Cultural Iatrogenesis



   We have dealt so far with two ways in which the predominance of medicalized health care becomes an obstacle to a healthy life: first, clinical iatrogenesis, which results when organic coping capacity is replaced by heteronomous management; and, second, social iatrogenesis, in which the environment is deprived of those conditions that endow individuals, families, and neighborhoods with control over their own internal states and over their milieu. Cultural iatrogenesis represents a third dimension of medical health-denial. It sets in when the medical enterprise saps the will of people to suffer their reality.1 It is a symptom of such iatrogenesis that the term "suffering" has become almost useless for designating a realistic human response because it evokes superstition, sadomasochism, or the rich man's condescension to the lot of the poor. Professionally organized medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against all suffering. It has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline and death.

   To be in good health means not only to be successful in coping with reality but also to enjoy the success; it means to be able to feel alive in pleasure and in pain; it means to cherish but also to risk survival. Health and suffering as experienced sensations are phenomena that distinguish men from beasts.2 Only storybook lions are said to suffer and only pets to merit compassion when they are in ill health.3

   Human health adds openness to instinctual performance.4 It is something more than a concrete behavior pattern in customs, usages, traditions, or habit-clusters. It implies performance according to a set of control mechanisms: plans, recipes, rules, and instructions, all of which govern personal behavior.5 To a large extent culture and health coincide. Each culture gives shape to a unique Gestalt of health and to a unique conformation of attitudes towards pain, disease, impairment, and death, each of which designates a class of that human performance that has traditionally been called the art of suffering.6

   Each person's health is a responsible performance in a social script.7 How he relates to the sweetness and the bitterness of reality and how he acts towards others whom he perceives as suffering, as weakened, or as anguished determine each person's sense of his own body, and with it, his health. Body-sense is experienced as an ever-renewed gift of culture.8 In Java people flatly say, "To be human is to be Javanese." Small children, boors, simpletons, the insane, and the flagrantly immoral are said to be ndurung djawa (not yet Javanese). A "normal" adult capable of acting in terms of the highly elaborate system of etiquette, possessed of the delicate aesthetic perceptions associated with music, dance, drama, and textile design, and responsive to the subtle promptings of the divine residing in the stillness of each individual's inward-turning consciousness is ampun djawa (already Javanese). To be human is not just to breathe; it is also to control one's breathing by yogalike techniques so as to hear in inhalation and exhalation the literal voice of God pronouncing his own name, hu Allah.9 Cultured health is bounded by each society's style in the art of living, feasting, suffering, and dying.10

   All traditional cultures derive their hygienic function from this ability to equip the individual with the means for making pain tolerable, sickness or impairment understandable, and the shadow of death meaningful. In such cultures health care is always a program for eating,11 drinking,12 working,13 breathing,14 loving,15 politicking,16 exercising,17 singing,18 dreaming,19 warring, and suffering.

   Most healing is a traditional way of consoling, caring, and comforting people while they heal, and most sick-care a form of tolerance extended to the afflicted. Only those cultures survive that provide a viable code that is adapted to a group's genetic make-up, to its history, to its environment, and to the peculiar challenges represented by competing groups of neighbors.

   The ideology promoted by contemporary cosmopolitan medical enterprise runs counter to these functions.20 It radically undermines the continuation of old cultural programs and prevents the emergence of new ones that would provide a pattern for self-care and suffering. Wherever in the world a culture is medicalized, the traditional framework for habits that can become conscious in the personal practice of the virtue of hygiene is progressively trammeled by a mechanical system, a medical code by which individuals submit to the instructions emanating from hygienic custodians.21 Medicalization constitutes a prolific bureaucratic program based on the denial of each man's need to deal with pain, sickness, and death.22 The modern medical enterprise represents an endeavor to do for people what their genetic and cultural heritage formerly equipped them to do for themselves. Medical civilization is planned and organized to kill pain, to eliminate sickness, and to abolish the need for an art of suffering and of dying. This progressive flattening out of personal, virtuous performance constitutes a new goal which has never before been a guideline for social life. Suffering, healing, and dying, which are essentially intransitive activities that culture taught each man, are now claimed by technocracy as new areas of policy-making and are treated as malfunctions from which populations ought to be institutionally relieved. The goals of metropolitan medical civilization are thus in opposition to every single cultural health program they encounter in the process of progressive colonization.23