Public health is not solely a medical issue; it is primarily a social and political one. I acknowledge that this is not a commonly held perspective, but I wish to challenge the enduring assumption that better medicine equals better health. In support of this challenge I will revisit the thinking of a well-known philosopher and critic of the medical system: Ivan Illich.

Ivan Illich (1926-2002) was a historian, and critic of contemporary institutions. His iconoclastic views enjoyed wide public interest in the 1960s and 70s, his popularity waned in the 1980s, and his interest shifted from direct critiques of institutional hegemony, towards medieval history and its influence on the modern world.

In Illich's assessment, the existing medical paradigm suffers from three structural flaws, they are: 1) institutional counter-productivity; 2) lack of proportionality; and 3) the economics of scarcity. The tri-focal lens offered by a study of these interlocking flaws leads to a consideration of this question: “Does more medicine make us sicker?”

The principle of institutional counter-productivity acknowledges that beyond a certain scale or intensity, institutional responses to health and other societal challenges displays a form of what the medical community refers to as iatrogenesis (physician or medicine induced harm), where the opposite of what was intended is created.1

It is Illich's simple claim that beyond a certain scale or intensity, not alone can care not be sustained by institutions, but that harm can be caused by their effort to help. The iatrogenic phase occurs at the point when Illich's scale or intensity is exceeded; the iatrogenic phase is preceded by two other phases, the first phase occurs in the early life of an institution when it is small in scale, and is marked by a period of modest productivity.

In the second-phase, as the organization grows beyond a certain threshold, its productivity begins to level-off, during which time there will typically be a neutral-impact, which is to say institutions are neither helpful nor harmful; they are in effect non-productive, relative to intended outputs.

Therefore, from early productivity, to non-productivity and ultimately counter-productivity the pattern of intense ‘scaling-up’, forms an inevitable bell curve where more institutional effort increases the likelihood of harm without achieving benefit. Notwithstanding such harm can be anticipated and potentially mitigated against, by committing to small, localized and proportionate solutions that begin outside institutional systems in the civic realm.2

Illich's critique was not confined to medicine-induced harm to health; he challenged similar trends in other institutions devoted to improvement and development: in Deschooling Society he contended that schools can become places that stupefy their pupils, functioning more like factories than families: and in Disabling Professions he described how prisons, erstwhile centers of behavioral reform became academies of crime.3,4,5

In one of his most influential pamphlets, on the expropriation of health, Medical Nemesis, he contends hospitals that claim sole dominion over health, at worst accelerate the demise of the sick, and at best create disabling factors that slow up recovery.6 With regards to his cautions in relation to the overreach of hospitals, consider by way of evidence, the rise of methicillin-resistant Staphylococcus aureus in hospitals around the world.7 Or the phenomenon of medical error, in relation to which Laura A. Stokowski writing in Medscape notes, “In 1999, the Institute of Medicine (IOM) published a landmark report on error in healthcare, concluding that medical care was responsible for 44,000-98,000 deaths annually in the United States. In the intervening years, several analyses’ have suggested that the IOM's figures rather significantly underestimated the problem. Studies published after 1999 estimate that 130,000-575,000 annual inpatient deaths are attributable to medical error.”8,9

While Illich was opposed to institutionalism, he was not against institutions per se. Rather his pamphlets challenged attempts on the part of institutions to monopolize functions related to the production of health and well-being, death, safety, wisdom and justice. Since, he contended, these social goods were not commodities unilaterally produced by institutional systems and thereafter consumed by individuals. Instead, he notes in Tools for Conviviality, there are certain irreplaceable functions that natural communities must perform to be well and to prevail culturally.10 And, if they do not do those things, then there are no institutional tools or systems’ alternatives that can appropriately replace those civic functions.

Indeed, Illich argued that it is not a case of ‘either/or’ (community or institution), so much as a question of, which comes first. He contended that an institutional inversion had taken hold in modern societies, through which the community role becomes that which is left after the institutions and their professional helpers have done what they think they can do better or more expertly. Illich contested this inversion, and argued for its reversal whereby the institutional and professional role should be defined as being that which is left after the community has done what it can and wants to do.

Robert Putnam in his groundbreaking publication Bowling Alone cites declining social capital in America as “one of the nation's most serious public health challenges”.11 He notes “the bottom line from this multitude of studies: As a rough rule of thumb, if you belong to no groups but decide to join one, you cut your risk of dying over the next year in half”. He goes on to observe: “by many objective measures, including life expectancy, Americans are healthier than ever before, but these self-reports indicate that we are feeling worse. These self-reports are in turn closely linked to social connectedness, in the sense that it is precisely less connected Americans who are feeling worse”.12

Increasingly industrialised countries are recognising that loneliness poses as significant public health challenge to respective populations. In Canada, for example, one in five people is estimated to be lonely. A study by researchers at Brigham Young University in 2015 found the ill effects of loneliness are as bad as smoking 15 cigarettes a day.13 Echoing Putnam's extensive review of available research literature at the turn of the millennium, the Brigham study looked at more than three million participants and found increased social connection is linked to a 50% reduced risk of premature death.

Loneliness has a less obvious twin sister: uselessness. According to a UK report by Brunel University, De Montfort University and older people's charity the Royal Voluntary Service, one of the greatest fears that older people report is being a burden to their neighbors and those they love; in many instances, they fear it more than loneliness.14 Therein is the rub. To address loneliness and other symptoms of the unraveling of our social fabric we must therefore reconnect people into reciprocal relationships based on their capacities, not their deficits. In seeming disregard of the evidence of impact of community oriented public health approaches, the investment priorities around the world are still largely, some would argue disproportionately, directed toward acute medical care; not preventive approaches.

According to Illich, institutions, rather than supporting social capital, through managerialism and professional overreach tend to inadvertently undermine, displace and eclipse the associational capacities of citizens, eventually rendering them individualized, passive and dependent on acute forms of intervention. Hence as specialisation and technocracy becomes more dominant and domineering, citizenship retreats in the face of the ever-increasing professionalization of civic functions including the function of health production. Mindful of the afore-mentioned dangers, for Illich, all institutional progress should be contingent on understanding the limits of institutional reach and the potential dangers of overreach.

Another of his theories relates to proportionality, which essentially addresses the question of how local, home based communities and institutions can get in right relationship with each other. While this concept is important, it is not as significant as institutional counter-productivity. Notwithstanding, proportionality features strongly in Illich's thinking —when combined with his insights on institutional overreach— and provides a powerful theoretical lens through which to further consider the question: does more medicine make us sicker?

Illich did not believe that proportionality could be attained through institutional reform, rather he saw the key pivot point for authentic progress as residing within civic life, beyond the limits of the institutional world. He believed that if we could restore or reclaim the commons that this would foreground a cultural revolution, which in turn would push back against the overreach of institutions, resulting in more proportionate and democratic relationships between citizens and institutions. Examples of the sort of proportionality that Illich was advocating for are uncommon, yet they do exist, and one of the finest examples comes in the guise of Dr. Robert Mendelsohn. Mendelsohn (1926-1988) was an American pediatrician and critic of medical hegemony.

Dr. Robert Mendelsohn, was a self-proclaimed medical heretic.15 In Dissent in Medicine he revealed:

“When I was a medical student at the University of Chicago, I participated in the DES experiments in which we gave women that female sex hormone diethylstilbestrol in a fruitless attempt to prevent miscarriages. It didn’t work, but it did leave us a generation of sons and daughters with tumors and malformations of the reproductive organs… When I first recognized those events in the late 1960s, I thought that perhaps that was all past history in medicine. Doctors today must have learned from their mistakes… But, when I look today at diagnostic ultrasound, immunizations, environmental pollution, amniocentesis, hospital deliveries, allergy treatment, and practically everything else in medicine, it is obvious that doctors haven’t changed at all. They are simply making a different, new set of mistakes.”