In the convivial range. Of the six balances: 1 tipping, 5 not assessed. Position somewhere between 53 and 98 of 100. The balances not assessed could put it past the second watershed.
- 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 Tipping Can people still meet the need another way, without this tool? Tipping: the tool has begun to cause this problem, without going past the limit.
- 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
Treats illness and injury with a growing set of remedies that work: antitoxins, insulin, sulfa drugs, penicillin, vaccines, and safe surgery.
Where it stops
At the illness, on Illich’s account. In these years, he argues, most treatment aimed at a specific disease or injury and ended when the patient recovered. He dates the change to the mid-1950s, when medicine began to manage people as patients for life. We have not yet checked this against the history.
How easily you can stop using it
Easier than it became, as far as this record goes. Much care was still given at home or by a general practitioner, and a course of treatment had an end. But the drugs that worked could be had only through a doctor. Five of the six balances are not yet assessed.
What is scored
- The unit: Medical treatment by trained physicians between Illich’s two watersheds. It treats “medicine” as one tool, which a fuller record would not. Left out: public health, and hospital medicine after the mid-1950s (see Hospital medicine since the 1950s).
- The job it is tested against: Curing or relieving specific illnesses and injuries. The timeline in this record is the evidence that it began to.
- Where and when: Rich countries, 1913 to about 1955, on Illich’s dating. One of the six balances is assessed.
This record fills the gap between two others. Medicine before 1913 sits below Illich’s first watershed, where the tool could not yet do what it claimed. Hospital medicine since the 1950s sits past his second, where it began to cause harm. In between are about forty years in which medicine worked, and still mostly ended when the patient was well.
What Illich saw
In Tools for Conviviality (chapter I, “Two Watersheds,” pp. 9–14) Illich dates the first watershed to about 1913 and the second to the mid-1950s. He treats the years between them as the period when the tool delivered what it promised. He also writes that it is not strictly necessary to accept his exact dates: the pattern matters more.
What worked
The treatments that made medicine worth trusting mostly arrived in these years.
- The First World War: the Thomas splint, which is usually said to have cut deaths from compound fractures of the femur from about 80% to about 20%, along with typhoid vaccination, tetanus antitoxin, and transfusion with stored blood.
- Insulin, for diabetes, in 1921–22.
- Sulfa drugs, the first broadly effective antibacterials, from 1935.
- Penicillin: discovered in 1928, first given to a patient in 1941, and mass-produced in 1944.
- Synthetic antimalarials in the 1930s and 1940s.
They were added to what already worked by 1913: anaesthesia, antiseptic surgery, diphtheria antitoxin, and Salvarsan.
A caution from Illich
Illich did not credit these treatments with as much as their makers did. In Medical Nemesis (1975) he argued that death rates from tuberculosis and other infections had been falling for decades before the drugs arrived, and that food, housing, and sanitation did more than doctors to bring them down. A fair record of this period has to hold both points: the treatments were real, and they explain less of the gain in health than is usually claimed.
The six balances
Scored as set out in How to evaluate tools. In these years medicine reliably did its job, so the record starts in the convivial range.
- Biological degradation: Not assessed.
- Radical monopoly: 1. The treatments that worked could be had only through a licensed doctor, and each new drug deepened that dependence. Home care, midwives, and general practice were still common.
- Overprogramming: Not assessed.
- Polarization: Not assessed. Access depended heavily on country and on the ability to pay.
- Obsolescence: Not assessed.
- Frustration: Not assessed.
Where the threshold falls
In the convivial range, at 53: one of the six balances is tipping, so its position is 50 + 3. This is a first reading. Five of the balances are not yet assessed, and “medicine” covers very different things in different countries during these years.
Open questions
- Score the five balances that are not yet assessed.
- When, and by what evidence, did medicine cross the second watershed? Illich says the mid-1950s. Did it happen at the same time everywhere?
- How much of the fall in death rates in these years was due to treatment, and how much to food, housing, and sanitation? Check Illich’s claim in Medical Nemesis against the history of medicine.
- Should the period be split by country? Britain’s National Health Service began in 1948, and care was paid for very differently elsewhere.
- Add sources for the dates that are not yet cited, and replace the Wikipedia timeline with a history of medicine.
Sources
- Illich, Ivan. Medical Nemesis: The Expropriation of Health. London: Calder & Boyars, 1975.
- 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.