Before the first watershed. Of the six balances: 1 holding, 5 not assessed. Position 12 of 100, set by judgment: the balances are recorded but do not move it.
- Biological degradation Not assessed Does this tool damage the living world, or the body, faster than either can recover? Not assessed: nobody has looked at this yet, so it is not counted as holding.
- Radical monopoly Holds Can people still meet the need another way, without this tool? Holds: the tool does not cause this problem.
- Overprogramming Not assessed Does using this tool require training or certification that people cannot give each other? Not assessed: nobody has looked at this yet, so it is not counted as holding.
- Polarization Not assessed Does this tool move power or advantage to a few, at others’ cost? Not assessed: nobody has looked at this yet, so it is not counted as holding.
- Obsolescence Not assessed Does this tool force people to replace what still works? Not assessed: nobody has looked at this yet, so it is not counted as holding.
- Frustration Not assessed Does this tool give back less than it takes, counting everything it takes? Not assessed: nobody has looked at this yet, so it is not counted as holding.
What it does
Offers care from a trained physician to people who are ill or injured, at a time when the training could not yet promise a treatment that worked.
Where it stops
Below the first watershed. The tool is not yet effective enough to justify the trust placed in it: a patient who went to a doctor was, on Illich’s account, no more likely to be helped than one who went elsewhere.
How easily you can stop using it
On Illich’s account, easy, and often sensible. Family remedies, midwives, and other healers were available, and on this account they were no worse placed to help. On Illich’s account nothing yet made leaving costly; that has not been checked against the history.
What is scored
- The unit: Treatment by physicians trained in medical schools, before about 1913. It treats “medicine” as one tool, which a fuller record would not. Left out: midwives, folk healers, and public health.
- The job it is tested against: Curing or relieving illness and injury. On Illich’s account it did not yet do this reliably, which is why the record sits below the first watershed.
- Where and when: Europe and North America, on Illich’s dating. One of the six balances is assessed, on his word alone.
This record is a bad example of a different kind from the others. Illich’s two watersheds mark where a tool stops failing at its job and where it starts defeating it. Medicine before 1913 sits before the first one: the tool is not yet good enough to be worth the claims made for it.
What Illich saw
In Tools for Conviviality (chapter I, “Two Watersheds,” pp. 9–14) Illich dates the first watershed to 1913. Around that year, he says, a patient began to have “more than a fifty-fifty chance” of being given a specifically effective treatment by a medical-school graduate, for the standard diseases that medical science then recognized. He adds that many shamans and herb doctors, trusted by their clients and familiar with local diseases, “had always had equal or better results.” The second watershed, in the “mid-fifties,” is where the same tool begins to create new kinds of disease. Illich writes that it is “not strictly necessary” to accept 1913 and 1955 as the exact years. Holbrook relays the same dates. See the record for hospital medicine.
What worked, and when
A short timeline tests Illich’s date. It shows how little a doctor could reliably do in 1913, and how much of what people now think of as effective medicine came later.
By 1913
- Anaesthesia (1846) and antiseptic surgery (Lister, 1867) had made operations survivable.
- Diphtheria antitoxin had been in successful use since 1894.
- X-rays (1895) let doctors see a fracture, and blood groups were identified in 1901.
- Salvarsan, for syphilis, arrived in 1909–10. It was the first drug designed to kill a specific infection.
- Quinine had long been used against malaria.
In the First World War
- The Thomas splint for a broken thigh bone reached the front in 1916 and was routinely supplied from 1917. Deaths from compound fractures of the femur are usually said to have fallen from about 80% to about 20%.
- Typhoid vaccination, tetanus antitoxin, and transfusion with stored blood all came into wide use.
After 1913
- Insulin, for diabetes, in 1921–22.
- Sulfa drugs, the first broadly effective antibacterials, from 1935.
- Synthetic antimalarials in the 1930s. Chloroquine was first made in 1934 but was not used until after 1945.
- Penicillin: discovered in 1928, first given to a patient in 1941, and mass-produced in 1944.
So Illich’s first watershed rests on a short list: safe surgery, one antitoxin, and one targeted drug. Antibiotics were a generation away. Most of the treatments that made medicine worth trusting belong to the forty years between his two watersheds.
Where the threshold falls
This record places pre-1913 medicine well below the first watershed. The position is a provisional reading of Illich’s argument, not a measurement. It also treats “medicine” as one tool, which a fuller record would not.
The six balances
This record sits below the first watershed, so these scores do not move its position. They are recorded because a tool that does not work can still do harm. Scored as set out in How we evaluate tools; one of the six balances has been assessed, on Illich’s word alone.
- Biological degradation: Not assessed.
- Radical monopoly: 0. On Illich’s account, shamans, herb doctors and other healers were still trusted and available (Tools for Conviviality, pp. 9–14). This has not been checked against the history of medicine; see the open questions.
- Overprogramming: Not assessed.
- Polarization: Not assessed.
- Obsolescence: Not assessed.
- Frustration: Not assessed. The harm done by treatments that did not work belongs here.
Open questions
- Illich says many shamans and herb doctors “had always had equal or better results” than medical-school graduates, but gives no evidence for it in this passage. What does the history of medicine say?
- Add sources for the dates in the timeline that are not yet cited: anaesthesia, antisepsis, X-rays, blood groups, insulin, and wartime vaccination and transfusion. Replace the Wikipedia timeline with a history of medicine.
- Where else does Illich discuss 1913, in Medical Nemesis or an essay, and does it change the reading above?
- What other tools sit below their first watershed today, so that using them costs more than it returns? We have no sourced example yet.
Sources
- Holbrook, J. Britt. “Two Watersheds for Open Access?” 2013. https://jbrittholbrook.com/2013/09/06/two-watersheds-for-open-access/.
- Illich, Ivan. Tools for Conviviality. New York: Harper & Row, 1973. https://archive.org/details/illich-conviviality.
- National Geographic. “How World War II put penicillin into every pharmacy.” August 2020. https://www.nationalgeographic.com/magazine/2020/08/how-world-war-ii-put-penicillin-into-every-pharmacy.
- Nobel Prize Outreach. “Emil von Behring.” Accessed October 5, 2026. https://www.nobelprize.org/nobel_prizes/medicine/laureates/1901/behring-article.html.
- The National Archives. “A revolution in treatment: the Thomas splint.” Accessed October 5, 2026. https://blog.nationalarchives.gov.uk/thomas-splint.
- Wikipedia contributors. “Timeline of antibiotics.” Accessed October 5, 2026. https://en.wikipedia.org/wiki/Timeline_of_antibiotics.