Returning to Ivan Illich

The writer whose vision of health most closely matches my own

When I read Limits to Medicine for the first time, I walked away thinking that Ivan Illich was one of those writers, similar to Freud, whose main points were obviously wrong, but whose work nonetheless helped me see the world in an entirely new way. I went on to read Tools for Conviviality and Deschooling Society, and neither changed my initial impression.

The opening of Limits to Medicine is so bold it made me snort. Illich claims in the first sentence that “[t]he medical establishment” (as of 1975) “has become a major threat to health.” The book proceeds to argue that the medical system is a net-negative because in addition to not adding much value, it also removes the impetus for individuals and communities to take care of themselves. The average person stops looking after their own health because the doctor—or surgery, or drug—will do it for them.

While parts of Illich’s argument are true, others are clearly false, and this is what leaves the reader undecided about the perspective Illich is offering. For example, people have outsourced the responsibility of their health to the medical system, and that’s not good. At the same time, medicine is a wonder of the modern world. I mean, just look at this chart of the life expectancy in the U.S. from 1950 to 2010:

At the time of Illich’s writing, medicine was providing people with a fountain of youth, extending the average lifespan over a year per decade. By arguing that medicine was not providing much value, Illich undermined his subsequent points, and for a while I marked him down in my head as a compelling writer, but biased thinker.

Recently, however, a few authors have made me reconsider. One is Peter Attia and his book Outlive. Another is Casey Means and her article I’m a Doctor. You Shouldn’t Always Trust Us. Both argue that the increased life expectancy shown on the graph above resulted from changes to how we treat acute (as opposed to chronic) conditions, and that the value we squeezed from those innovations is largely spent. As Means writes:

Life expectancy has increased primarily because of sanitation practices and infectious disease mitigation measures; because of emergency surgery techniques for acute and life-threatening conditions, like an inflamed appendix or trauma; and because of antibiotics to reverse life-threatening infections. In short, almost every “health miracle” we can point to is a cure for an acute issue (i.e., a problem that would kill you imminently if left unresolved).

But what about chronic issues, such as heart disease and cancer, that are currently the main problem for peope in the West? “Perhaps my biggest takeaway,” Attia writes of researching the current state of medicine for his book, “was that modern medicine does not have a handle on when and how to treat the chronic diseases of aging that will likely kill most of us.”¹

In fact, as Means points out, these chronic conditions have only gotten worse. How can that be? Part of the answer is undoubtedly evolutionary mismatch, which is on the bingo card of Living Fossils. People in the West live in environments that are chock-full of cheap sugar and fats, and don’t really need to exercise if they don’t want to. This is a toxic recipe for our cardiovascular health.

However, I believe another part of the explanation is that people have outsourced the responsibility for their health to the medical establishment, whether that means to their primary care physician, a surgery like bariatric, or a drug like Ozempic. So, maybe Illich wasn’t wrong so much as poorly timed. If he were making his argument now, he’d be hitting the nail on the head.

Three more to go…

To Mental Health and Beyond

I have expressed similar views about mental health. By and large, I think our increased focus on mental health is a good thing, but it comes with serious drawbacks, from the gentrification of disability and glorification of suffering, to the overuse of medication and often self-centered focus of therapy.

My main concern, though, is an Illichian one.² I worry that we are beginning to rely too much on “the experts.” People are starting to think that only professionals are qualified to talk to their child about suicidal thoughts or help their friend through a breakup. Or that medication is the only solution for something like ADHD. I believe, as Illich did, that individuals and their communities should retain much of the responsibility for their emotional and spiritual well-being.

Why?

First of all, because it’s more reliable. Your best friend isn’t going to drop you if your insurance changes, nor is your mom going to cancel Sunday dinner if you lose your job and can’t pay. In an ideal world, your mental health supports would be pillars of your life that you can count on. Secondly, how people navigate adversity becomes a part of their identity and life story. It is often during, or as a result of difficulty that people figure out who they are and what they want.³ All the better if this is done among people who are likely to be a part of life going forward.

Not too many mental health professionals encourage a DIY approach to mental health, though, and the reason is obvious: it puts them out of a job. There is far more economic opportunity for the clinical community if it continues to create more diagnoses with no biological underpinning, which necessitates more medication and increasingly specialized therapy, until ideally people come to understand mental health services as a sine qua non of the good life. Hence the idea floating around nowadays that “everyone should go to therapy at least once.”

I am all for therapy continuing to remain a part of the mental health landscape. What I object to is the notion that individuals and communities don’t have enough resources of their own and must as a matter of ethics escalate the issue to an “expert” who does. I want therapy to be a plant in the garden, not a weed that suffocates everything else.

The Principal-Agent Problem

As Means and Attia note, the medical system waits until a patient has a serious problem and then implements an expensive solution. That’s how the system is designed. With mental health, the issue is more that “experts” are claiming parts of personal and social life that used to be personal and social. If successful, this effort creates consumers out of thin air. For example, what used to be an unruly child is now a child with Oppositional Defiant Disorder, requiring a therapist and psychiatrist. Oh, and a school counselor who can make the initial diagnosis.

It's important to keep in mind that professionals in these fields are usually just trying to help the best they can. As Rob noted of academia: don’t hate the player, hate the game.

The underlying problem with both medicine and mental health is a principal-agent one, which describes the misalignment of incentives between a person or group (principal) and the representatives (agents) acting on their behalf. The medical and mental health communities are supposed to have the health of patients foremost in mind, but are distracted by financial incentives in a variety of ways. In a similar vein, the media is supposed to have the education of the public as their first priority, but might be tempted into covering topics based on their entertainment value instead.

Another cool example is from Samuel Thomson, a farmer-turned-physician living in New England at the turn of the 18th century. He writes of inviting a doctor to live on his farm for a few years:

I soon found that by having a doctor so near, there was plenty of business for him; for there was not a month in the year but what I had somebody sick in my family. If a child was attacked with any trifling complaint the doctor was sent for, and they were sure to have a long sickness; so he paid his rent and keeping very easy.⁴

The principal-agent problem is ubiquitous. It is a Theme of life. As Trivers has shown, not even parents and children have completely aligned incentives.⁵ Parents want to spread their attention over multiple children, whereas each child wants all of the attention for themselves. Of course, often neither party is conscious of this, but the behavior of many diverse organisms fits it. The conflict is even present in utero. The fetus wants more nourishment than mom wants to give, so the embryo secretes chemicals that basically dilate mom’s blood vessels, forcing her to give up the goods.

While the principal-agent problem isn’t new, it’s possible that our fast-paced, global, capitalist world has supercharged it. Producers have more potential customers than ever, what with the better part of eight billion people connected to everything, everywhere. The first step for many businesses is to convince people and their communities that the resources they have for Z—beauty, growing food, or friendship—are insufficient. There is no money in convincing people that what they have is good enough.

From the consumer side, the zone has never been flooded with more shit. Not only are there more products and information about those products than ever, but people are also living an increasingly specialized life, which means they know less and less about whatever isn’t their specialty.

Let’s ground all these dynamics in an example. A friend’s daughter, age nine, was diagnosed with anorexia the other day. As you would expect, the news sent my friend into a tailspin, so she reached out and asked if I could do some research for her. I found myself overwhelmed by the sheer amount of information, products and services I encountered. I can only imagine what it’s like for a non-expert. Or actually, I don’t have to imagine. This is exactly what happens to me for everything other than mental-health issues.

The Difference Between Want and Need

Something that occurred to me as I was doing research for my friend was that a powerful ally in consumers’ ability to fight back might be the distinction between want and need. There is a big difference between thinking you must or should go to therapy and that you can go to therapy if you wish. This optional route begins with the belief, however it is secured, that you have what it takes to address the issue yourself or with the help of those in your life. The mandatory route proceeds from thinking you couldn’t possibly go it alone.

People of many times and backgrounds have mulled the distinction between want and need. In Walden, Thoreau undertakes his experiment in simple living to “drive life into a corner” and “reduce it to its lowest terms.” He ends up concluding that the only necessity in life is to “maintain the heat.” If a person eats enough, sleeps enough, and has enough shelter and clothing to maintain a certain body temperature, then they are living. Anything beyond that is, from this spartan interpretation, extra. “[T]hink of dashing the hopes of a morning with a cup of warm coffee,” he writes, “or of an evening with a dish of tea!”

In The Elk of North America, Olaus Murie dedicates some time to whether providing salt to these animals is necessary, or just something they have come to enjoy:

It is true, of course, that wild animals that have become accustomed to eating salt continue to seek it eagerly and eat it with obvious relish. It may be well to tell here of a tame elk which had perfect freedom to range where it pleased, that was inordinately fond of tobacco and would eat cigarettes as long as they were given to him. Does it therefore follow that tobacco should have been provided for this animal as necessary ration?⁶

And, of course, who can forget the Stones lyric:

You can't always get what you want
But if you try sometimes, well, you just might find
You get what you need

Unfortunately, as much as we may want to distinguish between want and need, we can’t. We can prioritize, sure, which is why we have constructs such as Maslow’s hierarchy of needs. And on a more mundane level, we all know that if we were starving and had $5 left, we’d buy a sandwich and not a necklace. But we never seem to cross the line at which we stop expending because we have “everything we need,” or even the line at which we stop because we have “everything we want.”

Our inability to draw a line in the sand can be attributed to two causes, one proximate and one ultimate. The ultimate cause is something dedicated readers can probably guess. It is because, as Rob notes in Thief of Joy, success is relative; comparison-based.⁷ Evolution is an optimizer, not a satisficer.

Thoreau may have distilled the basic physical requirements of living, but in evolutionary terms, that’s table stakes. Ok, you’re alive…big whoop. Now go do something about it. And then do something more. And better. And more. Without the evolutionary perspective, we could never understand why people who already have more money than they could ever spend still want more money.

For the proximate cause, let’s turn to economist J.K. Galbraith. One of the main points in his most famous book, The Affluent Society, published in 1958, is that “we have wants at the margin only so far as they are synthesized.”⁸ That is, once the economy satisfies essential requirements such as food and shelter, it continues to create further wants. It would be one thing if goods and services were simply responding to wants “original in [us],” but what if these wants were being manufactured instead, for the express purpose of being subsequently satisfied? “Production,” Galbraith writes, “only fills a void that it has itself created.”⁹¹⁰

As it turns out, it’s pretty easy to make people want things. Many aspects of life could be better, and as soon as we resolve one thing, another rises to our attention. Once we track down the painter to finish the nursery, we notice an itchy spot on our back that we can’t quite reach. Once we smooth the wrinkles on our clothes with a new fabric softener, we notice wrinkles around our eyes. Once we fix the boredom of Zone 2 exercise with a new podcast, we realize that we don’t know the perfect time to have sex for conception.

The economy’s goal is to move wants from unrecognized to necessary. “You have to get a Vitamix,” someone said to me the other day. Me, who has never blended anything in his life, except maybe whiskey and Coke. “I couldn’t live without a Peloton,” I said to them in reply.

Much as we may want to leverage the distinction between want and need, then, the fact of the matter is that evolution didn’t design us to rest on our laurels, and the market economy wouldn’t let us anyway. Finally, as if the deck weren’t stacked enough, the line between want and need is always moving because the world around us changes so fast. What was a tolerable problem fifty years ago often no longer is, and in the meantime, new problems have arisen that need fixing. That’s why we have standing desks and blue-light glasses and boxes to put our god-forsaken smartphones in.

Why does any of this matter? It might not be a big deal as we contemplate vacuum cleaners and ask some tough questions about how much we really need both hardwood and carpet settings. But we should keep in mind that we are increasingly becoming consumers in the mental health space, too, a space that is encroaching upon things that used to be personal, communal, and cultural, such as: What is happiness? Purpose? What makes a good friend? Parent? What am I looking for in a partner? Who will I be? Can I handle this?

There are good reasons for not escalating these issues to either a professional or some product or service. People and communities are at their best when they have great power and great responsibility. As Illich puts it:

Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation of the sick on science and its functionaries instead of encouraging them to seek a poetic interpretation of their predicament or find an admirable example in some person—long dead or next door—who learned to suffer. Medical procedures multiply disease by moral degradation when they isolate the sick in a professional environment rather than providing society with the motives and disciplines that increase social tolerance for the troubled.¹¹

Conclusion

In this article I widened the lens to show readers just how far-reaching the principal-agent problem is. There is no shortage of examples of agents looking out for themselves before looking out for those they are supposed to help. Often, there is nothing nefarious about this, and the outcome can be a win for both. But we have to be careful about where we draw the line between personal and professional responsibility, and I think we’ve gone too far in the direction of professionals for mental health.

Really, what Illich was arguing against, in its simplest form, was the outsourcing of personal and communal responsibility, agency, and skill. He saw the meaning of life in personal and social involvement and competency. In the ability of people and their communities to be intimately involved in their lives, whether by maintaining their own health, growing their own food, or nourishing their own curiosity. He was decidedly not a fan of surrendering these vital elements to removed institutions, experts, bureaucracies, or products. He thought of local solutions as both more reliable and meaningful. Even fun. Or convivial, I think he would say.

As we think about how much power we want to grant the mental health industry, we have to keep in mind that it’s going to look out for itself. Incentives will be more thoroughly aligned to the extent that we can return the power to individuals and their communities to develop their own systems of and skills in healing. Therapy should be an option, not a requirement. People and their networks often have the resources to manage on their own.

As my supervisor says, there’s no reason therapists should have a monopoly on their clients’ well-being. “If therapy can help them a little, that’s great,” he’ll say to us in supervision. “But if they come by happiness another way, that’s great, too. Wanting to be the central figure is all ego, but we have to remember: this is about them.”  

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References

Attia, P. (2023). Outlive: The science and art of longevity. Harmony.

Galbraith, J. K. (1998). The affluent society. Houghton Mifflin Harcourt.

Illich, I. (2010). Limits to Medicine. Marion Boyars.

Murie, O. J. (2017). The elk of North America. Stackpole Books.

1. Attia, 2023, p. 16

2. Some people’s last names translate well into an adjective; Ivan’s isn’t one of them. But at least it’s not Rob’s. Kurzbanian sounds like someone from a place I don’t want to visit.

3. And, just as importantly, who they can trust.

4. Thomson, S. (1832). A Narrative of the Life and Medical Discoveries of Samuel Thomson: Containing an Account of His System of Practice, and the Manner of Curing Disease with Vegetable Medicine Upon a Plan Entirely New: to which is Prefixed an Introduction to His New Guide to Health, Or Botanic Family Physician; Containing the Principles Upon which the System is Founded, with Remarks on Fevers, Steaming, Poison, Ect. Pike, Platt & Company, p. 31.

5. Trivers, R. L. (1974). Parent-offspring conflict. American zoologist, 14(1), 249-264.

6. Murie, 2017, p. 310.

7. Another bingo square!

8. Galbraith, 1998, p. 113.

9. Galbraith, 1998, p. 125.

10. To hammer home the point: “A man who is hungry need never be told of his need for food. If he is inspired by his appetite, he is immune to the influence of Messrs. Batten, Barton, Durstine & Osborn [advertising agency]. The latter are effective only with those who are so far removed from physical want that they do not already know what they want. In this state alone, men are open to persuasion” (129).

11. Illich, 2010, p. 114-115, emphasis his.