Interview With Ivan Illich
Ivan Illich was born in Vienna in 1926; his father was Dalmatian, his mother a Spanish Jew. He grew up in Europe, and at the end of World War II attended the universities of Florence, Rome and Salzburg, obtaining degrees in history, philosophy and theology. An exceptional linguist, he speaks a dozen languages. In 1950 Illich went to New York, where he served as a parish priest in an Irish-Puerto Rican slum. In 1956 he was appointed vicechancellor of the University of Puerto Rico. He resigned from that post five years later, and in 1960 helped launch a movement that eventually became CIDOC, the Centre of Intercultural Documentation at Cuernavaca, Mexico.
In 1969 Illich began publishing a series of books that earned him a worldwide reputationasan implacablecritic of industrial institutions. His attacks have been concentrated on education, transportation and medicine. Celebration Of Awareness appeared in 1969; it was followed by Deschooling Society (1971 ), Tools For Conviviality (1973), Energy And Equity (1971), and Limits To Medicine (1976). His books are works of impeccable scholarship, the products of a remarkable analytical mind. Illich holds a mirror up to an ugly age that he regards as bent on selfdestruction. He has been called a prophet, but the prophet’s mantle does not sit comfortably on his shoulders. ‘‘I speak of the past and of the present: not of the future,” he says. He is not a pessimist, nor is he a revolutionary—though the implications of his work are revolutionary. Illich has been accused of being abrasive, arrogant, provocative, presumptuous, but on the occasion of this interview he seemed the reverse. He has the gaunt, ascetic face of a scholar. But there is also the warmth of the man, his courtesy, his humility, his infinite patience. He is slight, wiry, intense. His intellectual stamina is complemented by what can only be described as a moral radiance. He spoke to free-lance journalist Hubert de Santana, who remarked afterward that it is impossible not to be uplifted by being in the presence of Ivan Illich.
Maclean’s: In your latest book, Limits To Medicinemos argue that the medical establishment has become a major threat to health. Central to your thesis is the concept of iatrogenesis. Can you explain what you mean by that concept?
Illich: Iatros is the Greek word for healer; genesis means origin. Iatrogenesis literally means “doctor-producing disease.” And as
somebody has pointed out, there are only two doctor-producing agents known: namely the mothers of doctors and medical schools. But in fact the term iatrogenic was used originally for much more than half a century, by German doctors mostly, for those diseases for which the doctor is the pathogen. More precisely, those diseases for which either doctor or remedy— which today is increasingly in the hospital—is the pathogen, that is the sick-mak-
THE MORE GENEROUS ‘MISSIONARIES’ ARE IN THE THIRD WORLD THE MORE DANGEROUS
ing, or sickening agent. Now, usually in medical literature, iatrogenic disease is reserved for the unwanted consequences of remedies which are unavoidable, therefore distinct from medical callousness, which can cause disease; and from medical rapaciousness, which might cause disease. Maclean’s: Most modern medical treatment involves the use of powerful drugs whose side effects are accepted as being undesirable but unavoidable.
Illich: Every remedy, almost by biological logic, must have also unwanted side effects, because if the remedy—especially if it is a pharmacon—is a powerful chemical, it not only will have the effect a doctor wants, but some other effects which, the more spe-
cific the primary effect is, will be more profound. And it is in reference to these unwanted side effects of pharmaca, of surgical interventions, of radiological interventions, that iatrogenic disease in the narrowest sense has been applied.
Maclean’s: But you have broadened the application of the term to include clinical, social and cultural iatrogenesis. Let’s talk about some of these extra dimensions, beginning with clinical iatrogenesis.
Illich: I include in clinical iatrogenesis the inevitable unwanted side effects of most powerful treatments or interventions which are foreseen and accepted by the doctor; those which are not foreseen, either because of his negligence, or because of his ignorance, or because of a lack of scientific evidence on such treatments—this is a second category. Third, I include there all that damage that results from wrong judgment systems breakdown; lack of communication between patient and doctor; mix-up of information in the treatment establishment.
Maclean’s: Give me a concrete example. Illich: A woman friend of mine is just at this moment writing a very important book on photography. Her doctor had informed her that he intended to take off her breast. She went for a final checkup to the best American radiological diagnostician, a woman doctor. Just for security. And that woman doctor took out her X-rays and put them up on the screen: there were five different photos of her breast. And she said to her: “Mrs. So-and-so, I don’t see any reason for you to have this operation. There’s a slight shadow there; the operation I know is scheduled for the day after tomorrow, but I have already telephoned your doctor to call it off. Looking at the evidence, there is hardly anything for you to worry about now. Let’s review it after a while.”
Maclean’s: And what was your friend’s response?
Illich: Now a normal patient would not have been granted this request. My friend said : “I’m working on a book on photography. For this reason I’m particularly interested in seeing how one can look into one’s own insides with radiography. May I look at these pictures?” And somewhat reluctantly the doctor agreed. And when my friend looked at the X-rays, she said, “But, doctor, the name on these pictures is very similar to mine, but it is not mineV’ Maclean’s: Are there many similar cases that are documented?
Illich: I can refer you to an article in the most reputable of all U.S. medical journals
that deals epidemiologically with this kind of mix-up of X-ray plates. For that purpose you need a very wide base. You need hundreds of mix-ups in order to analyze them statistically.
Maclean’s: That implies that there have been hundreds of such mix-ups.
Illich: This article alone documents hundreds. I include in clinical iatrogenesis, therefore, most of what is done in hospitals. I have spoken three months ago with a team of young doctors at the largest hospital in the United States, Cooke County Hospital in Chicago. In the estimate of these doctors, four fifths of all treatment for knife-wounds, poisoning, asphyxiation, and radiation are required because of aggressions against the organism that were caused in the hospital rather than outside the hospital. That is, it is four fifths more probable that you be treated for a wound that was scalpel-inflicted in you rather than caused by your wife’s kitchen knife. Or that you were treated for a burn that originated with a machine in the hospital than by a kitchen stove. Or that you are treated for poisoning induced by medicine rather than poisoning induced by ingesting a toxic substance at home. Clinical iatrogenesis constitutes a very important form of damage to health; but it is dwarfed by what I call social iatrogenesis.
Maclean’s: How would you define social iatrogenesis?
Illich: By social iatrogenesis I mean the health-denying effect of a professional monopoly over health-care.
Maclean’s: Please explain the term “professional monopoly. ” llllch: Professions are just one form that the control by workers can take. People with specialized occupations tend to seek control over the work they do. Soldiers of fortune created bands or gangs to deny loyalty to a prince who wouldn’t allow them to plunder. . . . Medieval guilds of shoemakers determined what tests an apprentice had to go through before he was allowed to shoe fellow burghers. Unions, at least in capitalist countries, have some say on who shall work, under what conditions, and for what pay. What all these trade associations have in common is that they establish conditions under which work shall be done.
Maclean’s: It seems to me that in order to understand how social iatrogenesis works, it is necessary to distinguish between the professional and the craftsman. History has blurred the borderline between the two. Illich: The doctor became a professional when prescribing medicine became a gentlemanly job, and bleeding was left to a barber, bone-setting to a surgeon, tooth extraction to the tooth-puller, delivery to the midwife, and trade in drugs to the pharmacist. The doctor changed from a craftsman into a liberal professional.
Maclean’s: What do you mean by a “liberal professional”?
Illich: A liberal professional is he who imputes needs to a person who comes to seek
his help. Instead of prescribing individual needs as a person, the professional organization as such acquired the need of defining what society needs. The liberal professional is now mutated into a dominant professional. The prescribing counselor or adviser mutated into a social entrepreneur—a crusading missionary of corporate opinion about other people’s needs. And when this happened, medicine acquired entirely new powers to prescribe autonomous health care.
Maclean’s: How would you sum up social iatrogenesis?
Illich: To sum it up I would call social iatrogenesis the destruction in the environ-
YOU ARE FOUR TIMES MORE LIKELY TO BE INJURED IN A HOSPITAL THAN OUTSIDE ONE
ment of conditions for health care that are a result of professional monopoly over health care.
Maclean’s: Could you give a comparative evaluation of the medical systems of other countries? In your judgment is the Chinese medical system more efficient than that of North America?
Illich: It is less health-denying at this moment, certainly. One reason for this is because much less money is spent. But no doubt something extraordinary happened between 1968 and 1971, when the definition of what constitutes disease and the judgment of who is sick became tasks the commune itself assumed. That is, defining what constitutes disease used to be a professional task, and it became a political and grassroots task. But this has been reverted again very strongly since 1971, and as far as I can see now the domination over concepts and methods used in health per-
ception in China are now at least as centralized as in the United States.
Maclean’s: Is this equally true of the Russian medical system?
llllch: The Russian system is substantially the same. Notwithstanding their mistake of allowing private beds in public hospitals in England, you can argue that the fundamental goals of the Russian system have been better implemented in England than in Russia.
Maclean’s: Let's move away from medicine now, to those other subjects with which you have been concerned in your writings. May I begin with transportation. You believe that the volume and intensity of traffic represent a threat to mobility.
Illich: It can be shown—and I have done this in my book Energy And Equity—that whenever in a society vehicles with top speeds above 20 mph are used for traffic ... mutual accessibility will decline. People will spend more and more hours enslaved by traffic and, this is extraordinary, will spend more rather than less life time on each mile they do. In other words, as vehicles in a society run beyond 20 mph (and this is independent from technical and political considerations), they will create distance for everybody by distorting settlement patterns and will overcome them preferentially only for a few. You can express it differently. Vehicles that run above 20 mph are structurally instruments for the next transfer of power and privilege from a majority to a minority.
Maclean’s: But surely 20 mph is hardly a realistic figure for a man in a modern industrialized society to comprehend? llllch: Twenty mph is just so low that the person who is born next to a gas station cannot conceive of it as the socially critical threshold in the acceleration of vehicles. A study that was done in Mexico shows that 99% of all Mexicans in two typical states never, in the year of the study, even once moved over a distance of 20 miles in less than one hour. Therefore that speed lies in a blind angle of social vision: too low to be taken seriously by high-school graduates, and much too high to be meaningful for traditional people.
Maclean’s: You obviously feel very
strongly about the threat traffic poses, not only to human life and health, but to . . . llllch: Rationality! It becomes a religion into which one is forced for the sake of effectiveness, of efficiency—which is really the most degrading form of prostitution. Maclean’s: You have written and spoken eloquently about the problems that afflict modern, over-industrialized societies. Do you think those problems can be resolved in political terms?
Illich: I see the whole thing as a political issue, or, more precisely, as an issue of repolitization.
Maclean’s: Can legislation really provide answers to problems of such magnitude? A nd where are we to find legislators enlightened enough to recognize and deal with the crises you have described?
Illich: I don’t count on law; but, faute de mieux, I just do not know where else to look. Therefore I’d rather stick with the legal paradigm in speaking about the possible political answers than with any other. There has been over the last two generations a consistent prejudice in the courts, courtrooms, and in the legislative chambers to let experts tell the judge or the lawmaker how rights ought to be defined for people. And what has happened as a consequence is that rights were defined as that which is profitable for professionals and experts to produce.
Maclean’s: Is this a process characteristic only of capitalist societies?
Illich: This is a process which has gone on just as much in socialist as in so-called capitalist societies. Now, rights and liberties are in a fundamental conflict in every society. In every society, obviously, in order to exercise your liberties you must count on certain basic rights. But rights are not satisfactory if they are so defined that they crush liberty.
Maclean’s: How did you come to be such an impassioned critic of industrial institutions? Illich: I’ll tell you what brought it about. From 1950 to 1955 I worked in a slum in New York. And then in 1956 I was asked suddenly to take over the vice-chancellorship of the University of Puerto Rico. Basically, they needed somebody neither Puerto Rican nor American, with profound acquaintance of Puerto Ricans in New York and considerable knowledge of the island of Puerto Rico. And once you had these requirements, there was nobody else available. So at the age of 29 I found myself heading a university and, a year later, being in addition a member of the five-man government board in charge of the island’s education system.
Maclean’s: How long did you stay in that position in Puerto Rico?
Illich: Well, I stayed only five years in Puerto Rico in that educational position, because of three policies of mine that had to lead to my firing. I wanted to reduce the university budget. I wanted to increase the elementary educational budget by transferring some of the university budget to it, so as to make sure that everybody would get his primary education. And third, I wanted to tax Catholic schools out of existence because they were creating an opportunity for a minority that could pay a little bit to feel superior to those who went to public schools. With these policies, it’s a miracle that I held on for five years. Maclean’s: When did you reshape your ideas?
Illich: After many months in various parts of South America, having thought things through, I wrote those basic pieces such as Outwitting Developed Nations. It was in the late Fifties and early Sixties that I began to question the framework that was common to both the right and the left when one spoke about industrial development. Maclean’s: Reading you, and listening to you, one is impressed by the thoroughness of
your research and the lucidity of your thought. Your ideas seem to have germinated and grown during a long incubation period.
Illich: They have been incubating a long time. I was very much interested in medieval alchemy as far back as the mid-Forties. Much of the reading on which I draw today I did between the age of five and 12.1 was lucky enough to have grandparents each with a good library. I didn’t get much formal education, but I was lucky enough to be brought up in contact with good books, and to be allowed to sit under tea tables where 1 could listen to what seriously thinking people discussed.
PEOPLE WHO CLAIMED TO FLY ON BROOMS USED TO BE BURNED. NOW WE PAY THEM
Maclean’s: Tell me about your years as a parish priest in an Irish-Puerto Rican neighborhood of New York.
Illich: It taught me something about the degree to which those more gifted, and usually those with a little more money from the beginning, in the Puerto Rican group, made it faster into U.S. mainstream society than either the Italians or the Irish before them. It taught me about the corrupting influence of industrial society. Maclean’s: Tell me about the Centre of Intercultural Documentation which you founded at Cuernavaca in Mexico.
Illich: In 1960, on the evening I wrote my letter of resignation from the vice-chancellorship of the University of Puerto Rico, I sat down with some friends, and over a very good bottle of rum liqueur we discussed what was the next important thing we had to do. There was one little job I had planned to do in Puerto Rico and had not
yet managed to do: that was debunking volunteering for development.
Maclean’s: Do you not approve of volunteers overseas?
Illich: In my opinion, and in the opinion of the others—Peace Corps members, Service Alternatif de France, missioners—the more they were good and generous people, the more dangerous they were for Third World countries.
Maclean’s: Why is that?
Illich: Because their human kindness is used by the imperial power to infiltrate more effectively the world view of the imperial power than any diplomat or highpaid businessman ever could do. Maclean’s: And you decided to do something about it?
Illich: We decided to set up somewhere— finally we decided on Cuernavaca, a place already so corrupted by tourism that a few hundred more couldn’t do much damage—to set up a centre from which we could debunk volunteering by three types of action: attract to our centre every serious volunteer toward Latin America by offering absolutely first-class Spanish instruction and area briefing, so that the best and brightest volunteers would come to us and slowly be convinced that it would be better for them, for their whole country, and for their benevolent target, if they turned around. Second, by infiltrating the Peace Corps and similar agencies in order to question these activities from within, doing this mostly through our alumni. Third, by setting up throughout Latin America waves of ridicule against volunteers, which would immunize Latin America against those who still managed to get through.
Maclean’s: I want finally to refer to your strikingly original reinterpretation of the Prometheus myth in Limits To Medicine. Do you see modern man as a Prometheus doomed to bring nemesis upon himself because of his boundless presumption, his industrial hubris?
Illich: Yes. But today Prometheus has become Everyman. Without the Promethean nobility and heroism. Everyman today is a vulgar Prometheus.
Maclean’s: How can we escape punishment for our hubris?
Illich: Man is different from the animal in that he has to cope on not one but three fronts. He has to cope with nature, cope with his own neighbor—and most of history is a record of class war or intertribal war, of enslavement and exploitation. And he must cope with his own lustful, envious, greedy dreams. And more particularly with the translation into daytime reality of the greedy dreams of the most gifted of his fellow citizens. For this purpose traditionally he can rely on myth and taboo. Both have been profoundly destroyed, or undermined, or washed out by the industrial ethos. People who pretended to fly on broomsticks were burned alive: today they are paid. There are no more checks on the daytime realization of nightmares. O