrialist societies ; they are in the ‘lower ranks’ of the working class and they are highly vulnerable to the authoritarian medical system.’ In recent years, as the rate of medicalisation has increased, the tendency to see the hobo as one suffering from an illness has grown. The hobo’s illness has almost always been seen in terms of alcoholism. When public drunkenness was a crime the offender went to gaol for being guilty of it. Now that it is seen as alcoholism - an illness - he is more likely to be recommended for ‘treatment’. It is, of course, virtually impossible for the hobo so labelled to protest effectively since such treatment is ‘for

COMMUNITY HEALTH STUDIES 36 WARD

his own good’ and such interactions do not take place in the negotiating system.

As with many of the ‘new illnesses’, alcoholism is difficult to define so that unlike, say, tuberculosis there is more of a problem in making the label stick - particularly in making it stick long enough for a programme of treatment to be undergone. Alcoholism, by any definition, is not peculiar to the working class but treatment programmes that take place in ‘therapeutic institutions’ draw their patrons overwhelmingly from the working class. Hobos form a large proportion of this patronage.

The hobo is the victim of what Rubington referred to as the false syllo ‘sm of drunkenness

function of his inability to resist the label imposed on him both through popular stereotyping and medical labelling. In addition, he forms part of a literally captive population that is necessary if the burgeoning medical system is to have something to do with its human and capital resources. In a 715 bed alcoholism rehabilitation centre in Virginia over 80 per cent of patrons were working class and a large proporti06 of these were hobos.19 Although the Australian hobo has, until recently, avoided the medical labelling process, he too is now being threatened by the same situation as his American counterpart. A report in the Australian (14 December 1976) on the recommendation of a New South Wales special committee investigating victimless crimes states:

‘For drunkenness the committee recommends the present $10 penalty to be abolished. Police would have the power to take a suspect to court, and there he could either be admonished or required to undertake medical treatment.’ (emphasis added) The hobo is a salutary example of one

unable to resist the power of the authoritarian system - he can never hope to gain access to the negotiating system and thus he is likely to suffer one of the worst aspects of health care - the loss of freedom.

The increasing involvement of the health care system in the ‘rehabilitation’ area is a further manifestation of medicalisation. Behaviours such as public drunkenness, vagrancy and illicit drug use are moved from the criminal to the medical sphere. This movement supports McKnight’s contention that professional institutions need clients more than the clients need them?O When the proposed course of ‘treatment’ is backed by legal authority the industry has a captive market. Those least able to resist this process of compulsory treatment are those who deal only with the authoritarian medical

= skid row = alcoholism.’. P . This is primarily a

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system. It is at this point - the interaction between the authoritarian medical system and the one victimjsed by this system - that the class struggle is most obvious.

Illich and Navarro: Are There Compatible Soh tions?

Given that Navarro and Illich adopt differing stances to the crisis of medicine, are their solutions in any way compatible? Illich sees the problem as one of increased bureaucratisation in which the medical system has increased its ability to foist its version of reality on the world at large. His solutions are a de-profess iona l i sa t ion of medicine, disestablishment of their medical bureaucracies

’ and a need for the individual to become autonomous in his health care behaviour - a do it yourself philosoph .2 ’

Navarro takes filich to task for naively assuming that those in the medical system are those who have the power to determine the direction of the system. Any bureaucratic. system under capitalism - medicine included - is sim ly the mouthpiece of the dominant

“In this interpretation . . . the class conflict has been replaced by the conflict betwedn those at the top, the managers of the bureaucracies, indispensable to the running of an industrial society, and those at the bottom, the consumers of the products . . . administered by those bureaucracies.” In reality, however, the needs (for medical

care) are determined by the basic institutions of capitalist society. The bureaucracy (the medical system) is simply a socialising agent. Thus for Navarro it is necessary to make structural changes to bring medicine more into line with real needs. In much of his research Navarro advocates increased control of the medical system by the working class.2

For Navarro the ‘separate life-style’ solution put forward by Illich represents no threat to the present system since

. . . this strategy of self-care assumes that the basic cause of his sickness or unhealth is the individual citizen himself and not the system, and therefore the solution has to be primarily him and not the structural change of the economic and social system and its health sector.24

Thus the basic solutions offered to the medical crisis differ substantially. Navarro’s critique focusses on a criticism of capitalism, whereas Illich’s focusses on a criticism of industrialism. For Navarro structural changes must be made that will radically alter the class relations. in society,

class.2 4 Navarro writes:

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Increased State Involvement?

There is some current discussion in Australia about the pros and cons of increased State involvement in the medical system (for example, see Wallace and Duckett in earlier is- sues of this journal2 5 ) . On this point, however, Illich and Navarro agree: both see increased State involvement as no solution. As would be expected Illich sees nationalisation of health services as furthering the medicalisation process, since it would extend the institutional tendencies even further.2 Navarro sees further State involvement (under capitalism) as simply paving the way for an increased injection of finance capital into the area - the public sector being left to pay for the high cost responsibilities. National health insurance is seen as a subsidy for the medical-industrial complex. Navarro is, of course, adopting the classical marxist stance that the State under capitalism is a tool of the dominant class.2 ’

Despite their very great differences, both Illich and Navarro deliver stinging critiques of modern medicine. Each sees the medical system as irrelevant to the real health needs of society. Each presents convincing evidence that radica

’ changes must take place if medicine is to fulfil its ostensible function of providing relevant health care. The weaknesses of the present system are effectively highlighted from the two points of view but the solutions offered are not always realistic. Illich’s solutions of disestablishment are naive and utopian. how can institutions that are firmly embedded within the social structure be disestablished before the social structure itself is radically altered? Navarro’s solution of increased working dass control may reflect a better grasp of the reality of class structured societies. But this may be as difficult to implement as Illich’s solution. The basic questions that need to be asked in order to ascertain which of the two critiques is most realistic are: (1) Is there altogether too much medicine? (2) Is there too much medicine for some and too little for others? And if the answer to (2) is yes, who gets too much and who too little? If Navarro is right, it makes good sense to facilitate more equal access to the medical system. If Illich is right, it makes better sense to ‘Avoid the Doctor’. The latter is more difficult for some than for others

References

1.

2.

3. 4.

5 .

School of Sociology, University of New South Wales.

Ivan Illich, Medical Nemesis: The Expropriation o f Health (Calder and Boyars London 1975), and Limits to Medicine: Medical Nemesis: The Expropriation o f Health (Penguin Harmondsworth 1977); and Vincente Navarro, “The Industrialisation of Fetishism or the Fetishism of Industrialisation: A Critique of Ivan Illich” in Social Science and Medicine 9 (1 975) pp. 351-363, and Medicine under Capitalism (Croom Helm London 1976). V. Navarro, “Political Power, the State and their Implications in Medicine” in Review of Radical Political Economics 9 (1977)

Illich, Limits to Medicine . . ., p. 89. Sydney Morning Herald 19 February 1977, p. 1, and Australian (Sydney) 14 December 1976. Cf. N.N. Kittrie, The Right to be Different (Johns Hopkins Baltimore 197 1). I. Zola, “Medicine as an Institution of Social Control” in C. Cox and A. Mead (eds), A Sociology of ,Medical Practice (Collier-Macrnillan London 1975).

pp. 61-80.

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6. J. McKnight, “Professionalised service and disabling help” in I. Illich et al (eds), Disabling Professions (Marion Boyars London 1977). Navarro is not alone in attempting to dispel the notion of a middle class majority in America. Cf. H. Braverman, Labor and Monopoly Capital: The Degradation o f Work in the Twentieth Century (Monthly Review Press New York 1974), and A. Levison, The Working Class Majority (Coward, McCann and Geoghegan New York 1974) for evidence that most Americans are working class.

8. J. Tudor Hart, “The inverse care law” in Cox and Mead, A Sociology o f Medical Practice.

9. Navarro, “Political Power, . . .” 10. Illich, Medical Nemesis . . . 11. T. Szasz, The Myth o f Mental Illness

(Harper and Row New York 1961) and The. manufacture o f madness (Paladin St. Albans 1973); Kittrie, The Right to be Different; and J. Gardner, Inside the Cuckoo’s Nest (Planet Press Brisbane

12. Mark Diesendorf, “Mass X-rays: Risks versus benefits” in his The MaRic Bullet

7.

1977).

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(S.S.R.S. Canberra 1976) discusses the possible iatrogenic effect of mass x-ray screening in Australia.

13. Szasz, The Myth o f Mental Illness and The manufacture o f madness; Kittrie, The Right to be Different; and Gardner, Inside the Cuckoo’s Nest.

14. See D. Tuckett, “Doctors and Patients” in his An Introduction to Medical Sociology (Tavistock London 1976), ch. 5, for a review of help-seeking behaviour studies.

15. A. Strauss, “Medical Ghettos” in his Where Medicine Fails (Aldine Chicago 1970).

16. H.B. Waitzkin and B. Waterman, The Exploitation o f Illness in Capitalist Society (Bobbs-Merrill New York 1974).

17. See J.S. Ward, The Hobo’s Manifesto (Quartet - forthcoming), for some discussion on why hobos are powerless. I use the term hobo in preference to such terms as homeless men, ‘derro’, stiff, bum, wino because a man can wear the label ‘hobo’ with pride, since it has a long and colourful history going back to the days when the skid row was able to organise effective political groups.

18. E. Rubington, “Failure as a Heavy Drinker: The case of chronic drunkenness offender on Skid ROW” in D.J. Pittman and C.R. Snyder (eds), Society Culture and Drinking Patterns (Wiley New York 1962).

19. J.S. Ward, “Geographic Dynamics of Skid Rows in North America”, Ph.D. thesis, University of Maryland, 1975.

20. McKnight, “Professionalised service. . .” 21. Illich, Medical Nemesis . . . and Limits to

Medicine . . . 22. See J. Johnson, “The Professions in the

Class Structure” in R. Scase (ed), Industrial Society: Class, Cleavage and Control (George Allen and Unwin London 1977); N. Parry and J. Parry, “Social Closure and Collective Social Mobility” in ibid; and G. Carchedi, “On the economic identification of the new middle class’’ in Economy and Society 4 (1 976), p. 1, for a discussion of the relationships between professionals and the dominant class. It is interesting to note that Waitzkin and Waterman, The Exploitation o f Illness . . . fall into the same trap as Illich - even though their analysis claims to be marxist. An example of this is their misunderstanding of Marx’s notion of class manifested i n their suggestion that patients form a class.

23. Navarro, Medicine Under Capitalism. 24. Navarro, “The industrialisation of fetishism

. . .”, p. 360. 25. R. Wallace, “Medifinance: A Proposal for

an Alternative Health Insurance System” in Community Health Studies I: 1 ( 1 977) p. 5 ; and S. Duckett, “Medifinance: A Comment” in ibid. I:2 (1978) p. 7s.

26. Illich, Medical Nemesis, p. 66. 27. See R. Miliband, The State in Capitalist

Society (Quartet London 1973) for a convincing discussion of the role of the State under capitalism.

WARD 39 COMMUNITY HEALTH STUDIES