‘Illness is nature’s attempt to heal us.’ – Thomas Mann, The Magic Mountain.
Thomas Mann’s The Magic Mountain (‘Der Zauberberg’) is conventionally read as a Bildungsroman, a novel of ideas, an allegory of pre-war European decadence etc.
But I can’t help but feel that Mann was also exploring themes that have become central to health: medicalisation, iatrogenesis, and the expansion of medical authority.
Mann wasn’t merely documenting illness in a Swiss sanatorium. Long before Foucault or Illich, he imagines a world in which diagnosis, clinical routines, and the logic of medicine become the dominant frameworks through which individuals understand themselves, organise their lives, and construct meaning.
He shows that illness is not the opposite of health, but its organising grammar.
For me the Berghof (the name of the sanatorium) is an epistemic engine. The institution, led by Dr Behrens (the charismatic chief physician whose influence extends far beyond clinical judgment) exerts over its residents an authority.
It represents the social logic of modern medicine, where clinical authority becomes moral and political authority. The rituals (temperature readings, rest cures, surveillance, diagnostic pronouncements) don’t simply detect pathology, they embed the patient in a social economy where pathology and identity are intertwined. It’s a small-scale model of a medicalised society.
Social iatrogenesis at the Berghof
The protagonist Hans Castorp’s transformation from visitor to patient illustrates what Ivan Illich would later call social iatrogenesis: the process by which medical institutions generate a form of dependency where individuals internalise the norms, expectations, and categories of illness.
It’s never confirmed if Castorp has tuberculosis. He slides into his diagnosis, not so much because of its pathophysiology, but because of the institutional environment. By proximity and discourse.
“You belong here – one can see it at first glance,” he’s told by Behrens.
The novel is a case study in medicalisation avant la lettre. It anticipates this phenomenon decades before Illich named it in Limits to Medicine. In the sanatorium, this is a lived structure. Illness becomes a currency of meaning and status. Patients are not afflicted so much as cultivated into patienthood, acquiring legitimacy through diagnostic refinement and institutional routines. Their cases become their vocation. The longer one remains under surveillance, the more ordinary sensations are interpreted as symptoms. This is the iatrogenic feedback loop: medical authority justifies itself by producing the very conditions it claims to treat.
Mann even collapses the very distinction between health and disease:
“And life? Life itself? Was it perhaps only an infection, a sickening of matter? Is what one might call the original procreation of matter only a disease, a growth produced by morbid stimulation of the immaterial? The first step toward evil, toward desire and death […] the transition from the insubstantial to the substance. This was the Fall.”
Illness becomes the primary idiom of existence, and medicine as a theory of being.
Modern healthcare struggles with a similar logic. We’re in the era of chronic disease management, aggressive screening, overdiagnosis and low-value care, with healthy people paying thousands for full-body MRI scans just the latest example.
The system seems hell bent on reinforcing dependency through medical knowledge and technology.
Foucault’s ‘clinical gaze’
If this sounds thoroughly postmodern, Foucalult himself argued in The Birth of the Clinic, that modern medicine achieves power not only by curing, but by organising knowledge, behaviour, and identity. The “clinical gaze” turns bodies into objects of interpretation and management. It positions the individual not as an agent, but as a body to be monitored, measured and classified … the physician’s authority gentle but absolute.
In Mann’s depiction, patients internalise this gaze. They monitor and narrate their bodies through medical scripts. The architecture and routines of the sanatorium reorder time and conduct (“Three weeks! That’s nothing up here. A mere trifle!”). Patients diagnose each other. The gaze becomes distributed, communal and normalised.
The novel dramatises what Foucault suggested: the medical gaze does not stay technical. It becomes normative. We are all patients.
Physicians as moral authorities
The most striking aspect of the Berghof is that its physicians’ authority becomes moral and political as much as clinical. This is true power. They define the meaning of illness, the purpose of treatment, the criteria of belonging, as well as the proper conduct of life within the institution. It’s clear that their jurisdiction extends far beyond the clinical domain (which is legitimate) into questions of value, normativity, and purpose – domains for which they have no specific training or democratic mandate.
Castorp on Dr Krokowski, the Berghof’s psychoanalyst, for example:
“He does seem rather weird […] Some of the things he said were very queer: it sounded as if he meant to say that the sun revolves round the earth.”
Or on the physicians in general:
“Up here, the doctors are always right.”
The Berghof foreshadows what Eliot Freidson later called professional dominance: the conversion of technical expertise into a jurisdiction over social meaning and policy. Clinical authority becomes moral authority.
We see this in the political economy of contemporary health systems, where the medical profession has become the main architect and arbiter of policy. Where medical knowledge morphs into the grammar and the currency through which governments allocate resources, regulate behaviour and define ‘need’. The result is not merely medicalisation of individuals but the medicalisation of public reasoning, priority-setting and expenditure.
The medical profession now sees itself as not just healer, but legislator of conduct and steward of social and political institutions, and in some cases an arbiter of truth.
(For example, the patently false claim that the private sector takes pressure off the public sector, which has for some reason been accepted more or less as an article of faith and is parroted everywhere.)
Subsuming other forms of authority
Mann contrasts the physicians’ authority with other competing figures in the novel. For me in particular Settembrini, Naphta, and Peeperkorn.
These characters dramatise the collapse of other forms of moral and intellectual authority. Settembrini represents humanist enlightenment and the liberal faith in education, progress and reason (“Man must be free, despite his suffering”). Naphta, ideological absolutism that would soon define the 20th century – political religion masquerading as certainty and purity (“Man needs an idea for which he’s willing to die”).
But despite their constant attempts to instruct, persuade and moralise, neither successfully shapes the conduct or destiny of the patients. Castorp listens to them, admires them, even debates them. But he obeys the doctors.
Medicine succeeds where the traditional sources of moral authority falter. Behrens’s clinical power is institutionalised. It controls bodies, schedules time and regulates behaviour.
The exuberant Peeperkorn offers another alternative: life as brio, will and sensual intensity (“Life! We must drink it like wine”). But even he cannot break the gravitas of Behrens and the medical institution. His presence only reinforces how exhausted the other claims to authority have become.
In the Berghof, medicine fills the vacuum left by the declining authority of philosophy, ideology and culture. It is the only fully functioning behavioural framework in the novel. Clinical authority replaces other moral orders.
Yes, it is a sanatorium where one would expect medical authority to be dominant. But Castorp arrives not as a patient but as a visitor, travelling from Hamburg to spend some time in the Swiss mountains with his convalescing cousin.
And he is gradually medicalised, persuaded by the charismatic and powerful Behrens to undergo tests and scans. “To begin with, let’s observe how you develop,” he suggests to the naive Hans. The result is inevitable. The visit extended. Weeks turn into months. He transitions into a patient and, like many of his fellow patients, ends up staying permanently.
Diagnostic expansion
Mann depicts a community in which the threshold for illness is extraordinarily low. Ordinary sensations like fatigue, boredom or anxiety are reclassified as pathology (“Illness up here was a form of life”). Diagnosis becomes a form of social capital. The sanatorium reorganises relationships, prestige, identity, and hierarchy. It’s a proto-medicalised society (“The path into illness was a path into his destiny.”)
The novel thus foreshadows the logic of modern health systems that increasingly treat individuals not as episodic patients but as permanent subjects of medical management.
Proliferating diagnostic categories, expanding screening programs, reclassifying ordinary experience as pathology … extending medical jurisdiction into everyday life. This expansion occurs through inter alia broadening thresholds and “preventive interventions” (an oxymoron if you think about it).
Our systems can easily be characterised by overdiagnosis, medical dependency, institutional authority, and diagnostic identity, what Illich called the “expropriation of health”: the displacement of self-care and autonomy by institutional norms and professional authority. [4, 5]
(Similar themes appear in later literature [Ken Kesey’s One Flew Over the Cuckoo’s Nest is a clear descendant]. Yet Mann writes before antibiotics, almost immediately after the invention of X-ray machinery – an example of medical technology becoming a form of social power.)
(A system where people with stable symptoms receive cardiac stents … while others in actual need go without [NB. Mann makes it pretty clear that the Berghof is an institution for the rich].)
Look hard enough and you’ll find pathology everywhere (and in every body).
I’m not claiming that medicine is without purpose or value. I’m observing that its jurisdiction has expanded from clinical practice into socio-political ordering.
(Two examples: [1] the political storm created by political storm by ophthalmologists top proposals to adjust their most lucrative Medicare item; [2] Overblown reactions to health funds co-owning health service organisations.)
Medical authority as political authority
The Magic Mountain prefigures institutional dependency, the clinical gaze, and the sociology of medicalisation. It anticipates the social logic of modern medicine: the transformation of diagnosis into identity, the expansion of clinical authority into moral governance, and the rise of institutions that generate many of the conditions they treat.
It also foreshadowed how medicine became a central organising principle of modern society, and annexed the moral and political space traditionally occupied by philosophy, democracy, and culture.
Mann’s physicians governed the sanatorium. Today’s professions govern the system. Whether this is desirable is a question we must ask. But first we must recognise that it’s happening.
Luke Slawomirski is a health economist, policy expert and former clinician with international experience and expertise in health system strategy, performance, policy analysis, development and implementation.
This article was first published on Mr Slawomirski’s LinkedIn feed. Read the original article here.
