By Silja Samerski
“The medical establishment has become a major threat to health” was the first line of Ivan Illich’s widely translated book of 1976 titled Limits to Medicine: Medical Nemesis— the expropriation of health.1) For the 1995 republication of this book, Illich added a preface. The old title made explicit that placing limits to medicine is the only way to regain health. The new preface argued that the pursuit of health itself had become a major threat to embodied self-perception. Only those familiar with this book can see that all the salient features of the covid years — above all, disembodied self-management —are malign consequences of too much medicine.
In Nemesis, Illich persuasively showed that the attempt to produce health with more and more technique would be counterproductive. He argued that “beyond a critical level of intensity, institutional health care—no matter if it takes the form of cure, prevention, or environmental engineering—is equivalent to systematic health denial.”2) The book and this argument was discussed around the world, in many instances sparking vehement controversy.3) The times have changed though. The damages to health caused by an expanding, hi-tech, and profit-oriented health system are now routinely discussed on TV talk shows. Though some of his arguments have become received wisdom, Nemesis is by no measure an outdated book. On the contrary, a careful reading of the book and its preface reveals it far exceeds the commonplace medical criticism. Illich not only indicts the medical establishment for prescribing harm, but also for promoting the destructive “pursuit of health.” As he wrote in the epilogue of the German reprint of Nemesis, “…I wanted to make the medically mobilized pursuit of health a paradigm for a mega-technology which makes it possible to abandon the conditio humana.”4)
Illich’s critique of the pursuit of health is crucial to understanding the management of the COVID-19 pandemic. The book Nemesis makes its attentive readers aware that all the seemingly distinctive features of managing the Covid-19 illness — the naming of a disease as a crisis, the war against illness and death by all available means, and the curtailment of basic rights and liberties, the medicalization of everyday life through tests and medical classifications, and the supremacy of experts–— had already been predicted by him as malign and necessary outgrowths of an unlimited medical enterprise.
Nemesis is a fundamental critique of unlimited technological progress. The illusion that technology can save people from the dark sides of life such as infirmity, death, and hardship leads directly to new forms of dependence and submission: “When overconfidence in industrial production and servicing determines the social order in such a manner that industry gains a virtual monopoly on the employment of new applications, then the enslavement of humans by machines will not be abolished but pressed in new, globally homogeneous forms. The tool changes from a servant to a despot.”5)
The biggest “despot” during the COVID-19 pandemic was, without doubt, the vaccination. Faith in a technological solution was so great that vaccination was seen as the only way out of the pandemic – even before it was possible to know anything about the effect of the vaccines. The approval studies of manufacturers did not establish whether the vaccines prevented transmission or even infection. Nevertheless, the politicians still promised “we will vaccinate Germany back to freedom”6) and declared to give all people a vaccination as the most important goal. Even though in Israel, regarded as the “vaccination world champion”, so-called “breakthrough infections” increased in Autumn 2021, and it was already clear that vaccinations would not lead to the desired herd immunity7), politicians and health officials in Germany stubbornly proclaimed a “pandemic of the unvaccinated.”8) Unvaccinated people became scapegoats for the fact that the supposed panacea, the vaccination, did not live up to people’s expectations. Though numerous studies prove that the immunity of recovered people is at least as good as the immunity of vaccinated people,9) even today, German health politicians devalue recovery from illness as a way to immunity while they exalt the vaccine.
Other covid-19 management tools are no less despotic. The state of emergency is still not over in Germany. Almost half a century ago, Illich noted that “the ritualization of crisis, a general trait of a morbid society, […] provides [the medical functionary] with a license that usually only the military can claim. Under the stress of crisis, the professional who is believed to be in command can easily presume immunity from the ordinary rules of justice and decency”.10) This is precisely what happened in the “war against corona”11) which empowered those who believed themselves to be fighting a battle — mainly virologists, medical authorities, and health politicians — to rule over the daily lives of citizens. Basic rights were suspended and the government - supported by a board of scientists - determined by decree who was allowed to leave the house when and for what, who could meet who, and what immune status somebody needed to be able to go Christmas shopping or assist his or her dying grandmother. There was ineffectual if noisy resistance. Only since spring 2022, has a very cautious public debate gained momentum, in which questions have been posed about the relative benefits of pandemic management measures. And it turns out that there is almost no evidence for the idea that lockdowns, compulsory masks, and vaccination certificates would have stopped the virus from spreading.12) On the other hand, such measures have harmed society severely, including the health of its members. As Illich pointed out many years ago, “the orientation of any institution towards ‘crisis’ justifies enormous ordinary ineffectiveness.”13) What Illich concluded about the medical “terminal ceremonies”14) back then, can also be said about the recently concluded COVID-19 measures: they testify that “the religious use of medical technique has come to prevail over its technical purpose.”15)
Numerous institutions, hospitals, children and youth facilities, and state schools continue to demand G-verifications, often without any legal basis.16) Institution-related compulsory vaccination which is unable to serve the purpose it was intended for – the protection of vulnerable people against infection – will not be revoked. The obligation to wear a mask in trains was tightened, the legal basis for compulsory masks indoors was created (an infringement of fundamental rights), and new vaccination campaigns were launched. According to health secretary Lauterbach, the idea of such ineffectual current infection protection laws is to “avoid having many deaths, severe cases, and long-COVID”17) and “avoiding the overload of infrastructure and hospitals.”18) These goals are so vague that the measures cannot be evaluated. It is hard not to think that pandemic management reversed the relation between aims and means.
Medical Nemesis is a book about the growing unfreedom in a society which replaces independent actions and individual abilities with industrial goods and professional services. People are not only discouraged from being born and dying at home, but also actively prevented from assisting one another, recovering from illness and keeping healthy without medical services. Illich foresaw that “society becomes a hospital”19) once the medical establishment establishes a monopoly on health. He did not mean that everybody would then disappear behind the walls of hospitals, but rather that the boundaries of medical institutions would dissolve and spread into society. From then, people would have to adapt their lives to the plans and diagnoses of health experts.
The COVID-19 measures have made this medicalization of everyday life worse and enforced continuous control. Just as inside a hospital, people in society are divided into different medical categories and allocated to different “treatment courses.” For example, in many German schools in autumn 2021, vaccinated pupils could go directly into the classroom while unvaccinated pupils had to be tested first – often in a separate room. Sometimes school trips and events took place with the 2G rule so that pupils without a corresponding G-certificate were excluded. In a society turned clinic, educational institutions are enrolled in the cause of social control. Similarly, this classification and certification took on unprecedented dimensions in the general population. Numerous new COVID-19 categorizations were created whereby medical bureaucrats subdivided people into those who – although completely healthy – could be locked up home for two weeks, who could only go shopping for groceries, who were not allowed to go back to their home country, who are considered a health risk due to their unconventional opinions and who, despite being vaccinated, are considered “unvaccinated after a certain date and are therefore not allowed to go to work.” If citizens and pupils were institutionally discriminated by biological features instead of such “medical” categories there would have been an outcry. Since such discriminatory measures occur in the name of “health”, barely anyone takes offense.
When Illich wrote Nemesis, doctors were still regarded as “half-gods in white.” They have mostly lost this dominant position in the health system nowadays. According to Illich, 25 years after Nemesis, biocratic health management is taken over by a “bio-team” in which the doctor only has a symbolic function: “his white coat serves the myth, that health could be industrially improved here.”20) What he did not foresee though, was the digitalization of the health system in which the “bio-team” is replaced by apps and artificial intelligence. While medical assessment and attestation were previously needed for a medical category, the categorization and discrimination are automatic nowadays: by means of digital tools, the classification of people, who are allowed or not allowed to do something, can be made with a few clicks – doctors are not needed for that anymore. COVID-19 vaccination cards for example have created a digital infrastructure which can be used as passports in one’s own country. Depending on the registered vaccination or test, people receive different rights and obligations at the touch of a button. A software update is sufficient in Germany to distinguish between people who must wear a mask and those who do not have to wear one. For the recently vaccinated, the G certificate is green, for the others blue, announced the health secretary in autumn 2022.21)
The medically justified classification and monitoring of people become especially pervasive and comprehensive, “once a society organizes for a preventive disease-hunt.”22) When Illich wrote this line, he did not have the “war against COVID-19” in mind; he spoke instead of hunting the illness itself, meaning medicine that aims at preventing illnesses before they occur. In the COVID-19 pandemic, the “preventive disease-hunt” became a daily routine and made permanent monitoring and mistrust commonplace. Citizens were prompted to control infection risks in everyday life. All people, including the completely healthy, were seen as a risk, as a potential health hazard. What “sleeper cells” are to the fight against terrorism, the asymptomatically ill are to the war against the coronavirus: nondescript and therefore especially dangerous risk persons. Mistrust was generalized; citizens were not seen as bearers of rights, but primarily as carriers of infection risks. For example, only when they could prove that they had recently been tested, recovered, or vaccinated, were they allowed to go into a hotel or on board a train. Within a short period of time, a digital infrastructure was created which compelled people to prove again and again that they were not “superspreaders.” The constitutional presumption of innocence was reversed – a typical and far-reaching perversion of law in the prevention regime. In a constitutional state, every human is considered innocent until the opposite is proved. A society which is committed to prevention, guilt is presumed and its members must furnish proof of their normality or innocence.23)
COVID-19 policies have not only declared war on a virus but also on another enemy: death. Politics, media, and medicine insinuate that every person who died with or from COVID-19, had died an unnecessary and avoidable death – even at an old age of 80 or 90. Until the 20th century, a doctor withdrew when he saw that a patient was on his deathbed. The doctor let a priest take over – he could not do anything for his patient anymore. Nowadays medicine tries to fight death. As Illich observed, “…medicine is now concerned less with the empirical art of healing the curable and much more with the rational approach to the salvation of mankind from attack by illness, from the shackles of impairment, and even from the necessity of death.”24) This aim of maximizing life years by means of technology causes people to be less able to adopt the conditio humana. People die every day because of inhuman living conditions which could be changed politically, be it at the EU borders, on the autobahn, or because of social inequality. During the COVID-19 pandemic, “Life” in a biological sense became sacrosanct and sheer survival the main objective. Dying was thus deprived of any dignity: people on their deathbeds with the diagnosis “COVID-19” often could not say farewell to their beloved ones and died isolated and deprived of all social and cultural support in hi-tech surroundings. Similar indignities attended manyin retirement and nursing homes who locked in their rooms and without visits from their relatives, first died a social death before their biological termination.
Besides the “hostility towards death”, Illich also points out another related dimension of fictionalization which destroys the traditional art of living and suffering: the “disembodiment”, the obliteration of the “sensually accessible body of the past”. “Every encounter with the health system”, as Illich wrote, leads to their “epistemic transformation.”25) Modern medicine, according to Illich, imputes to people an iatrogenic body, which they cannot feel and experience anymore, but can only manage with diagnoses and test results. Numerous technological and medical rituals prevent us from using our “common sense”, and prompt us instead to see ourselves in the categories of hi-tech medicine. We do not perceive ourselves as physical and mortal beings but, for example, as flexible immune systems that need resilience support and immune boosters to adapt to their crisis-ridden environment. This “turmoil in the experience of the world and death” as Illich puts it, leads to “world estranged disembodiment and programmed helplessness.”26)
Such fictionalizing disembodiment took on absurd dimensions during the COVID-19 pandemic. For months media, pamphlets, and posters visualized the invisible enemy, with whom society was at war, as an oversized spiky ball; old and young were exposed to incomprehensible technical lingo like “mRNA”, “antibody level”, “R value”, “incidence”, “antigens”, “T cell immunity”, “vulnerable groups” etc., to justify their confinement. The instructed citizens neither learned something about themselves nor about science. Instead, they learnt not to trust their senses but to see themselves as controllable biological systems whose immunity needs to be checked and maintained by medical staff. During the COVID-19 pandemic, children already learned to see themselves through the eyes of doctors, epidemiologists, and virologists. Even if they felt completely healthy, they were inculcated to believe that an invisible danger could be inside them. Only the red test strip and finally the PCR results from the laboratory reveal the hidden truth about their own bodies. An entire generation has been drilled to glorify technology and to feel in obedience to test results; they have been prepared to become the helpless and dependent medicine consumers of tomorrow.
Whoever asks cui bono when analyzing the COVID-19 measures rapidly spots capitalist profiteers like Pfizer and the Gates Foundation as influential instigators or even manipulators. That the pharmaceutical industry bribes licensing authorities and politicians and is not afraid of using Mafia-like methods has been frequently reported.27) The murky approval process of vaccines, the massive marketing, and insufficient official control of COVID vaccines is unquestionably a scandal.28) Studies also show how the philanthropic capitalism of the Gates Foundation determines global health and development policies and thus stabilizes existing power and exploitation relationships.29) But it would be misleading to make Pfizer and Bill Gates liable for compulsory vaccinations and COVID-19 panic, “just as irrelevant as blaming the Mafia for the use of illicit drugs.”30) The technocratic measures of the last three years are a manifestation of the irrationality of a society which is ruled by the faith in technological feasibility. The result is a “compulsive survival in a scheduled, technological hell.”31)
In the 1970s, Illich foresaw the unbearable overplanning and engineering of everyday life, which increased drastically during the COVID-19 pandemic. “Never before in history have the lives of people outside of prisons been regulated as rigorously as during the COVID-19 pandemic”32) The abolition of liberties and the increased programming of environment and behavior are not unprecedented measures of an alleged “COVID dictatorship”, but the unavoidable results of the endeavor to technically control health and manage life. Even without a state of emergency, a “scheduled, technological hell” is initiated by ongoing digitalization – a massive increase of technocratic management and dictatorship —in the name of health.33) The COVID-19 pandemic has only made socially acceptable what was already commonplace in the health sector.
A comprehensive and fair-minded reappraisal of the management of the SARS-Cov2 virus would provide the opportunity to question the self-evidence of the “war against COVID-19” and promises of a digitalized preventive medicine. Ivan Illich’s Nemesis is a rich source of profound answers to questions of its own time and ours. Illich criticizes not only those who appear to produce and sell health, but also those who believe to be able to consume, control, and optimize it. If we are to have hope in not losing our abilities to care for each other, to be healthy, to give birth, to recover, to heal, to assist and to die in the teeth of a “mega-technology” designed to destroy those abilities, there is no way around carefully reading Medical Nemesis.