Political Transmission of Iatrogenic Disease#
Until recently medicine attempted to enhance what occurs in nature. It fostered the tendency of wounds to heal, of blood to clot, and of bacteria to be overcome by natural immunity1 Now medicine tries to engineer the dreams of reason2 Oral contraceptives, for instance, are prescribed "to prevent a normal occurrence in healthy persons."3 Therapies induce the organism to interact with molecules or with machines in ways for which there is no precedent in evolution. Grafts involve the outright obliteration of genetically programmed immunological defenses3 The relationship between the interest of the patient and the success of each specialist who manipulates one of his "conditions" can thus no longer be assumed; it must now be proved, and the net contribution of medicine to society's burden of disease must be assessed from without the profession4 But any charge against medicine for the clinical damage it causes constitutes only the first step in the indictment of pathogenic medicine5 The trail beaten in the harvest is only a reminder of the greater damage done by the baron to the village that his hunt overruns.
Social Iatrogenesis#
Medicine undermines health not only through direct aggression against individuals but also through the impact of its social organization on the total milieu. When medical damage to individual health is produced by a sociopolitical mode of transmission, I will speak of "social iatrogenesis," a term designating all impairments to health that are due precisely to those socio-economic transformations which have been made attractive, possible, or necessary by the institutional shape health care has taken. Social iatrogenesis designates a category of etiology that encompasses many forms. It obtains when medical bureaucracy creates ill-health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance for discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care. Social iatrogenesis is at work when health care is turned into a standardized item, a staple; when all suffering is "hospitalized" and homes become inhospitable to birth, sickness, and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledegook; or when suffering, mourning, and healing outside the patient role are labeled a form of deviance.
Medical Monopoly#
Like its clinical counterpart, social inatrogenesis can escalate from an adventitious feature into an inherent characteristic of the medical system. When the intensity6 of biomedical intervention crosses a critical threshold, clinical iatrogenesis turns from error, accident, or fault into an incurable perversion of medical practice. In the same way, when professional autonomy degenerates into a radical monopoly7 and people are rendered impotent to cope with their milieu, social iatrogenesis becomes the main product of the medical organization. A radical monopoly goes deeper than that of any one corporation or any one government. It can take many forms. When cities are built around vehicles, they devalue human feet; when schools pre-empt learning, they devalue the autodidact; when hospitals draft all those who are in critical condition, they impose on society a new form of dying. Ordinary monopolies corner the market;9 radical monopolies disable people from doing or making things on their own8 The commercial monopoly restricts the flow of commodities; the more insidious social monopoly paralyzes the output of nonmarketable use-values9 Radical monopolies impinge still further on freedom and independence. They impose a society-wide substitution of commodities for use-values by reshaping the milieu and by "appropriating" those of its general characteristics which have enabled people so far to cope on their own. Intensive education turns autodidacts into unemployables, intensive agriculture destroys the subsistence farmer, and the deployment of police undermines the community's self-control. The malignant spread of medicine has comparable results: it turns mutual care and self-medication into misdemeanors or felonies. Just as clinical iatrogenesis becomes medically incurable when it reaches a critical intensity and then can be reversed only by a decline of the enterprise, so can social iatrogenesis be reversed only by political action that retrenches professional dominance. A radical monopoly feeds on itself. Iatrogenic medicine reinforces a morbid society in which social control of the population by the medical system turns into a principal economic activity. It serves to legitimize social arrangements into which many people do not fit. It labels the handicapped as unfit and breeds ever new categories of patients. People who are angered, sickened, and impaired by their industrial labor and leisure can escape only into a life under medical supervision and are thereby seduced or disqualified from political struggle for a healthier world10
Social iatrogenesis is not yet accepted as a common etiology of disease. If it were recognized that diagnosis often serves as a means of turning political complaints against the stress of growth into demands for more therapies that are just more of its costly and stressful outputs, the industrial system would lose one of its major defenses11 At the same time, awareness of the degree to which iatrogenic ill-health is politically communicated would shake the foundations of medical power much more profoundly than any catalogue of medicine's technical faults12
Value-free Cure?#
The issue of social iatrogenesis is often confused with the diagnostic authority of the healer. To defuse the issue and to protect their reputation, some physicians insist on the obvious: namely, that medicine cannot be practiced without the iatrogenic creation of disease. Medicine always creates illness as a social state13 The recognized healer transmits to individuals the social possibilities for acting sick14 Each culture has its own characteristic perception of disease15 and thus its unique hygienic mask16 Disease takes its features from the physician who casts the actors into one of the available roles17 To make people legitimately sick is as implicit in the physician's power as the poisonous potential of the remedy that works18 The medicine man commands poisons and charms. The Greeks' only word for "drug"---pharmakon---did not distinguish between the power to cure and the power to kill19
Medicine is a moral enterprise and therefore inevitably gives content to good and evil. In every society, medicine, like law and religion, defines what is normal, proper, or desirable. Medicine has the authority to label one man's complaint a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability, and even his death20 It is medicine which stamps some pain as "merely subjective,"23 some impairment as malingering,21 and some deaths---though not others---as suicide22 The judge determines what is legal and who is guilty23 The priest declares what is holy and who has broken a taboo. The physician decides what is a symptom and who is sick. He is a moral entrepreneur,24 charged with inquisitorial powers to discover certain wrongs to be righted25 Medicine, like all crusades, creates a new group of outsiders each time it makes a new diagnosis stick26 Morality is as implicit in sickness as it is in crime or in sin.
In primitive societies it is obvious that in the exercise of medical skill, the recognition of moral power is implied. Nobody would summon the medicine man unless he conceded to him the skill of discerning evil spirits from good ones. In a higher civilization this power expands. Here medicine is exercised by full-time specialists who control large populations by means of bureaucratic institutions27 These specialists form professions which exercise a unique kind of control over their own work28 Unlike unions, these professions owe their autonomy to a grant of confidence rather than to victory in a struggle. Unlike guilds, which determine only who shall work and how, they determine also what work shall be done. In the United States the medical profession owes this supreme authority to a reform of the medical schools just before World War I. The medical profession is a manifestation in one particular sector of the control over the structure of class power which the university-trained elites have acquired. Only doctors now "know" what constitutes sickness, who is sick, and what shall be done to the sick and to those whom they consider at a special risk. Paradoxically, Western medicine, which has insisted on keeping its power apart from law and religion, has now expanded it beyond precedent. In some industrial societies social labeling has been medicalized to the point where all deviance has to have a medical label. The eclipse of the explicit moral component in medical diagnosis has thus invested Aesculapian authority29 with totalitarian power.
The divorce between medicine and morality has been defended on the ground that medical categories, unlike those of law and religion, rest on scientific foundations exempt from moral evaluation30 Medical ethics have been secreted into a specialized department that brings theory into line with actual practice31 The courts and the law, when they are not used to enforce the Aesculapian monopoly, are turned into doormen of the hospital who select from among the clients those who can meet the doctors' criteria32 Hospitals turn into monuments of narcissistic scientism, concrete manifestations of those professional prejudices which were fashionable on the day their cornerstone was laid and which were often outdated when they came into use. The technical enterprise of the physician claims value-free power. It is obvious that in this kind of context it is easy to shun the issue of social iatrogenesis with which I am concerned. Politically mediated medical damage is thus seen as inherent in medicine's mandate, and its critics are viewed as sophists trying to justify lay intrusion into the medical bailiwick. Precisely for this reason, a lay review of social iatrogenesis is urgent. The assertion of value-free cure and care is obviously malignant nonsense, and the taboos that have shielded irresponsible medicine are beginning to weaken.
The Medicalization of the Budget#
The most handy measure of the medicalization of life is the share taken out of a typical yearly income to be spent under doctor's orders. In America before 1950, this was less than a month's income, but by the mid-seventies, the equivalent of between five and seven weeks of the typical worker's earnings were spent on the purchase of medical services. The United States now spends about $95 billion a year for health care, about 833 percent of the gross national product in 1975, up from 434 percent in 196235 During the past twenty years, while the price index in the United States has risen by about 74 percent, the cost of medical care has escalated by 330 percent. Between 1950 and 1971 public expenditure for health insurance increased tenfold, private insurance benefits increased eightfold,36 and direct out-of-pocket payments about threefold.
Some of this has enriched doctors, who until the French Revolution earned their living as artisans. A few always lived well, but more died poor. The proverb "Few lawyers die well, few physicians live well" had its equivalent in most European languages. Now physicians have come to the top, and in capitalist societies this top is high indeed. Yet it would be inaccurate to blame the inflation in medicine on the greed of the medical profession. Much more of the increase has gone to a host of well-titled medical paper-shufflers whom United States universities began to graduate in the fifties: to those with masters' degrees in nursing supervision or with doctorates in hospital administration, and to all the lower ranks on which the new bureaucrats feed. The cost of administering the patient, his files, and the checks he writes and receives can take a quarter out of each dollar on his bill37 More goes to the bankers; in some cases the so-called "legitimate" administrative costs in the medical health insurance business have risen to 70 percent of the payment made to commercial carriers.
Even more significant is the new prejudice in favor of high-cost hospital care. Since 1950 the cost of keeping a patient for one day in a community hospital in the United States has risen by 500 percent38 The bill for patient care in the major university hospitals has risen even faster, tripling in eight years. Administrative costs have exploded, multiplying since 1964 by a factor of seven; laboratory costs have risen by a factor of five, medical salaries only by a factor of 2[^46] The construction of hospitals now costs in excess of $85,000 per bed, of which two-thirds buys mechanical equipment that is made obsolete within less than ten years39 These rates are almost twice those of the cost increases and of the obsolescence prevalent in modern weapons systems. Costs overruns in programs of the Health, Education, and Welfare Department exceed those in the Pentagon. Between 1968 and 1970 Medicaid costs increased three times faster than the number of people served. In the last four years hospital insurance benefits have almost doubled in cost, and physicians' fees have increased almost twice as fast as had been planned40 There is no precedent for a similar sustained expansion in any other major sector in the civilian economy. It is therefore ironic that during this unique boom in health care the United States established another "first." Shortly after the boom started, the life expectancy for adult American males began to decline and is now expected to decline even further. The death rate for American males aged forty-five to fifty-four is comparatively high. Of every 100 males in the United States who turn forty-five only 90 will see their fifty-fifth birthday, while in Sweden 95 will survive the decade41 But Sweden, Germany, Belgium, Canada, France, and Switzerland are now catching up with the United States: both their age-specific death rates for adult males and their global medical costs are shooting up42
The phenomenal rise in cost of health services in the United States has been explained in different ways: some blame irrational planning,43 others the higher cost of the new gimmicks that people want in hospitals44 The most common interpretation at present relates to the growing incidence of prepayment of services. Hospitals register well-insured patients, and rather than providing old products more efficiently and cheaply, are economically motivated to move towards new and increasingly expensive ways of doing things. Changing products rather than higher labor costs, bad administration, or lack of technological progress are blamed for the rise45 In this perspective the change in products seems due precisely to the increased insurance coverage which encourages hospitals to provide products more expensive than the customer actually wants, needs, or would have been willing to pay for directly. His out-of-pocket costs appear increasingly modest, even though the services offered by the hospital are more costly. Insurance for high-cost sick-care is thus a self-reinforcing process which invests the providers of care with the control of increasing resources46 As an antidote, some critics recommend enlightened cost consciousness on the part of consumers;55 others, not trusting the self-control of laymen, recommend mechanisms to heighten the cost consciousness of producers47 Physicians, they argue, would prescribe more responsibly and less wantonly if they were paid (as are general practitioners in Britain) on a "capitation" basis that provided a fixed amount for the maintenance of their clients rather than a fee for service. But like all other such remedies, capitation enlarges the iatrogenic fascination with the health supply. People forgo their own lives to get as much treatment as they can.
In England the National Health Service has tried, albeit unsuccessfully, to ensure that cost inflation will be less plagued by conspicuous flimflam48 The National Health Service Act of 1946 established access to health-care resources for all those in need as a human right. The need was assumed to be finite and quantifiable, the ballot box the best place to decide the total budget for health, and doctors the only ones able to determine the resources that would satisfy the need of each patient. But need as assessed by medical practitioners has proved to be just as extensive in England as anywhere else. The fundamental hope for the success of the English health-care system lay in the belief in the ability of the English to ration supply. Until about 1972 they did so, in the opinion of an author who surveyed British health economics, "by means in their way almost as ruthless---but generally held to be more acceptable---than the ability to pay."58 Until that time health care was kept below 6 percent of GNP, 10 percent of public spending. Private practice had shrunk from half of all care to 4 percent. Direct charges to patients were kept at a phenomenally low 5 percent of the cost. But this stern commitment to equality prevented only those astounding misallocations for prestigious gadgetry which provided an easy starting point for public criticism in the United States. Since 1972 the Health Service in Britain has undergone a traumatic change, for complex economic and political reasons. The initial success of the Health Service and the present unique disarray in the system make predictions for the future impossible. Demedicalization of health care is as essential there as elsewhere. Yet curiously, England is also one of the few industrialized countries where the life expectancy of adult males has not yet declined, though the chronic diseases of this group have already shown an increase similar to that observed a decade earlier across the Atlantic.
Information on costs in the Soviet Union is more difficult to come by. The number of physicians and hospital days per capita seems to have doubled between 1960 and 1972, and costs to have increased by about 260 percent49 The main claim to superiority of Soviet medicine is still based on "prophylaxis built into the social system itself," without this affecting the relative volume of disease or care in comparison with other industrial countries of similar development50 But the theory that therapeutics would wither away with the state became and has remained heresy since 193251
Distinct political systems organize pathologies into different diseases and thus create distinct categories of demand, supply, and unmet needs52 But no matter how disease is perceived, the cost of treatment rises at comparable rates. The Russians, for instance, limit by decree mental disease requiring hospitalization: they allow only 10 percent of all hospital beds for such cases53 But at a given GNP all industrial nations generate the same kind of dependence on the physician, and do so irrespective of their ideology and the nosology these beliefs engender54 (Of course, capitalism has proved that it can do so at a much higher social cost55) Everywhere in the mid-seventies the main constraint on professional activity is the necessity to reduce costs.
The proportion of national wealth which is channeled to doctors and expended under their control varies from one nation to another and falls somewhere between one-tenth and one-twentieth of all available funds. But this should lead nobody to believe that health expenditures on the typical citizen in poor countries are anywhere proportionate to the countries' per capita average income. Most people get absolutely nothing. Excepting only the money allocated for treatment of water supplies, 90 percent of all funds earmarked for health in developing countries is spent not for sanitation but for treatment of the sick. From 70 percent to 80 percent of the entire public health budget goes to the cure and care of individuals as opposed to public health services56 Most of this money is spent everywhere on the same kinds of things.
All countries want hospitals, and many want them to have the most exotic modern equipment. The poorer the country, the higher the real cost of each item on their inventories. Modern hospital beds, incubators, laboratories, respirators, and operating rooms cost even more in Africa than their counterparts in Germany or France where they are manufactured: they also break down more easily in the tropics, are more difficult to service, and are more often than not out of use. As to cost, the same is true of the physicians who are made to measure for these gadgets. The education of an open-heart surgeon represents a comparable capital investment, whether he comes from the Mexican school system or is the cousin of a Brazilian captain sent on a government scholarship to study in Hamburg57 The United States might be too poor to provide renal dialysis at $15,000 per year to all those citizens who would claim to need it, but Ghana is too poor to provide the people equitably with physicians for primary care58 Socially critical maximum cost of items that can be equitably shared varies from one place to another. But whenever tax funds are used to finance treatment above the critical cost, the system of medical care acts inevitably as a device for the net transfer of power from the majority who pay the taxes to the few who are selected because of their money, schooling, or family ties, or because of their special interest to the experimenting surgeon.
It is clearly a form of exploitation when four-fifths of the real cost of private clinics in poor Latin American countries is paid for by the taxes collected for medical education, public ambulances, and medical equipment59 In this case the concentration of public resources on a few is obviously unjust because the ability to pay out of pocket a fraction of the total cost of treatment is a condition for getting the rest underwritten. But the exploitation is no less in places where the public, through a national health service, assigns to physicians the sole power to decide who "needs" their kind of treatment, and then lavishes public support on those on whom they experiment or practice. The public acquiescence in the doctor's monopoly on identifying needs only broadens the base from which doctors can sell their services60
Indirectly, conspicuous therapies serve as powerful devices to convince people that they should pay more taxes to get them to all those whom doctors have declared in need. Once President Frei of Chile had started on one palace for medical spectator-sports, his successor, Salvador Allende, was forced to promise three more. The prestige of a puny national team in the medical Olympics is used to intensify a nationwide addiction to therapeutic relationships that are pathogenic on a level much deeper than mere medical vandalism. More health damage is caused by people's belief that they cannot cope with their illness unless they call on the doctor than doctors could ever cause by foisting their ministrations on people.
Only in China---at least, at first sight---does the trend seem to run in the opposite direction: primary care is given by nonprofessional health technicians assisted by health apprentices who leave their regular jobs in the factory when they are called on to assist a member of their brigade61 Nutrition, environmental hygiene, and birth control have improved beyond comparison. The achievements in the Chinese health sector during the late sixties have proved, perhaps definitively, a long-debated point: that almost all demonstrably effective technical health devices can be taken over within months and used competently by millions of ordinary people. Despite such successes, an orthodox commitment to Western dreams of reason in Marxist shape may now destroy what political virtue, combined with traditional pragmatism, has achieved. The bias towards technological progress and centralization is reflected already in the professional reaches of medical care. China possesses not only a paramedical system but also medical personnel whose educational standards are known to be of the highest order by their counterparts around the world, and which differ only marginally from those of other countries. Most investment during the last four years seems to have gone towards the further development of this extremely well qualified and highly orthodox medical profession, which is getting increasing authority to shape the over-all health goals of the nation. "Barefoot medicine" is losing its makeshift, semi-independent, grassroots character and is being integrated into a unitary health-care technocracy. University-trained personnel instruct, supervise, and complement the locally elected healer. This ideologically fueled development of professional medicine in China will have to be consciously limited in the very near future if it is to remain a balancing complement rather than an obstacle to high-level self-care62 Without comparable statistics, statements on Chinese medical economy remain vague. But there is no reason to believe that cost increases in pharmaceutical, hospital, and professional medicine in China are less than in other countries. For the time being, however, it can be argued that in China modern medicine in rural districts was so scarce that recent increments contributed significantly to health levels and to increased equity in access to care63
In all countries the medicalization of the budget is related to well-recognized exploitation within the class structure. No doubt, the dominance of capitalist oligarchies in the United States,64 the superciliousness of the new mandarins in Sweden,65 the servility and ethnocentrism of Moscow professionals,66 and the lobby of the American Medical and Pharmaceutical Associations,67 as well as the new rise of union power in the health sector,68 are all formidable obstacles to a distribution of resources in the interests of the sick rather than of their self-appointed caretakers. But the fundamental reason why these costly bureaucracies are health-denying lies not in their instrumental but in their symbolic function: they all stress delivery of repair and maintenance services for the human component of the megamachine,69 and criticism that proposes better and more equitable delivery only reinforces the social commitment to keep people at work in sickening jobs. The war between the proponents of unlimited national health insurance and those who stand up for national health maintenance, as well as the war between those defending and those attacking all private practice, shifts public attention from the damage done by doctors who protect a destructive social order to the fact that doctors do less than expected in defense of a consumer society.
Beyond a certain encroachment on the budget, money that expands medical control over space, schedules, education, diet, or the design of machines and goods will inevitably unleash a "nightmare forged from good intentions." Money may always threaten health. Too much money corrupts it. Beyond a certain point, what can produce money or what money can buy restricts the range of self-chosen "life." Not only production but also consumption stresses the scarcity of time, space, and choice70 Therefore the prestige of medical staples must sap the cultivation of health, which, within a given environment, to a large extent depends on innate and inbred mettle71 The more time, toil, and sacrifice spent by a population in producing medicine as a commodity, the larger will be the by-product, namely, the fallacy that society has a supply of health locked away which can be mined and marketed72 The negative function of money is that of an indicator of the devaluation of goods and services that cannot be bought73 The higher the price tag at which well-being is commandeered, the greater will be the political prestige of an expropriation of personal health.
The Pharmaceutical Invasion#
Doctors are not needed to medicalize a society's drugs74 Even without too many hospitals and medical schools a culture can become the prey of a pharmaceutical invasion. Each culture has its poisons, its remedies, its placebos, and its ritual settings for their administration75 Most of these are destined for the healthy rather than for the sick76 Powerful medical drugs easily destroy the historically rooted pattern that fits each culture to its poisons; they usually cause more damage than profit to health, and ultimately establish a new attitude in which the body is perceived as a machine run by mechanical and manipulating switches77 In the 1940s few of the prescriptions written in Houston or Madrid could have been filled in Mexico, except in the zona rosa of Mexico City, where international pharmacies flourish alongside boutiques and hotels. Today Mexican village drugstores offer three times as many items as drugstores in the United States. In Thailand[^88] and Brazil, many items that are elsewhere outdated, or illegal surplus and duds, are dumped into pharmacies by manufacturers who sail under many flags of convenience. In the past decade, while a few rich countries began to control the damage, waste, and exploitation caused by the licit drug-pushing of their doctors, physicians in Mexico, Venezuela, and even Paris had more difficulty than ever before in getting information on the side-effects of the drugs they prescribed78 Only ten years ago, when drugs were relatively scarce in Mexico, people were poor, and most sick persons were attended by grandmother or the herbalist, Pharmaceuticals came packaged with a descriptive leaflet. Today drugs are more plentiful, more powerful, and more dangerous; they are sold by television and radio; people who have attended school feel ashamed of their lingering trust in the Aztec curer; and the leaflet has been replaced by one standard note which says "on prescription." The fiction which is meant to exorcise the drug by medicalizing it in fact only confounds the buyer. The warning to consult a doctor makes the buyer believe he is incompetent to beware. In most countries of the world, doctors are simply not well enough spread out to prescribe double-edged medicine each time it is indicated, and most of the time they themselves are not prepared, or are too ignorant, to prescribe with due prudence. As a consequence the physician's function, especially in poor countries, has become trivial: he has been turned into a routine prescription machine that is constantly ridiculed, and most people now take the same drugs, just as haphazardly, but without his approval[^90]
Chloramphenicol is a good example of the way reliance on prescription can be useless for the protection of patients and can even promote abuse. During the 1960s this drug was packaged as Chloromycetin by Parke, Davis and brought in about one-third of the company's over-all profits. By then it had been known for several years that people who take this drug stand a certain chance of dying of aplastic anemia, an incurable disease of the blood. Typhoid is almost the only disease that, with serious qualifications, does justify the taking of this substance. Through the late fifties and early sixties, Parke, Davis, notwithstanding strong clinical contraindications, spent large sums to promote their winner. Doctors in the United States prescribed chloramphenicol to almost four million people per year to treat them for acne, sore throat, the common cold, and even such trifles as infected hangnail. Since typhoid is rare in the United States, no more than one in 400 of those given the drug "needed" the treatment. Unlike thalidomide, which disfigures, chloramphenicol kills: it puts its victims out of sight, and hundreds of them in the United States died undiagnosed79
Self-control by the profession on such matters has never worked,80 and medical memories have proved particularly short81 The best one can say is that in Holland or Norway or Denmark, self-regulation has at certain moments been less ineffective than in Germany or France82 or Italy,83 and that American doctors have a particular facility for admitting past mistakes and jumping on new bandwagons84 In the United States in the fifties, control over drugs by regulatory agencies was at a low ebb and self-control was nominal85 Then, during the sixties, concerned newspapermen,86 medical men,87 and politicians100 launched a campaign that exposed the subservience of physicians and government officials to pharmaceutical firms and described some of the prevalent patterns of white-collar crimes in medicine88 Within two months after the exposure at a congressional hearing, the use of chloramphenicol in the United States dwindled. Parke, Davis was forced to insert strict warnings of hazards and cautionary statements about the use of this drug into every package. But these warnings did not extend to exports[^102] The drug continued to be used indiscriminately in Mexico, not only in self-medication but on prescription, thereby breeding a drug-resistant strain of typhoid bacilli which is now spreading from Central America to the rest of the world.
One doctor in Latin America who was also a statesman did try to stem the pharmaceutical invasion rather than just enlist physicians to make it look more respectable. During his short tenure as president of Chile, Dr. Salvador Allende103 quite successfully mobilized the poor to identify their own health needs and much less successfully compelled the medical profession to serve basic rather than profitable needs. He proposed to ban drugs unless they had been tried on paying clients in North America or Europe for as long as the patent protection would run. He revived a program aimed at reducing the national pharmacopeia to a few dozen items, more or less the same as those carried by the Chinese barefoot doctor in his black wicker box. Notably, within one week after the Chilean military junta took power on September 11, 1973, many of the most outspoken proponents of a Chilean medicine based on community action rather than on drug imports and drug consumption had been murdered89
The overconsumption of medical drugs is, of course, not restricted to areas where doctors are scarce or people are poor. In the United States, the volume of the drug business has grown by a factor of 100 during the current century:105 20,000 tons of aspirin are consumed per year, almost 225 tablets per person90 In England, every tenth night of sleep is induced by a hypnotic drug and 19 percent of women and 9 percent of men take a prescribed tranquilizer during any one year91 In the United States, central-nervous-system agents are the fastest-growing sector of the pharmaceutical market, now making up 31 percent of total sales92 Dependence on prescribed tranquilizers has risen by 290 percent since 1962, a period during which the per capita consumption of liquor rose by only 23 percent and the estimated consumption of illegal opiates by about 50 percent[^109] A significant quantity of "uppers" and "downers" is obtained in all countries by circumventing the doctor93 Medicalized addiction111 in 1975 has outgrown all self-chosen or more festive forms of creating well-being94
It has become fashionable to blame multinational pharmaceutical firms for the increase in medically prescribed drug abuse; their profits are high and their control over the market is unique. For fifteen years, drug industry profits (as a percentage of sales and company net worth) have outranked those of all other manufacturing industries listed on the Stock Exchange. Drug prices are controlled and manipulated: the same bottle that sells for two dollars in Chicago or Geneva where it is produced, but where it faces competition, sells for twelve dollars in a poor country where it does not95 The markup, moreover, is phenomenal: forty dollars' worth of diazepam, once stamped into pills and packaged as Valium, sells for 140 times as much, and for 70 times more than phenobarbital, which, in the opinion of most pharmacologists, has the same indications, effects, and dangers96 As commodities, prescription drugs behave differently from most other items: they are products that the ultimate consumer rarely selects for himself97 The producer's sales efforts are directed at the "instrumental consumer," the doctor who prescribes but does not pay for the product. To promote Valium, Hoffmann-LaRoche spent $200 million in ten years and commissioned some two hundred doctors a year to produce scientific articles about its properties98 In 1973, the entire drug industry spent an average of $4,500 on each practicing physician for advertising and promotion, about the equivalent of the cost of a year in medical school; in the same year, the industry contributed less than 3 percent to the budget of American medical schools99
Surprisingly, however, the per capita use of medically prescribed drugs around the world seems to have little to do with commercial promotion; it correlates mostly with the number of doctors, even in socialist countries where the education of physicians is not influenced by drug industry publicity and where corporate drug-pushing is limited100 Over-all drug consumption in industrial societies is not fundamentally affected by the proportion of items sold by prescription, over the counter, or illegally, and it is not affected by whether the purchase is paid for out of pocket, through prepaid insurance, or through welfare funds101 In all countries, doctors work increasingly with two groups of addicts: those for whom they prescribe drugs, and those who suffer from their consequences. The richer the community, the larger the percentage of patients who belong to both102
To blame the drug industry for prescribed-drug addiction is therefore as irrelevant as blaming the Mafia121 for the use of illicit drugs. The current pattern of overconsumption of drugs---be they effective remedy or anodyne; prescription item or part of everyday diet; free, for sale, or stolen---can be explained only as the result of a belief that so far has developed in every culture where the market for consumer goods has reached a critical volume. This pattern is consistent with the ideology of any society oriented towards open-ended enrichment, regardless whether its industrial product is meant for distribution by the presumption of planners or by the forces of the market. In such a society, people come to believe that in health care, as in all other fields of endeavor, technology can be used to change the human condition according to almost any design. Penicillin and DDT, consequently, are viewed as the hors d'oeuvres preceding an era of free lunches. The sickness resulting from each successive course of miracle foods is dealt with by serving still another course of drugs. Thus overconsumption reflects a socially sanctioned, sentimental hankering for yesterday's progress. The age of new drugs began with aspirin in 1899. Before that time, the doctor himself was without dispute the most important therapeutic agent103 Besides opium, the only substances of wide application which would have passed tests for safety and effectiveness were smallpox vaccine, quinine for malaria, and ipecac for dysentery. After 1899 the flood of new drugs continued to rise for half a century. Few of these turned out to be safer, more effective, and cheaper than well-known and long-tested therapeutic standbys, whose numbers grew at a much slower rate. In 1962, when the United States Food and Drug Administration began to examine the 4,300 prescription drugs that had appeared since World War II, only 2 out of 5 were found effective. Many of the new drugs were dangerous, and among those that met FDA standards, few were demonstrably better than those they were meant to replace104 Fewer than 98 percent of these chemical substances constitute valuable contributions to the pharmacopeia used in primary care. They include some new kinds of remedies such as antibiotics, but also old remedies which, in the course of the drug age, came to be understood well enough to be used effectively: digitalis, reserpine, and belladonna are examples. Opinions vary about the actual number of useful drugs: some experienced clinicians believe that less than two dozen basic drugs are all that will ever be desirable for 99 percent of the total population; others, that up to four dozen items are optimal for 98 percent.
The age of great discoveries in pharmacology lies behind us. According to the present director of FDA, the drug age began to decline in 1956. Genuinely new drugs have appeared in decreasing numbers, and many which temporarily glittered in Germany, England, or France, where standards are less stringent than in the United States, Sweden, and Canada, were soon forgotten or are remembered with embarrassment[^124] There is not much territory left to explore. Novelties are either "package deals"---fixed-dose combinations---or medical "me-toos"125 that are prescribed by physicians because they have been well promoted105 The seventeen-year protection that the patent law gives to significant newcomers has run out for most. Now anyone can make them, so long as he does not use the original brand names, which are indefinitely protected by trademark laws. Considerable research has so far produced no reason to suspect that drugs marketed under their generic names in the United States are less effective than their brand-named counterparts, which cost from 3 to 15 times more106 The fallacy that society is caught forever in the drug age is one of the dogmas with which medical policy-making has been encumbered: it fits industrialized man107 He has learned to try to purchase whatever he fancies. He gets nowhere without transportation or education; his environment has made it impossible for him to walk, to learn, and to feel in control of his body. To take a drug, no matter which and for what reason---is a last chance to assert control over himself, to interfere on his own with his body rather than let others interfere. The pharmaceutical invasion leads him to medication, by himself or by others, that reduces his ability to cope with a body for which he can still care.
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