The Iatrogenic Society

By Raffaele Alberto Ventura

May 7, 2020. Published March 27, 2020 in Italian by Not, an online cultural criticism magazine by Nero Press. Translated by Pablo a Marca; proofreading, translation checking, and paratext by Alessandro Moghrabi.

This publication is part of a collaborative project devoted to analyzing the Italian philosophical response to the COVID-19 pandemic, developed in the Spring 2020 graduate seminar “Italian Thought: Inside and Out” taught by Laura Odello and Suzanne Stewart-Steinberg.

iatrogenic: relating to illness caused by medical examination or treatment (New Oxford American Dictionary).

Nature created the virus, but it is the technological system that transformed it into an epidemic. In this way, the virus issues its extreme blackmail: either sacrifice bare life or accelerate towards dystopia.

In this time, I will not be the first one to quote the famous scene from The Sword in the Stone, where Merlin, in order to defeat Madam Mim, transforms into a bacillus and makes her ill. The irony in that scene lies in the fact that the two enemies transform into ever bigger creatures; but when Merlin is close to being defeated by a giant dragon, he suddenly inverts the strategy: he understands that the greatest menace comes from the world of the infinitely small. Madam Mim, notwithstanding her strong magical arts, cannot do anything against an illness that infects her from within. A similar plot twist can be found in H. G. Wells’s The War of the Worlds, when the alien tripods that invaded Earth are defeated by the bacteria in the atmosphere.

The allegory is far too obvious when one observes the way in which the microscopic SARS-CoV-2 paralyzed the capitalistic mega-machine by suspending mobility, slowing down consumption, and forcing production into a crisis. David has put Goliath on his knees, to cite an even more ancient myth that, according to Arnold Toynbee, describes the immanent logic of historical cycles. The champion of the philistines was a big boy, fully armored — an “augmented man,” the closest thing to a cyborg in the eleventh century before Christ — but a disruptive maneuver like throwing a stone in the face was enough to knock him down. Goliath’s fatal mistake, Toynbee remarks, was to expect an adversary who was as well equipped, and to take for granted a certain idea of how the duel would have unfolded; the giant had won so many battles with his spears that he considered himself invincible. A recurrent mistake that many great civilizations incur before collapsing — for those who want more examples, we refer to the fourth volume of Study of History.

The typically capitalist certainty that it is enough to have more resources to make a system more efficient is constantly contradicted by the industrial and military failures of the great powers.

Coronavirus has struck in an almost chirurgical manner the fragile spots of the capitalist machine, causing what appears to be a global recession. In the following months, we expect a chain of bankruptcies, mass unemployment, and unforeseeable geopolitical consequences. Yet, it would be a mistake to consider this epidemic as a natural phenomenon: on the contrary, it has been a social phenomenon from the beginning. A simple microorganism would have never been able to do what it has done without the infrastructures that the system itself has given it, such as transports, hospitals, institutions, and means of communication. Contrary to what Giorgio Agamben seems to think, the ever-increasing risks that modern society needs to manage are not “inventions” but its real productions, even if involuntary. Acknowledging that we are dealing with an anthropic catastrophe is the first necessary step to confront ourselves with the possibility that some remedies can be even worse than evil. While many precarious workers are already losing their jobs and many prisoners are losing their physical or mental health, while in the streets one can hear the ruckus of the soldiers’ boots, it is absolutely not premature to reflect on the technological trap that is closing on us.

The virus in the machine

According to the virologist Ilaria Capua, the appearance of the same viral strain in a different historical context would have had much milder consequences: it would have been born and died in a village north of Lake Dongting or would have taken decades to spread, leaving the necessary time for humanity to immunize. In short, even if the SARS-CoV-2 virus had come into the world, the conditions for an epidemic would not have existed. But the world of the twenty-first century is made up of a dense network of connections that, like large syringes, quickly bring pathogens from one part of the world to another. The transmission and evolution cycle of viruses is thus accelerated, it too augmented through symbiosis with the mega-machine of aeronautical transport.

If in the first phase many specialists gave the impression of “minimizing” the severity of the disease, it is because yet another flu-like syndrome was not, in itself, a new or extremely alarming phenomenon. They had underestimated the ability of the technological system to function as a contagion booster and risk amplifier — and in particular, also already known, the ability of the health system to do the same. A little over a month after the discovery of the first case of coronavirus on Italian territory, hypotheses are compellingly emerging on the role played by hospitals in the catastrophe that occurred in Lombardy. A catastrophe that is likely to occur wherever there are similar conditions.

Among the ranks of health personnel, forced to work in unsuitable, stressful, and dangerous conditions, there are a very high number of infected and dozens of fallen. As early as the end of February, an investigation had been launched into the procedures adopted in the hospitals of Codogno, Casalpusterlengo, and Lodi, which may have contributed to the infection. To Capua, who recalled that the SARS 1 virus had spread by exploiting the ventilation ducts of a hotel in Hong Kong, a former health director of the Lombard ASL, Giuseppe Imbalzano, replied by insisting that the matter is organizational before being medical: it would have been appropriate, as in China, to isolate the structures for those infected by coronavirus. The issue is therefore not so much the availability of “beds” in absolute terms, which in some cases can prove to be part of the problem, but the ability of a complex bureaucracy to quickly adapt its protocols. The typically capitalist certainty that it is enough to have more resources to make a system more efficient is continually contradicted by the industrial and military failures of the great powers.

In an open letter delivered to the New England Journal of Medicine Catalyst Innovations in Care Delivery, thirteen doctors from the Papa Giovanni XXIII hospital in Bergamo denounced the paradox of a crisis made possible not despite an excellent health system, but precisely because of its intrinsic characteristics:

Hospitals can be the main transmission vehicles for COVID-19 as they fill up faster and faster with infected patients who infect uninfected patients. The regional health system itself contributes to the spread of the infection, as ambulances and health workers quickly become carriers. Healthcare workers are asymptomatic carriers of the disease or sick without any surveillance.

The epidemic storm could not have been triggered without the contribution of a whole series of technological tools put at the service of the virus’s spread. Among these “media” in a broad sense there are also, as Capua always suggests, the media: according to the virologist, the panic that spread in Italy since the end of February has been able to stimulate a counterproductive “rush to the hospitals.” But in the long list of malfunctions that have amplified the destructive potential of COVID-19 we also find the conflicts between powers at the regional, national, European, and international level, which has stimulated a kind of race to unload responsibilities and detect the least number of infected. In short, coronavirus did not simply make the system “sick,” but hacked it. It exploited the system’s infrastructure and resources, using them as an exoskeleton to achieve its unique vocation: to reproduce. The most convincing analogy could be with those parasites (fungi or insects) capable of taking control of the mind of ants, ladybugs, or cockroaches. For example, the jewel wasp is able, with its neurotoxins, to influence the movement of its victim, while the clubheaded mushroom, for its part, is able to push it towards suicide. Something similar seems to have happened with coronavirus, which has acted on the mega-machine of western capitalism as a real computer virus.

The production of the addiction

In the early days of the health crisis, someone joked about the intellectual legacy of authors such as Michel Foucault and Ivan Illich, guilty of having criticized the modern approach to the disease in various ways; they would have done better to reread them. In particular Medical Nemesis, that in 1974 denounced the iatrogenic risks of medicine, that is, the production on an industrial scale of side effects. Today, the work seems to be echoed by this bitter observation made by the doctors of Bergamo, with surprisingly Illichian tones: “The more society is medicalized and centralized, the more the virus spreads.” It is with this paradox that we have to deal with understanding the tragic choice that is imposed on us.

Of course, throwing the baby away with contaminated water does not make sense. If calculated in terms of “bare life,” to quote Agamben, there is no doubt that the system saves many more people than (very occasionally) it kills: the victims of any nosocomial coronavirus contamination are largely patients who were up to that moment kept alive by the health system through surgical and pharmacological tools. If anything, Illich’s criticism concerns the quality of life guaranteed in this way, because in its incessant medicalization of every aspect of existence, the system tends towards overdiagnosis and overtreatment. This way, millions of healthy people are enrolled in the ranks of the sick, which sometimes ends up actually making them sick. In this, Ulrich Beck’s logic, which he called society of risk, holds: that is, in the inexhaustible production of threats whose necessary prevention always guarantees new needs to be met.

However, the Illichian discourse on quality of life risks being rather subjective, and at times moralistic, especially if opposed to the powerful objectivity of the reduction of mortality rates in advanced societies, an undoubted progress on which the health system (and, with it, the entire technological system) has founded its legitimacy over the past century. The problem is that this narrative is only half true. The extraordinary drop in mortality rates of the last century is primarily due to the increase in quality of life, drinking water, and sewage systems, and only secondly to medicine, indeed to a narrow spectrum of medical technologies — Illich stresses, for example, the undoubted effectiveness of vaccination policies. But outside of this spectrum, the results are much less striking. The production of health basically follows the same trend as all the production curves and therefore inevitably reaches the plateau of decreasing returns: once the threshold of the things that it does “very well” is exceeded, medicine is condemned to make increasingly important efforts to obtain increasingly less satisfactory and at some point harmful results. It always gets a little less for every single Euro it invests, and for every single doctor it hires; while on the other hand, it is being stretched by a growing demand for health generated by the system itself. This logic of infinite expansion is evidently as unsustainable in the health sphere as it is in the wider economic sphere.

There is no trade-off between the needs of survival and those of production, since the biological subsistence itself in our societies is now largely mediated by the capitalist system.

If vaccines and antibiotics have pushed the health production curve to its ascending phase, psychiatric treatments characterize the plateau where they are struggling to measure convincing results. The most striking case of iatrogenesis in recent years is certainly the abuse of psychotropic drugs and opiates, which in the United States has taken on the character of a real epidemic: according to Allen Frances, former editor of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), it has been provoked by the growing tendency in psychiatry to identify more and more disorders and potential deviations to be medicalized. Remember the jewel wasp and the clubhead mushroom? In this case, it is the mega-health machine that conditions the behavior of millions of human beings by transfusing neurotoxins into their nervous system. This symbiotic relationship with the machine can in some cases save the patient’s life, while in others it condemns them to greater unhappiness. But what happens when, due to force majeure, the medical treatment of the now addicted individual is interrupted? The plot of Todd Phillips’s Joker provides some insight. 

The technological system actually produces individuals who are addicted to technology. Let’s go back to the image of the cyborg, half-man and half-machine — in this case, everyone is wired to the same large machine that guarantees the supply of resources, safety, and in some cases physical survival. This machine cannot afford any “voltage drop” without endangering the millions of people who live in symbiosis with it, whether in hospitals in the strict sense or in urban centers in the broad sense. Which also means that we are indirectly dependent on the mode of production that generates the wealth necessary to finance this technostructure that keeps us alive, from drinking water to ventilators. There is therefore no trade-off between the needs of survival and those of production, since the biological subsistence itself in our societies is now largely mediated by the capitalist system. The damage to the economic sphere is already producing an army of unemployed, and soon millions of people will be unable to guarantee their livelihood and health.

Accelerate or die

Once again, the technological system, after helping to produce the problem, offers us its remedies. But in this case, they are much more drastic than usual: forced imprisonment of a majority of the population, massive presence of the army in the streets, and plans for pervasive control of movements. Tomorrow, probably, a rigid system of workfare to revive the productive forces. To these remedies “there is no alternative,” to quote Prime Minister Conte, at least if we want to shelter our healthcare facilities. After all, there is nothing new: the real absence of alternatives is precisely the logic of the technological system. From the moment it is historically produced, it presents itself as truly irreversible. By always producing new risks, it continues to reproduce its own needs. By imposing its radical monopoly, it has eliminated the spectrum of possibilities. Nature created the virus, but it is the technological system that has transformed it into an epidemic. In this way, it issues its extreme blackmail: to sacrifice bare life or accelerate towards dystopia.

Reflecting, in 1966, on The Legitimacy of the Modern Age, the philosopher Hans Blumenberg had observed that “the evils of the world depend less and less on the physical defects of nature, and, due to technical amplifications, more and more clearly on the effects of human actions.” Therefore, the principle of legitimization of the technological system is now that of a pure race forward, in the hope of solving the problems generated by its very existence, accelerating. But as the iatrogenic risks accumulate, this race is increasingly desperate and soon to be useless. To take up a concern formulated (not entirely effectively) by Giorgio Agamben, we must ask ourselves: at what point will the preservation of bare life end up condemning us, as a civilization, to an existence no longer worth living?

At what point will the preservation of bare life condemn us, as a civilization, to an existence no longer worth living?

Capitalism had sold itself as the only system now able to manage the messes it made, but we had not taken into due consideration the existence of wide barbarization margins. Today, taking the trajectory of modernization to the extreme, the health emergency requires for the West to evolve its political-economic system into something more similar to the Chinese model: a highly rationalized, centralized, hierarchical system, an evolutionary leap in the species. The eclipse of the most basic civil rights seems to raise only a few timid objections to our animal fear of survival. “There is no alternative:” we must accelerate or die.

Technological progress promised to free humanity; instead, it ended up throwing us into the iron cage glimpsed by Max Weber a century ago in his studies on bureaucratic rationality. Perhaps, it will save us from coronavirus, isolating us from all contact with the outside world and imposing the definitive triumph of “generalized separation” on us. But what seems to us to be the safest refuge today may soon prove to be the place of greatest danger.

Raffaele Alberto Ventura is an Italian public intellectual currently residing in Paris. He collaborates with the Groupe d’études géopolitiques at ENS and publishes in various cultural criticism magazines (Le Grand Continent) as well as magazines (Wired, Esquire). He is the author of Teoria della classe disagiata (minimum fax, 2017) and La guerra di tutti (minimum fax, 2019).