Emma Rothschild writes about a new French book on the economics of illness
- L’Ordre Cannibale: Vie et Mort de la Médecine by Jacques Attali
Grasset, 325 pp
One of the more mournful consequences of the economic crisis is the boom in the business of illness. This is in one sense a figure of speech. The economies of the West are evidently unwell: since 1973, they have been obsessed with the etiology of economic impairment, the electroencephalograms of unemployment and inflation. But it is also literally true.
The medical economy is involved directly in the present crisis. The costs of illness contribute to inflation virtually everywhere. Medicine is inculpated in the political economy of the recession, as expressed in successive crises of public expenditure. At the same time, medical services are a leading source of new employment: in Britain, in France, in the United States where nearly a third of all new jobs from 1973 to 1977 were in ‘medical and other health’ occupations; at this rate, we will all soon be working for blood banks, nursing-homes and journals of medical information.
What, in these circumstances, is the relationship between medicine and the economic troubles of the 1970s? Jacques Attali asks this question in his new book about the medicalisation of economic life. The medical system, he sets out to show, is both a cause of the economic crisis and the source of its likely and melancholy resolution.
Attali is a French economist, prominent in the Socialist Party, who writes best-selling books about the French economy as well as studies of, for example, music (Bruits) and information technology. The present book is a history of illness and medicine, from cannibalism in ancient Croatia to insurance schemes in Britain and Prussia and to the prosthetic science of the 22nd century.
The demand for medical care, Attali shows, is booming. This is partly because people in rich countries are getting older. It is partly because medicine itself is a seductive ‘spectacle’. It is also a consequence of industrial expansion, with its environmental costs, occupational injuries, new carcinogens and sicknesses of civilisation. (Money, says Attali, is ‘pathogenic’, and the vision of the book is indeed unremittingly gloomy.)
At first, as in the mid-1970s, the demand for health is met by expanded medical services. But this exacerbates the economic crisis. Technical change in medicine fails to reduce the costs of health services. The people who find new employment in the medical economy are mostly low-productivity workers, producing services rather than goods. (Businesses, meanwhile, are obliged to reduce the environmental costs of their operations. But this ‘unproductive’ investment itself contributes to economic difficulties.) In a second phase, therefore, governments cut back their medical programmes. There are reductions in hospital services, queues for operations, a black market in medical treatment, rigid and often contradictory controls on doctors. In the third phase of the new medical order, our societies reduce the demand for medical care by making people less ill. Consumers themselves (potential patients) become responsible for the prevention of illness. Attali describes a hypochondriacal society to come, in which citizens are charged with the ‘surveillance’ of their own bodies. They watch for the earliest signs of morbidity. They aspire to a normal life, perusing the indicators of death and medical demography. To eat fat is to be predisposed to heart disease, to eat sugar is to risk diabetes. Smoking, drinking, not taking exercise, are transgressions, and pathogenic commodities are sold as ‘minor forms of suicide’.
In this society of valetudinarians, Attali sees a fourth and transcendent phase in the economic illness. It points the way to the resolution of the economic crisis of the late 1970s and 1980s, to a future long boom in capitalist economies. For the desire to prevent disease creates new markets for goods. Medicine, preventive and curative, is no longer a spectacle but rather the basis of a new mass-production industry. It is no longer a fiscal charge, but a gold-mine.
Home electrocardiograms, computers which describe the cholesterol content of lunch, endoscopic devices to be enjoyed in the privacy of the family: Attali imagines new commodities, new utensils used in the prevention and early detection of disease. In Salt Lake City, apparently, psychiatric patients are interviewed by computers; some patients might find the experience so reassuring that they wish to purchase such programmes for use in their own homes. The market for medical hardware and software booms beyond the wildest hopes of General Electric and Hoffmann-LaRoche. Its clients are no longer hospitals, constrained by parsimonious governments and insurance companies: rather they are individual consumers, by definition fancy-free, impulse buyers of audio-visual medical encyclopedias and do-it-yourself pregnancy tests.
Doctors, in the new economy of consumer medicine, are often salaried employees. They provide fewer services, and their procedures are controlled by the computer diagnosticians to whom they have access. At the same time, they are increasingly in demand as productive workers, employed by the businesses which produce medical equipment: designing implantable blood-testing devices, or writing programmes to detect the latest modish disease, whether it be liver cancer or mal-du-siècle.
Attali’s ‘order of codes’ ends in a fantasy of prosthetic medicine, with normalising stimulators for carotid arteries, artificial pancreases (already installed in diabetic dogs), a grisly offering of plastic limbs and innards. The book is in general fantastic. It is forced fairly relentlessly into an extended metaphor of cannibalism as explanation, of symmetrical ‘signs’ from the steps of Aztec pyramids to genetic engineering. It is a curiously French combination: on the one hand, a Cartesian, even Aztec sense of schematisation; on the other hand, a keen and magpie-like interest in the newest follies of Japanese medical technology, or in the horrors of 17th-century hospitals for the destitute. But Attali’s theory of illness is always ingenious: it is recognisable, in our present society of jogging, therapy and health-food supermarkets, and it illuminates the continuing economic uncertainty within which the business of medicine subsists.
There is no indication, late in 1979, that the economic troubles of the 1970s are ending. It seems more likely, indeed, that the modest and mixed prosperity of the last couple of years was a period of remission rather than of recovery. Unemployment is increasing rapidly in France and the United States. Inflation is troubling West Germany, and even Switzerland. Britain is acting out, for other countries to admire and gasp, the political crisis of public expenditure. Rates of growth of productivity, meanwhile, are lower virtually everywhere than they were before 1973.
In these dismal circumstances, it seems prudent to consider the long-term or structural changes which may explain the present conjuncture. One such change is the increase in employment in low-productivity services, particularly those paid for by public expenditure. Another is the increase in resources spent on protecting the physical environment. The economics of illness is critical in each case, as Attali’s book shows. It will be a long, sick winter.