Health as a Virtue

by Ivan Illich

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This is a short excerpt from Medical Nemesis...pp. 273-275...(NY: Random House, 1976)

Health designates a process of adaptation. It is not the result of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to ageing, to healing when damaged, to suffering, and to the peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it.

Health designates a process by which each person is responsible, but only in part responsible to others. To be responsible may mean two things. A man is responsible for what he has done, and responsible to another person or group. Only when he feels subjectively responsible or answerable to another person will the consequences of his failure be not criticism, censure, or punishment but regret, remorse, and true repentance. The consequent states of grief and distress are marks of recovery and healing, and are phenomenologically something entirely different from guilt feelings. Health is a task, and as such is not comparable to the physiological balance of beasts. Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions, his diet, and his sexual activity. Knowledge encompassing desirable activities, competent performance, the commitment to enhance health in others - these are all learned from the example of peers or elders. These personal activities are shaped and conditioned by the culture in which the individual grows up: patterns of work and leisure, of celebration and sleep, of production and preparation of food and drink, of family relations and politics. Long-tested health patterns that fit a geographic area and a certain technical situation depend to a large extent on long-lasting political autonomy. They depend on the spread of responsibility for health habits and for the socio-biological environment. That is, they depend on the dynamic stability of a culture.

The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population. This ability to cope can be enhanced but never replaced by medical intervention or by the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self, to others, and to the environment, the less management of adaptation will be needed or tolerated.

A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of ageing, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die.

Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline. The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.

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