M.I.P. #1: Illich on Solutions Becoming Problems
From Ivan Illich, "Tools for Conviviality," 1973
“In the case of transportation it has taken almost a century to pass from an era served by motorized vehicles to the era in which society has been reduced to virtual enslavement to the car. During the American Civil War steam power on wheels became effective. The new economy in transportation enabled many people to travel by rail at the speed of a royal coach, and to do so with a comfort kings had not dared dream of. Gradually, desirable locomotion became associated and finally identified with high vehicular speeds. But when transportation passed through [its second stage of adoption], vehicles had created more distances than they helped to bridge; more time was used by the entire society for the sake of traffic than was ‘saved.’”
Here Illich presents the evolution of transportation as an example of industrial society’s formulaic error: widespread adoption of an effective innovation paradoxically eliminates its effectiveness, and in some cases even creates additional problems. It is not that cars aren’t an effective tool, but that their introduction into society—which happened because they were indeed effective—produced a feedback effect. As more people purchased cars to make their existing journeys easier to traverse, the distance between common destinations (think home, grocery store, school, work, social gatherings, and so on) simply increased—things were built much father apart under the assumption that people would be driving rather than walking (or cycling, or whatever). In other words, our environment responds to our interventions. Placing a piece on the board causes it to change into a different game.
So that’s the first part: the adoption of the effective tool reduces or eliminates its effectiveness. The additional problems created by the adoption of the car are myriad and oft-discussed. Vast amounts of public space and funds are dedicated to maintaining highways and parking lots. There are more than 100 car accident fatalities every day in the US. If you escape that fate and other such tragic ends to reach average life expectancy, given the standard American commute and errands you’ll have spent more than 4 years of your life just sitting in the car. The primacy and necessity of the car has had a measurable effect on family size in the US: parents tend to limit the number of children they have to the amount of carseats their current car can accommodate. And so on. I don't think you have to be 100% opposed to cars (I’m not!) to recognize the validity of this two-part pattern, and Illich identifies this same general arc in modern medicine, education, social work, policing, “the mails,” and most other modern institutions.
Aside from the specific problems listed above, the biggest meta-problem is that once the environment has changed in response to the intervention, you cannot individually opt out. If you live in a suburb, as I have for much of my life, you cannot opt out of driving to the big box grocery store and instead just walk down the street to the corner market. There is no corner market, and the 4.7 miles of streets that stretch between your home and the grocery store are major highway interchanges with no shoulders or sidewalks. However, I imagine it was not altogether clear to people in the early days of cars that in choosing to drive instead of walk they were effectively choosing to someday not be able to choose. In much the same way I imagine that people choosing to order something online instead of schlep off to a store do not fully comprehend that they are choosing to someday not be able to choose to go to a store. Not owning a cell phone in 2003 was not the same prospect as not owning a cell phone in 2023—forget being able to get in telephonic touch with someone else while out and about (no more pay phones), can you even eat at a restaurant if you can’t scan the QR code?
I have been thinking about this theme especially with reference to healthcare. I am now 22 weeks pregnant, which means I have scheduled (and rescheduled) half a dozen prenatal appointments, had bloodwork done, settled up with the insurance people, and so on. The amount of non-human interfaces involved in this process is astonishing: endless “please listen to the following options…” automated call menus, check your email to sign up for our patient portal with two-factor authentication for any and all doctor-patient communication, fill out these digital forms on your phone, and so on. Even my health insurance card is “conveniently” available in the app—requesting a physical card means traversing another digital process. No doubt all of these innovations were introduced to save time and/or money, but taken together, the overall effect is one of tremendous baggage weighing down what could otherwise simply be a brief exchange of questions and answers between two human beings. It’s hard to imagine that interacting with this amount of software and automation in order to accomplish relatively straightforward tasks is really cheaper for anyone. It is certainly not easier for me.
I'm figuring you knew this but when you consider the objective of health care is to prevent you from using it the layers of impossibly obtuse interfaces make sense.