In the Mirror of the Past

by Ivan Illich

  For Frank, words are units of information that he strings together into a message. Their objective consistency and denotational precision, not their subjective connotates, count. He operates upon abstract notions and he programs the use of data. His perception is locked into his head. He controls redundancies and noise. Feelings and meanings would arouse anxiety, terror and surges of affection, and he keeps them low, he keeps his cool. The text composer is the model which imprints his mode of perception. He conceives of his senses as ‘perceptors’ and of his ego as a proprioceptor.

  Susan (now taken as an ideal type) is a perceptually embodied self. Her utterances surge from the mass of flesh and blood, from the forest of feelings and meanings which engulf everything she has said. She is a teacher, because she has disciplined meanings and feelings without downgrading them. With great pains she has trained her inner Descartes and her inner Pascal to watch each other: to balance mind and body, spirit and flesh, logic and feeling.

  Frank is, at this moment for me, the emblem of the opposite perceptual state. He has detached himself from the morass of feelings. He has learned how to take off, to leave the dense atmosphere behind and operate in free space, without gravity. He has hooked on to the computer and he has been caught in the dragnet of operational thinking. Turing’s formula has induced for him the cybernetic dream. He can coast above the Sahel, view the parched Earth, the dying camel, and register growing despair and hostility. His mind is a camera which does not distort those signals it does not let in. He wants Susan to grade the takes that he has composed into a ‘text.’

  Susan and Frank are both persons. They are responsible for the mental state in which they are. Susan can steer her way between romantic sentimentality and critical lucidity, between sloppy and sensitive choice of connotates, choose the traditional lineage of authors into which she wants her metaphors to fit. When she speaks she is using words that have been written, and thinking for her is a way of silently spelling things out. This constant reference to the alphabet makes her different from the preliterate, but also in a very different way, from Frank. Frank, too, is responsible for what he does. He can use the cybernetic metaphor for what he does when he speaks as an analytic tool which misses more than it models. He can use it as a joke. Like Fromm when he speaks of psychic plumbing, Frank can refer to shit-in, shit-out. But he can also become sloppy and let this metaphor swallow all others, and finally move into the state Berman calls the cybernetic dream.

  As the two mind-sets confront each other, both can harden into ideologies. I have known several Susans for whom literacy has become an anti-cybernetic ideology. They react to every reference to computers as fundamentalists react to communism. For these anti-computer fundamentalists a trip through computerland, and some fun with controls, is a necessary ingredient for sanity in this age. Those of you who study computer literacy sometimes forget its importance as a means of exorcism against the paralyzing spell the computer can cast. But I know many Franks who, under this spell, have turned into zombies, a danger Maurice Merleau-Ponty clearly foresaw almost thirty years ago. He then said — and I quote — that ‘cyberneticism has become an ideology. In this ideology human creations are derived from natural information processes, which in turn have been conceived on the model of man-as-a-computer.’ In this mind-state, science dreams up and ‘constructs man and history on the basis of a few abstract indices’ and for those who engage in this dreaming ‘man in reality becomes that manipulandum which he takes himself to be.’

  When I earlier described Susan and Frank standing opposite each other, separated by an epistemological chasm, I avoided saying that they ‘face’ each other. To speak with Merleau-Ponty, Susan’s body is the ‘soil of the sensible which emerges with every word and gesture,’ and Frank’s body is the defaced artifice of the ‘information machine.’ The two cannot face each other, and to ‘interface’, Frank would have to pick another of his own ilk.

  When I think of the glazing which the screen brings out in the eyes of its user, my entrails rebel when somebody says that screen and eye are ‘facing’ each other. A verb for what happens there had not been coined when Merleau-Ponty wrote in 1959. The verb was created ten years later by McLuhan, and within a year ‘to interface’ was current in psychology, engineering, photography and linguistics. I hope that Susan is a friend who is seeking Frank’s face. Perhaps Susan sees her vocation in seeking Frank’s face.

  PART FOUR

  Twelve Years after Medical Nemesis:

  A Plea for Body History

  * * *

  Consultation on ‘Health and Healing in America’ Pennsylvania State University, January 1985

  Twelve years ago I wrote Medical Nemesis. The book began with the statement: ‘The medical establishment has become a major threat to health.’ Hearing this today I would respond, ‘so what’? Today’s major pathogen is, I suspect, the pursuit of a healthy body. And, importantly, this endeavor has a history.

  As a public cause, the pursuit first appears with the emergence of the nation state. People came to constitute a resource, a ‘population.’ Health became a qualitative norm for armies and then, during the nineteenth century, for workers; and later, for mothers. In Prussia, as in France, the medical police were charged with its enforcement. But the pursuit of health was also understood as a personal right, as the physical realization of the Jeffersonian right to the pursuit of happiness. The valetudinarian’s dream of a ripe old age on the job, together with the economy’s demand for productive workers and fertile reproducers, fused in the idea of health. But what began as a duty and entitlement has been transmogrified into a pressing need. In 1985, I would place the historical phenomenology of this novel need into the center of research. For many of our contemporaries, the pursuit of health has become consubstantial with the experience of their bodies.

  Since I wrote Medical Nemesis, the symbolic character of health care has changed. Americans now pay more money to health professionals than they spend on either food or housing. An instructive paradox appears: medicines, psychologies, environments and social arrangements increasingly influence how people think and feel, while the concepts and theories to which the professions appeal are publicly questioned. As a result, expenditures on various and sundry programs of holistic well-being have increased faster than medical costs. Health appears to lie between the lines of every second advertisement, to be the inspiration of every other media image. Allocations for safety, ecology, law enforcement, education and civil defense are approved if they can be related to integral health care. Therefore the relative importance of the medical establishment within the health sector has been reduced. A curious mixture of opinionated and detailed self-care practices joined to a naive enthusiasm for sophisticated technology make the efforts and personal attention of physicians ever more frustrating. I suspect that the actual contribution of medicine to the pathogenic pursuit of health is a minor factor today.

  In Medical Nemesis, I set out to examine the spectrum of effects generated by medical agents. I called these effects ‘iatrogenic,’ doing so with a rhetorical purpose. I wanted to call public attention to the research on medical effectiveness carried out during the late fifties and sixties. My conclusion stated the obvious: only a small percentage of all healing, relief from pain, rehabilitation, consolation and prevention was attributable to medicine. Most of these outcomes occur without or despite medical attention. Further, the iatrogenesis of disease is comparable in importance to the iatrogenesis of well-being. What sounded shocking then has now become commonplace. In his forecast for 1986, the US Secretary for Health estimates that 80 to 100,000 patients will be seriously injured by hospitalization. But this kind of accidental damage to individuals was marginal to the central argument of my book. I wrote in order to highlight the institutional, social, and cultural effects of the medical system. At the center of my analysis stood the iatrogenic reshaping of pain, disease, disability and dying, as these phenomena are experienced by their subject. The cultural constraints o
f these experiences and their symbolic impact, insofar as they are mediated by medicine, were my interest. I am not dissatisfied with my text, as far as it goes, but I am distressed that I was blind to a much more profound symbolic iatrogenic effect: the iatrogenesis of the body itself. I overlooked the degree to which, at mid-century, the experience of ‘our bodies and our selves’ had become the result of medical concepts and cares.

  I did not recognize that, in addition to the perception of illness, disability, pain and death, the body-percept itself had become iatrogenic. Therefore, my analysis was deficient in two respects: I did not clarify the historical ‘gestalt’ of that period’s body-percept or the role of medicine in shaping it. And since I was unaware of the iatrogenic nature of the experienced body, I did not explore its metamorphosis: the emergence of a body-percept congruent with a post-professional high-tech lifestyle. To gain perspective on such a contemporary metamorphosis, body history became for me an important condition for an examined life in the eighties.

  I originally came to body history through teaching about the Middle Ages. In my courses on the twelfth century, I focus on the emergence of certain ideas, on themes and concepts for which antiquity has no true equivalents, but which in our time are experienced as certainties. One of these we call our ‘selves.’ ‘Some thirty inches from my nose / the frontier of my person goes,’ wrote W.H. Auden in one of his poems. If you are uncertain about this distinction between yourself and others, you cannot fit into Western society. There is general agreement that this sense of self emerges with the Crusades, cathedrals, European peasantry, and towns. Further, its successive forms and its contrast with different cultures have been well studied.

  Little attention has been directed to the fact that the Western self is experienced as flesh and blood, that the birth of selfhood endowed Europe with a body of experience unlike any other. In collaboration with a colleague studying the early eighteenth-century body, I developed concepts necessary for a historical phenomenology of the body. And I soon met others struggling with the same questions in various periods and settings. As body history takes shape, we are able to understand how each historical moment is incarnated in an epoch-specific body. We now begin to decipher the body of subjective experience as a unique enfleshment of an age’s ethos. Through these studies, I have learned to see the Western body as a progressive embodiment of self.

  Searching for a common element which might help me interpret disparate changes in the transition from a Romanesque to a Gothic world view, I hit upon the notion of body history. I needed to explain how the odor of sanctity could disappear between 1110 and 1180, how relics came to heal on sight, the circumstances under which the bodies of the poor souls in Purgatory assumed their shapes. Why did the zoomorphs which decorate the inside of Romanesque churches become gargoyles poised for take-off on the outside of Gothic cathedrals? How did the Christ figure, with outstretched arms and clothed in royal raiment, become the naked, martyred body hanging on a cross by the year 1200? How to explain St Bernard training abbots for a thousand reformed Cistercian monasteries and teaching these men to breastfeed their young monks with the pure milk of Christ? And, most important, because of immense social consequences, I began to understand the context within which the ideas of modern sex and marriage were shaped. Men and women were endowed with ‘human’ bodies which each self could give to the other, thereby creating kinship ties between their respective families, not by the will of elders, but by a legal contract between individuals who exchange rights of the body.

  I came to see that there was a distinct awareness of the body as the primary locus of experience. This body, specific to one period but subject to profound transformations sometimes occurring within relatively short spans of time, was parallel to, but clearly distant from, the body that was painted, sculpted, and described. This insight and understanding revealed to me the kind of critique which Medical Nemesis needed. At the core of my argument I had placed the art of living, the culturally shaped skill and will to live one’s age, bearing or enduring and enjoying it. As a philosopher, I was interested in fostering and protecting this art and its traditions in a time of intensive medicalization of daily life. I tried to show that the art of living has both a sunny and a shadowy side; one can speak of an art of enjoyment and an art of suffering. On this point, I was criticized by some who questioned my motives in redefining ‘culture’ in a subjective way. My critics claimed that, by stressing the benefits of a culture that is the model for and the result of an ‘art of suffering’, I spoke as a romantic masochist, or as a preacher anxious to restrain any expectations of progress. Others applauded my attempt to root the concept of culture in the experienced meaning of personal suffering.

  Body history, however, led me to see what was genuinely deficient in my analysis. Both enjoyment and suffering are abstract concepts. They name opposite forms in which sensations are culturally embodied. Enjoyment refers to the cultured incarnation of pleasure, and suffering to the topology of frustration, depression, anguish or pain. Each age has its style of experiencing the human condition that traditionally has been called ‘the flesh.’

  Until recently, I had looked at the body as a natural fact which stands outside the historian’s domain. I had not understood the difference, which can be great, between the experienced body and other less ephemeral objects which the historian must examine for their use and meaning. My wonder at not finding a body like mine in the twelfth century led me to recognize the iatrogenic ‘body’ of the sixties as the result of a social construction which belonged to only one generation.

  I realize that the medical system cannot engender a body, even if it cares for one from conception to brain death. In every epoch, bodies exist only in context. They form the felt equivalent of an age, in so far as that age can be experienced by a specific group. In most periods, women seem to have different kinds of bodies from men, serfs different from those of lords. It is the feel of the patient which tells the physician what to prescribe. The first to repair the new windmills which appeared in the thirteenth century, itinerant mechanics, were shunned by city and country folk alike because of their uncanny feel.

  In the sociogenesis of our bodies, transportation plays as large a part as medicine does. Bodies which require daily shipment were unthinkable a few generations ago. We say that we ‘go somewhere’ when we drive or fly. Engineering manuals speak of ‘self-transportation’ when we use our feet rather than the elevator. And we feel entitled to high-tech crutches, deprived if we must fall back on our feet. I can understand the body of Americans during the period of the Vietnam war as belonging to homo transportandus, and caricature this body as the cancer-frightened consumer of valium. But after some study I see that the most apt terms must directly refer to a transition now taking place: the dissolution of the iatrogenic body into one fitted by and for high-tech. Choosing the adjective ‘iatrogenic,’ I call attention to the very special relationship between the medical establishment and body perception, a relationship which now dissolves before my eyes. I see something occurring.

  Around the middle of this century, the medical establishment reached an unprecedented influence over the social construction of bodies. Designers deferred to medical norms in creating new furniture or automobiles; schools and the media inundated the imagination with medical and/or psychiatric fantasies; and the structures of welfare and insurance systems trained everyone for patienthood. We experienced a special moment of history when one agency, namely medicine, reached toward a monopoly over the social construction of bodily reality.

  Usually the generation of the felt body cannot be assigned to just one agent. When the plague reached Florence in 1622–1623, no health care system was mobilized. In a remarkable study, Guilia Calvi describes how the entire city rose to the challenge of the scourge. Barbers and surgeons, together with candlemakers and smelling-salt vendors, magistrates and grave diggers, chaplains of special sanctuaries for desperate cases and incense merchants, each had their particular response
to the epidemic. Each ‘guild’ was mobilized to become an ‘antibody’ of the plague. The flesh of each Florentine, male or female, anguished or diseased, was caught, interpreted and reflected by different mirrors. No single professional body could by itself encompass the plagued flesh in a single mirror. No one agency was endorsed with the power to establish the felt body as such. The mid-twentieth century bid for such a monopoly on the part of medicine has been unprecedented and, as it turns out, shortlived.

  I have come to believe that the medical establishment has lost this claim during the last ten years. Professional power over the definition of reality has reached its apogee and is now in decline. At this moment, a confusing mixture of high-tech and herbal wisdom, bio-engineering and autonomous exercise operate to create felt reality, including that of the body. Twenty years ago it was common to refer to ‘the body I have’ as ‘my body.’ We know that this reference to ownership in ordinary speech is post-Cartesian. It first appears in all European languages with the spread of possessive individualism, a phenomenon well described by C.B. McPherson. But now I frequently meet young people who smile when somebody does not ‘identify’ with his or her body. They speak of the body they ‘are,’ but then paradoxically, refer to it as ‘my system.’

  During the sixties the medical profession was prominent in determining what the body is and how it ought to feel. During the seventies it has begun to share with other agents the power to objectify people. From an enterprise that objectifies people as bodies or psyches, a new model has sprung up that engenders people who objectify themselves: those who conceive of themselves as ‘producers’ of their bodies. It is so far only a part of a new epistemological matrix which is in the process of formation. It may be one that brings forth people who experience themselves as contributors to a complex computer program, who see themselves as part of its text. Nothing seems to me more important now than the clear distinction between the current trend toward ‘body building’ and the traditional art of embodying culture.