Reading Medical Nemesis and writing a letter to Ivan Illich during the COVID-19 pandemic: A social work education activity for undergraduate students

Elena Cabiati

Catholic University of Milan, Italy

Maria Turati

Catholic University of Milan, Italy

Correspondence:

Elena Cabiati

e-mail: elena.cabiati@unicatt.it

Abstract

This paper reports on a social work education activity conducted in Italy during the COVID-19 pandemic.

During the Methodology of Social Work course, undergraduate social work students read the book Medical nemesis. The expropriation of health written by Ivan Illich in 1974. Subsequently, students were invited to join an online workshop and write an imaginary letter to the author of the book. This activity aimed to encourage students to critically reflect on the content of the book with reference to future social work and the current health emergency that has significantly affected Italy. Content analysis of student letters revealed three main areas of discussion: (1) viewpoints regarding Illich’s thesis, (2) connections between the author’s thought and the experience of the COVID-19 pandemic, and (3) transversal concepts between the author’s thought and social work. The activity could inspire similar teaching and learning initiatives to develop critical thinking among students. These findings could inspire social work educators and students to reflect on mechanisms, dynamics, and approaches that are counter-productive for social work, and on what they were living, teaching, and learning during COVID-19 time.

Keywords

Social work education, COVID-1, Medical Nemesis, critical thinking, Ivan Illich, social work.

Introduction

This paper reports on an activity conducted at the Catholic University of Milan, Italy during the lockdown weeks of the COVID-19 pandemic, from March 10^th to May 4^th, 2020. The COVID-19 pandemic caused significant changes in daily life, including ways of teaching and learning.

Italy has been severely affected by the COVID-19 pandemic, with 74,386 confirmed cases and 7,505 deaths as of March 26^th, 2020, according to the World Health Organization (WHO).¹

Along with health, social, and economic areas, social work education has changed drastically. From the end of February until the end of the academic year, May 2020, all the teaching activities were conducted via the internet.

The activity reported in this paper involved 2 social work educators and 40 second year undergraduate students during the Methodology of Social Work course. This course is divided into two semesters: the first develops theory and methodology content on cases for social work interventions, while the second is dedicated to methodological elaboration of placement experience.² The course is inspired by key principles of social work (IFSW and IASSW, 2014; IFSW, 2020) and the relational social work method (Folgheraiter, 2004; Cabiati, 2016).

The activity focused on the book Medical nemesis. The expropriation of health written by Ivan Illich in 1974. The book is not popular among social work education programs and is a book not easy to understand for undergraduate students. The activity aimed to encourage students to reflect on the content of the book, both individually and collectively.

Reading the book in the 21 century and during the COVID-19 pandemic stimulated both social work educators and students in critically reflecting on what Ivan Illich’s radical discourses can teach social workers. In this paper, the authors particularly focussed on the third step of the initiative, described below.

About the author and the book

Ivan Illich (1926-2002) was a Roman Catholic priest, theologian, philosopher, and social critic. His most popular book was the Deschooling Society (1971). Implicit in this revolutionary book is a tough-minded analysis of human society, its institutions and its problems (Petrie, 1972).

Illich, a social critic and philosopher, was at the forefront of arguing for a collective health approach and challenging medical hegemony (Russell, 2019). His iconoclastic views enjoyed wide public interest in the 1960s and 70s. His popularity waned in the 1980s, and his interest shifted from direct critiques of institutional hegemony toward mediaeval history and its influence on the modern world (Russell, 2019).

His 1975 book Medical Nemesis importing the concept of medical harm to sociology of medicine, and poses some questions about the medical profession, the lifestyle changes and the direction of modern society who pathologizes and medicalize life creating harm and dependency.

The crux of Illich’s ideas is as follows (Killeeen, 1976; Finger and Asún, 2001; Smith, 2002; Russell, 2019):

• increasing and irreparable damage accompanies industrial expansion in all sectors. In medicine, this damage appears as iatrogenesis. Iatrogenesis is clinical when pain, sickness, and death result from medical care, social when health policies reinforce an industrial organisation that generates ill health, and cultural and symbolic when medically sponsored behaviour and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other, and ageing, or when medical intervention cripples personal responses to pain, disability, impairment, anguish, and death;
• social iatrogenesis results from the «medicalization of life», where an increasing number of life’s problems are seen as amenable to medical intervention. Pharmaceutical companies develop expensive treatments for non-diseases, and better medicine equals better health;
• «counter-productivity» acknowledges that beyond a certain scale or intensity, institutional responses to health and other societal challenges display a form of what the medical community refers to as iatrogenesis (physician or medicine induced harm), where the opposite of what was intended is created.

Illich’s radical perspective can then be summarised in 5 points (Smith, 2012; Russell, 2019).

1. Health is not a product.
2. Citizens/patients are not passive consumers.
3. Doctors and medical professionals are not tools.
4. Hospitals and surgeries are not factories.
5. The medical establishment has become a major threat to health.
6. Society’s image of death reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.

Rationale and methodology of activity

The activity aimed to engage social work students in a critical reflection on Ivan Illich’s thesis in the book Medical Nemesis. The peculiar context of the COVID-19 pandemic represented an added incentive for engaging students in a critical reflection on what the book teaches, what inspires their future as social workers, and on the present as citizens involved in an unprecedented health emergency.

The activity was organised in the following steps:

• Students were invited to read the book;
• Students were engaged in a single session workshop aimed to discuss the content of the book;
• Students were invited to write an imaginary letter to Professor Ivan Illich.

The activity was carried out in March–May 2020. In conclusion, the authors analysed the content of the letters written by students to Ivan Illich.

Writing of the imaginary letter to Ivan Illich was fully voluntary for the students, and no grades or academic credits were expected even if the book was part of the bibliography of the final exam of the course.

A single-session workshop

After the students read the book, course educators invited them to participate in a single-session workshop. Due to containment measures imposed by the COVID-19 pandemic, the workshop was conducted via the Internet through a virtual platform provided by the university. Students were able to participate in the discussion using microphones and webcams. Participants were second-year undergraduate social work students at the Catholic University of Milan.

The students included 38 women and 2 men, and their average age was 20 years. The workshop lasted for 2 hours. The workshop was audio and video recorded with the students’ agreement.

This workshop aimed to offer a virtual classroom in which students could conduct a joint reflection on the Medical Nemesis book content.

Conversation among students in the workshop was accompanied by educators through 3 inspirational questions.

• What is the main message of the book?
• What are the connections between the content of the book and the content of the course (Methodology of social work)?
• What does this book say to me as a future social worker in this historic and dramatic moment?

These questions were shared with students three weeks in advance to allow them to read the book and make some initial reflections. The role of the educators was to support the dialectical process within the classroom, create a space for all voices, stimulate reflection, and give feedback or explanations when needed. During the workshop, students shared important considerations on the main concepts developed in the book (iatrogenesis, medicalisation of health, and counter-productivity).

Students showed critical thinking and desire to better understand the meaning of some strong concepts presented by Ivan Illich.

Writing a letter to Professor Ivan Illich

After the single session workshop, educators invited students to write a letter to Ivan Illich. This step was meant to stimulate students to make a final individual effort of reflection, on the basis of what had already emerged in the workshop.

Students received an email with the following message:

Having read Medical nemesis by Ivan Illich, write a letter to Professor Illich to share with him the thoughts that this book inspired in you as a future social worker.

Using a specific digital format, students were invited to write a letter of up to 1000 words, starting with the sentence «Dear Professor Illich…». Students were given two weeks to complete the letter.

Analysis of the students’ letters: Methodology

At the beginning of May 2020, the educators received 40 imaginary letters written by the students to Ivan Illich. All letters were written in PDF files.

The letters were first collected in a folder and student names were removed to protect anonymity during the analysis. The letters were numbered from 1 to 40 and the content was analysed. Content analysis is the scientific study of the content of communication (Prasad, 2008). The authors read all the letters and selected the prevalent and recurrent themes. These themes were organised by content area. The three areas of discussion are presented in the section below. The third area of discussion was organised into three themes to illustrate the topics more clearly.

After an initial overall reading aimed to identify the main themes, the letters were organised by area and themes identified inductively from the data. All contents were recorded to avoid subjectiveness and ensure credibility. Next, the themes and sub-themes were assembled or divided following semantic analogies. This step allowed us to identify categories that were organised from general to particular (Ritchie et al., 2003). The categories were mutually exclusive and defined to be internally homogeneous and externally heterogeneous. The three content areas corresponded to the main messages reached from the student letters written to Ivan Illich.

What students wrote to Ivan Illich: Findings

All students liked the book and were thankful to the author, although some expressed difficulty in reading it. Some students pointed out that they were impressed by the actuality of the author’s reflections.

The content analysis made it possible to identify three categories: (1) students’ viewpoints about the thesis presented in the book, (2) connections between the author’s thought and the experience of the COVID-19 pandemic, and (3) transversal concepts between the author’s thought and social work.

The last category was further organised into three themes to illustrate the topics more clearly.

Viewpoints about Illich’s thesis in Medical Nemesis

All students started the letters expressing their viewpoints about Illich’s position on the medical institution, demonstrating a good ability to approach the book critically. Most of them partly agreed with the author.

Eleven letters showed explicit recognition of five characteristic elements of today’s society: addiction to medicine, a positive and acritical view of medicine as progress, failure to see the negative effects of medicalisation, particularly on the freedom of persons, and a delegation of responsibility for health to the health system. Moreover, students expressed that medicine has contributed to the improvement of the quality of life and saw excessive generalisation in the author’s criticism.

Some students, while agreeing with the author on some points and recognising the provocative intent, described his statements as «exorbitant», «extreme», «radical», «exaggerated», and «hyperbolic».

Connections between the author’s thoughts and the experience of the COVID-19 pandemic

Ten students made explicit connections between what they thought reading the book and what they experienced during the COVID-19 pandemic. Students observed how the pandemic has destabilised the health and social services systems, undermining people’s sense of security and trust in the health system, previously deemed infallible:

This period has left us with our backs to the wall. (Letter n. 7)

This left us baffled by the mystery that is challenging the human knowledge. (Letter n. 8)

Everyone (…) is imprisoned within the limits of social distancing, is alone with their pain. (Letter n. 40)

The limitation of the human condition becomes more tangible; we are forced to recognize the inevitability of the disease. (Letter n. 40)

One student highlighted the limit of considering the hospital as the only place for care in the community:

I find in what happened the clear representation of the criticism you (ed. Professor Illich) presented to the system: the monopoly of hospitals as places for care and at that moment their total collapse (...) and the total paralysis of the individuals’ ability to take care of themselves. (Letter n. 6)

On the other hand, students observed that the pandemic also awakened the sense of solidarity, activating a dynamic of mutual help among citizens:

People learned to engage themselves and not only to receive. (Letter n. 7)

I saw how many of us (ed. neighbours) collaborated and helped gladly. (Letter n. 14)

During the COVID-19 pandemic, it was possible to see the drive to take care for others (e.g., health professionals and volunteers), turning the crisis into an opportunity:

It will be possible to turn a crisis into an opportunity to leave behind an anesthetized society. (Letter n. 40)

Finally, with reference to the author’s speech on the meaning of death, some students emphasised that the pandemic stimulated a critical thinking about «reappropriating the act of dying», choosing not to hospitalise themselves or their loved ones to prevent them from dying alone in the hospital.

Transverse concepts between the author’s thoughts and social work

Most of the letters focussed on the identification of transversal themes between Illich’s thought and the methodological content of relational social work.

Counter-productivity and disabling profession as risk in social work

Students found a connection between social work and the concept of counter-productivity. The lack of self-agency, which students acknowledge as typical in contemporary society, brings people to experts (particularly, social workers) with the expectation of an effective and precise solution to problems that do not depend on their own action, searching for sure results. This can lead to the risk that social workers offer standardised interventions to all people in need, regardless of their unicity and agency. Standardisation doesn’t support the agency of people, making them more passive:

Social workers can discourage people’s agency. (Letter n. 9)

There is a risk of practitioners not valuing people and their resources. (Letter n. 32)

By offering standardized solutions to life problems, social workers impoverish people, depriving them of their power of action. (Letter n. 29)

Furthermore, students included the loss of value of the subjective experience as an effect of standardisation. Finally, reflections on counter-productivity were linked by some students with critical thinking regarding the role of experts and institutions. Some of them wrote that autonomy does not mean not needing anyone: experts, such as social workers, may promote people’s autonomy, as people facing challenges may need social work intervention to improve their life conditions:

...It’s hard to believe that people have to overcome all the difficulties on their own. (Letter n. 34)

Social work profession has the duty to encourage people in changing their life for better. (Letter n. 2)

Therefore, some students partly disagreed with the author’s position about welfare institutions. In fact, some of them pointed out the importance of the role of institutions in guaranteeing people’s freedom and in giving them the possibility to better their condition, in contradiction with the author’s idea that institutions are only manipulative, oppressive and disabling. Some students affirmed that Illich was too radical in this respect.

Relevance of social work core principles

As a result of the arguments about counter-productivity, some students focussed on core principles of social work as a reference point to avoid falling into the error of standardisation and building relationships that make the other passive. Students referred to social work principles as empowerment and self-determination, also strongly affirmed by Illich as «self-realization» and the recognition of the centrality and uniqueness of each human being. Students considered these principles to be the best antidote to cope with the dominion professional omniscience and omnipotence:

Social workers must keep the person at the centre of intervention, letting her participate. (Letter n. 11)

Professionals have to embrace people as capable. (Letter n. 19)

We must remember that people are capable of self-determination and our goal as social workers is (...) to understand problems together with clients and then to help them to face these problems. (Letter n. 27)

Moreover, some students argued that respecting people also means being realistic: accepting limits is a professional attitude that helps social workers to identify achievable goals in each situation and not falling into the risk of being salvific, as happens to medical professionals from Illich’s perspective.

What makes a social worker a good expert?

The last theme is related to the question (identified during data analysis): if social workers are experts in helping people face their problems, what makes them good experts? These are some practical recommendations, suggested by the students according to social work practise: implement processes of empowerment, focus on agency, recognise that people are responsible for their own well-being and provide assistance while respecting the principle of self-determination, build solutions together and help each other, recognising that both social workers and clients have knowledge and skills to address the problem together, develop a relationship based on trust and exchange:

As future social worker, I must not pretend to know everything. (Letter n. 2)

Promoting people’ empowerment means becoming non-essential professionals. (Letter n. 4)

In leading the decision-making process, it is fundamental to never take the place of the other. (Letter n. 21)

Discussion

The content analysis of the students’ letters showed how students reasoned about the text. For educators, it was interesting to note that students learned from the Medical Nemesis book on multiple levels.

First, students reflected on their personal experience during the COVID-19 pandemic. The book offered them a possible key to understanding what was happening: students demonstrated that they were able to allow themselves to be questioned in depth about the dramatic situation and to be critical about the interpretation offered by the author. Reading their letters, it was possible to note the propensity of students to conduct social work delving deep into situations and experiences that surround them.

Moreover, they connected the book’s content with what they were studying (see the third area of discussion in the findings). On one hand, they linked the author’s thesis to transversal concepts of social work, unrelated to the specific methodological approach they were studying, as principles of social work. In fact, it is possible to find the mentioned principles (empowerment, self-determination, recognition of uniqueness of each person) in the Social Work Global Definition (IFSW and IASSW, 2014) and in the Global Social Work Statement of Ethical Principles (IASSW, 2018).

On the other hand, students critically reflected on the author’s viewpoint using the notions learned during the course of the Methodology of Social Work about the Relational Social Work Approach. In particular, this is reflected in the concept of reciprocity in the relationship between social workers and clients, the importance of enhancing the knowledge that comes from lived experience and, consequently, recognising that clients are experts by experience, and the relevance of sharing goals and interventions, building a participatory and equal relationship with clients in which they can make decisions for themselves.

Students also imagined themselves as future social workers, not only using methodological notions, but also transforming them into practical recommendations. Finally, it was remarkable to notice how seriously students were engaged in reading a challenging book and in developing critical thinking regarding its content, particularly reflecting on the role of the welfare institutions and their future role as professionals.

Conclusion

In conclusion, this paper focussed on 4 points:

• the importance of engaging students in creative thinking beyond traditional teaching and learning activities;
• the need to encourage the development of students’ critical thinking, exposing them to new and challenging activities;
• the value of accompanying students in reflecting and acting on their personal experiences through social work education lenses;
• the efficacy of inviting students to make connections between their personal experiences (and their experiences of the pandemic) and what they were studying as social workers.

The Medical Nemesis book offered students the opportunity to make efforts to understand complex content, revisit their viewpoint on the welfare system, and be active in the face of the challenges and provocations posed by Ivan Illich. Coming back to the aim of the activity, findings from the content analysis confirmed that students gained important insights for their future profession. The authors believe that the activity was successful as students were not only invited to read the book, but were also accompanied in the elaboration of the main content. This process was conducted through two steps: a single session workshop in which students were helped by colleagues in delving deep inside the main concepts of the book, and the writing of an imaginary letter to Ivan Illich that encouraged students to discuss their position towards important topics, giving imaginary feedback to the author.

The time and context of the experience were particularly meaningful. Reflecting on the core content of the book, such as health, death, illness, curing, and caring during the COVID-19 pandemic, was powerful and inspiring for students and educators. The activity utilised critical thinking as a learning tool in social work education and could inspire educators to guide students through similar processes.

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