The Simulation of Care

"We live in a world of simulation, in which the highest function of the sign is to erase reality and, at the same time, to conceal its disappearance." – Jean Baudrillard

There is a question we would rather not ask ourselves. Not because it is too intellectually difficult. Rather because, once it is spoken aloud, it begins to act like a crack in a pane of glass. At first it is small, almost invisible. Then it spreads further, cutting across one self-evident truth after another, until at last it shatters the whole picture that had until then seemed stable.

We look at hospitals rising on the outskirts of cities like the cathedrals of a new age. At wards, laboratories, clinics, registration systems, digital test results, magnetic resonance imaging, computed tomography scanners, surgical robots, reimbursement procedures, qualification algorithms, corridors full of light and people in white moving with quiet certainty. And we feel calm. Not the calm that comes from a real experience of health, but the calm that comes from the sight of infrastructure. A calm that needs no proof beyond the mere presence of the sign. Since all of this exists, someone must be taking care of us.

But it is precisely here that the problem begins.

There is a difference between pretending and simulating. The one who pretends to care still lives in a world in which care remains something real. There is some original to which the copy can be referred. There is genuine care and its false imitation. The boundary between the thing and the appearance still exists. One can still say: here authenticity ends and the game begins.

Simulation goes further. Simulation does not consist in a simple lie. It does not say "I care" while there is no care. Simulation creates such an arrangement of signs, procedures, images and institutions that the very question of real care begins to seem unnecessary, suspect, or even absurd. There is no longer an original against which the copy can be compared. There is a copy that has become the only available reality. We no longer ask whether something actually serves health. We ask whether it fits within the system we have learned to identify with health.

And this is exactly what has happened to care for the human being.

We have its sign. We have its perfect, gleaming, costly, monumental form. So elaborate, so technological, so administratively advanced that we have stopped asking whether the thing it was meant to denote stands behind it. The sign suffices. The sign authenticates itself. The more money it costs, the more space it occupies, the more specialized the language it uses, the less inclined we are to check what it actually confirms.

For here is the greatest paradox of the modern state: it declares that it cares for the citizen's health, and at the same time organizes reality in a way that systematically erodes that health. This is not only about medicine as a field. It is not about doctors, nurses, paramedics, or the individual people who often do heroic work within a flawed system. It is about the entire architecture of life into which we are inscribed from the first breath to the last. An architecture that first creates the conditions favorable to illness, and then presents its own response to that illness as proof of its goodness.

First it produces the deficit. Then it sells the easing of the deficit as care.

Let us look at this transaction from the inside, because its brutality does not lie in a single spectacular act of violence. It lies in the fact that the cost is dispersed, daily, and therefore almost invisible.

We give up time. The greater part of the day, the greater part of the week, the greater part of the biologically best years of life. We give up attention, energy, sleep, spontaneity, circadian rhythm, the capacity to regenerate. We work in chronic tension, in artificial light, in haste, in informational noise, in an environment that constantly forces us into vigilance. We live under economic pressure that keeps the nervous system in a state of chronic readiness. A person cannot truly rest if their body does not believe it is safe. And the body does not believe in safety on the basis of declarations. The body reads the rhythm of the day, the availability of food, the quality of sleep, exposure to light, the quality of human relationships, the predictability of tomorrow, the tension of the muscles, the breath, the heart rate, the glucose level, the temperature, the inflammatory state.

Modern man rarely lives in an environment of health. More often he lives in an environment of compensation.

This is an important distinction, because the organism can compensate for overload for a very long time. It can maintain the appearance of normality at the cost of an ever-greater energetic expenditure. It can raise, beyond the threshold of benefit, cortisol, adrenaline, sympathetic tone, so that a person can "somehow function." It can lower libido, flatten the emotions, restrict thermogenesis, reduce spontaneous activity, quiet repair processes, shift resources from regeneration to survival. And for a while everything looks normal. The person works. Answers messages. Does the shopping. Pays taxes. Smiles when required. Fulfills a function.

But biology knows no free lunches.

Every hour of stress we are unable to meet, every shortened night, every decision made under pressure, every meal eaten on the run, every screen-light late in the evening, every relationship experienced as a threat, every task carried out in a state of inner resistance leaves its trace in physiology. Cortisol, which over a short horizon is a hormone of mobilization, over a long horizon becomes a signal that the organism cannot enter full regeneration. Glucose metabolism begins to lose its flexibility. The thyroid axis may be suppressed, not because the body has developed some defect, but because slowing the metabolism is a survival strategy in a world that does not provide the conditions for full energy production and metabolic expansion. Anabolic hormones fall, because building, libido, fertility and growth are a biological luxury available when the organism feels it can meet its needs without rationing resources (energetic substrates and nutrients). Inflammation smolders low, without a spectacular symptom, but long enough to alter the work of the vessels, the brain, the mitochondria, the gut, the adipose tissue and the immune system.

The crux, then, is not a single disease. The crux is the gradual loss of the capacity to produce energy and maintain biological order without constant compensation.

There is no exaggeration here, and no metaphor. These are real processes: allostatic load, dysregulation of the HPA axis, insulin resistance, disturbances of the circadian rhythm, chronic inflammation, decline of mitochondrial capacity, loss of muscle mass, deterioration of sleep quality, the flattening of dopaminergic motivation, the lowering of reproductive function. They do not appear suddenly. They accumulate over years. In silence. Without a dramatic moment of breakthrough. That is why a person so rarely sees the price. No single day feels like a catastrophe. The catastrophe appears only as the sum of days that were never taken seriously.

And then the system of treatment enters the stage.

Not as the one that asks: why was the body brought to such a state? Rather as the one that says: we have a procedure. We have a specialist. We have a drug. We have a test. We have a queue. We have a classification. We have a diagnostic code. We have a patient pathway.

The living, feeling, suffering body is replaced by a map. By a test result. By a chart. By a laboratory reference range. By a disease entity. By a position in the system. The body as experience is erased by the body as documentation. And then the very same arrangement that helped create the conditions of overload sets about managing its effects, without questioning its own share in their emergence. Because to question that share, it would first have to admit that the territory exists at all. And increasingly it acknowledges only the map.

This is the heart of the matter.

The sign once had a referent. It denoted something. It pointed to something. It served something. The hospital was meant to be a place for saving health. The test was meant to help understand the body. The drug was meant to be a tool for restoring function. The procedure was meant to be a means, not a meaning. But at a certain stage the sign emancipates itself from its source. It ceases to be a testimony of the thing and becomes the thing itself. It no longer mirrors reality. It begins to produce it. And then it begins to precede it.

It is not the need that gives rise to the answer. It is the ready-made answer that begins to shape the need it supposedly satisfies.

This is precisely why medical infrastructure becomes such a dangerously convincing sign of care. Magnetic resonance imaging will not improve the quality of your sleep. A CT scanner will not rebuild the social bonds that for health can matter more than another procedure. A surgical robot will not restore the body's capacity for metabolic adaptation. The newest drug will not resolve the fact that a person lives in a rhythm at odds with their own biology. A health app will not replace a sense of safety, contact with daylight, adequate nourishment, muscles working under load, a stable nervous system, and a life one is not constantly forced to recover from.

One can possess the most advanced diagnostic apparatus in the history of the species and at the same time a society that is ever more exhausted, obese, stressed, infertile, lonely, depressed and metabolically dysregulated. The machine is real. The procedure is real. The technical competence may also be real. And yet their sum need not be care. It may be merely its grand sign, which has hidden behind itself the very thing it was meant to denote.

What is most disturbing, however, is that this sign does not only hide reality. It precedes it.

The vast infrastructure of treatment is not solely a response to a wave of illness that it found as a ready-made fact. It partly co-produces that wave. Not because the doctor wants illness. Not because every intervention is bad. Only because every large system begins to define reality through the categories it is able to handle. If it has a diagnostic apparatus, it will diagnose. If it has procedures, it will qualify. If it has pharmacology, it will pharmacologize. If it has statistics, it will manage what can be counted. If it has queues, it will produce the logic of queues. If it has norms, it will shift attention from function to the reference range.

The map begins to produce the territory.

The more tools we have for detection and treatment, the more we find to detect and treat. The more states we describe in the language of deficit, disorder and risk, the more of life is captured by the apparatus of intervention. The more the system expands its own capacity to react to illness, the more it begins to treat the rising number of reactions as proof of its own usefulness. And yet it may be exactly the reverse. A rising number of interventions may not be proof of progress in health. It may be proof of the deepening failure of the environment, the culture and the organization of life.

That is why the question that ought to come first is: why do more and more people need such a number of interventions at all?

If metabolic diseases, depression, hormonal disorders, autoimmune conditions, fertility problems, sleep disorders, neurodegeneration, chronic fatigue and the diseases of civilization keep increasing in populations that have access to the most advanced care in history, then the problem probably does not lie solely in a "lack of treatment." It must lie deeper. In the construction of a world that first forces biological overload, and then calls the management of that overload's effects care.

The modern system does not ask: how do we make a person have enough energy, resilience, bonds, sleep, metabolic fitness and satisfied needs that they need medicine as rarely as possible? It asks rather: how do we more efficiently service the rising number of people who are already breaking down?

This is a fundamental difference.

The first question concerns health. The second concerns the administration of illness.

And this is where the second layer of simulation appears. For a system can be ever more efficient at handling illness and at the same time ever less interested in producing the conditions of health. It can shorten the time of a procedure, digitize documentation, increase the number of consultations, broaden reimbursement, buy new equipment, build new wards, and still not touch the crux. Because the crux is not located in the medical facility. It is located in the rhythm of life, in the employment relationship, in the quality of food, in light, in sleep, in the level of loneliness, in the architecture of cities, in art, in economic pressure, in the loss of agency, in the culture of constant availability, in the permanent arousal of the nervous system.

A state that truly cared about health would have to ask questions far more dangerous than the question of the number of hospital beds. It would have to ask why a person lives in such a way that they need so many beds. It would have to ask why work consumes the best hours of their biological day. Why sleep is treated as a private indulgence rather than as the foundation of cognitive, hormonal and immune capacity. Why low-quality food is logistically easier than real nourishment. Why a person has ever less contact with the sun, movement, community, nature and peace. Why an enormous part of life is turned into servicing the costs of existence itself.

But such questions are dangerous, because they shift attention from the patient to the order that produces the patient.

That is why the system far more willingly treats the individual than analyzes the conditions in which the individual falls ill. An individual can be examined, classified, recorded, referred, reimbursed, monitored. The conditions would have to be changed. And changing the conditions would mean striking at an entire structure of interests, habits, institutions and comfortable myths.

And here we reach the most difficult part: what happens when someone tries to see through this order and call it by its name?

In theory, science is a process of ceaselessly questioning its own assumptions. Its strength is not that it is always right. Its strength is the capacity to correct errors. Science is alive when it is able to ask about its own blind spots. When it can distinguish proof from authority, mechanism from dogma, method from institution. The trouble begins when science as a process is identified with the system as a structure. For the process seeks truth, while the structure protects the continuity of itself.

Every large system defends itself. Not always cynically. Not always consciously. Often precisely through people convinced that they are defending the good. The larger the institution, the greater its cognitive inertia. The more status, money, positions, procedures and careers have been built on a given model, the harder it is to ask that model the question that might unsettle it. The system protects not so much truth as its own code: the set of assumptions that define which questions may be deemed reasonable, which data relevant, which mechanisms admissible, and which people credible.

That is why someone who proposes solutions that reduce people's dependence on long-term pharmacotherapy, on years of symptomatic treatment and on centrally controlled structures, very quickly (often immediately) ceases to be treated as a potential innovator. They begin to be treated as a threat. And this regardless of whether they are right. Because in an order in which the sign has broken away from reality, the truth of a proposal ceases to be the first criterion. The first criterion becomes conformity with the code.

For this reason, the debate about health increasingly ceases to be a debate about mechanisms and becomes a debate about belonging. The question "does it work?" is displaced by the question "does it fit the recognized order?" The question "what is the mechanism?" is displaced by the question "who said it?" The question "is the person actually getting healthier?" is displaced by the question "does it fit within the procedure?"

From a sober perspective, this is not science but the administration of legitimacy dressed in something that merely resembles science.

A person who steps outside the prevailing model is rarely analyzed calmly. More often they are labeled. Reduced to a meme. Tossed into a bag marked "quackery," "pseudoscience," "anti-systemic thinking," "dangerous views," often before the first honest question about the proposed mechanism is even asked. The reflex of rejection fires faster than the reflex of analysis. And this reversal of order is itself a symptom that what is at play is no longer the search for truth. What is at play is the defense of a position.

Simulation cannot abide the question of its referent, because every such question threatens to reveal that the referent has been lost.

And so the system speaks most loudly of the "fight for health" while sustaining a world in which a healthy person, full of energy, thinking independently, biologically capable, becomes an ever rarer phenomenon. Not because someone at a desk planned that people should be weak. That would be too simple. The problem is deeper and therefore harder to grasp. Such a person is, for the order of simulation, almost invisible. They generate no procedures. They confirm no demand. They do not strengthen the statistics of intervention. They do not feed the narrative about the necessity of further expanding the apparatus. They are a hole in the map. And the map cannot abide empty places.

A truly pro-health system is not measured by the number of hospitals, procedures, machines and prescriptions issued. These are indicators of the activity of the treatment system, not indicators of the health of the population. A truly pro-health system is measured by the number of people who retain energy, fitness, fertility, sleep, immunity, clarity of thought, muscular strength, metabolic stability and the capacity to regenerate for so long that medicine remains for them a safeguard rather than a permanent environment of life.

The success of a health system is not that it can efficiently manage illness. The success is that illness appears more rarely, later, more mildly, and does not become the basic language for describing a human being. The success is not a greater number of interventions. The success is a greater number of people who do not need them.

As long as we measure care by the number of procedures, we will mistake motion for progress. As long as we measure health by the number of tests, we will mistake observation for regeneration. As long as we measure care by the size of the apparatus, we will mistake the monumentality of the sign for the reality of the thing. And these are two entirely different matters, separated from each other by the whole abyss between the map and the territory.

We already live inside a sign that has forgotten what it was meant to serve. We look at its scale and call it care, because it is easier to believe in the image than to ask why the body beneath that image more and more often lacks the strength to live.

That is why the question we would rather not ask ourselves sounds so simple and at the same time so unbearable:

Do we truly see care, or only its perfect simulation?

Bibliography:

1. Baudrillard, Jean, Symulakry i symulacja, przeł. Sławomir Królak, Wydawnictwo Sic!, Warszawa 2005.

2. Baudrillard, Jean, Społeczeństwo konsumpcyjne. Jego mity i struktury, przeł. Sławomir Królak, Wydawnictwo Sic!, Warszawa 2006.

3. Foucault, Michel, Narodziny biopolityki, przeł. Michał Herer, Wydawnictwo Naukowe PWN, Warszawa 2011.

4. Foucault, Michel, Nadzorować i karać. Narodziny więzienia, przeł. Tadeusz Komendant, Wydawnictwo Aletheia, Warszawa 2009.

5. Illich, Ivan, Medical Nemesis: The Expropriation of Health, Pantheon Books, New York 1976.

6. Illich, Ivan, Limits to Medicine: Medical Nemesis - The Expropriation of Health, Marion Boyars, London 1995.

7. Debord, Guy, Społeczeństwo spektaklu, przeł. Mateusz Kwaterko, Państwowy Instytut Wydawniczy, Warszawa 2006.

8. Han, Byung-Chul, Społeczeństwo zmęczenia i inne eseje, przeł. Rafał Pokrywka, Wydawnictwo Krytyki Politycznej, Warszawa 2022.

9. Rose, Nikolas, The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century, Princeton University Press, Princeton 2007.

10. Canguilhem, Georges, The Normal and the Pathological, Zone Books, New York 1991.

11. Sterling, Peter, Eyer, Joseph, “Allostasis: A New Paradigm to Explain Arousal Pathology”, w: Handbook of Life Stress, Cognition and Health, red. S. Fisher, J. Reason, Wiley, New York 1988.

12. McEwen, Bruce S., “Protective and Damaging Effects of Stress Mediators”, New England Journal of Medicine, 1998;338(3):171-179.

13. McEwen, Bruce S., Wingfield, John C., “The Concept of Allostasis in Biology and Biomedicine”, Hormones and Behavior, 2003;43(1):2-15.

14. Juster, Robert-Paul, McEwen, Bruce S., Lupien, Sonia J., “Allostatic Load Biomarkers of Chronic Stress and Impact on Health and Cognition”, Neuroscience & Biobehavioral Reviews, 2010;35(1):2-16.

15. Sapolsky, Robert M., Why Zebras Don’t Get Ulcers, Holt Paperbacks, New York 2004.

16. Sapolsky, Robert M., Romero, L. Michael, Munck, Allan U., “How Do Glucocorticoids Influence Stress Responses?”, Endocrine Reviews, 2000;21(1):55-89.

17. Ludwig, David S., Ebbeling, Cara B., “The Carbohydrate-Insulin Model of Obesity: Beyond ‘Calories In, Calories Out’”, JAMA Internal Medicine, 2018;178(8):1098-1103.

18. Hall, Kevin D. et al., “Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain”, Cell Metabolism, 2019;30(1):67-77.

19. Swinburn, Boyd A. et al., “The Global Obesity Pandemic: Shaped by Global Drivers and Local Environments”, The Lancet, 2011;378(9793):804-814.

20. Egger, Garry, Dixon, John, “Beyond Obesity and Lifestyle: A Review of 21st Century Chronic Disease Determinants”, BioMed Research International, 2014.

21. Walker, Matthew, Why We Sleep: Unlocking the Power of Sleep and Dreams, Scribner, New York 2017.

22. Czeisler, Charles A., “Perspective: Casting Light on Sleep Deficiency”, Nature, 2013;497:S13.

23. Panda, Satchin, The Circadian Code, Rodale Books, New York 2018.

24. Wright, Kenneth P. et al., “Entrainment of the Human Circadian Clock to the Natural Light-Dark Cycle”, Current Biology, 2013;23(16):1554-1558.

25. Holt-Lunstad, Julianne, Smith, Timothy B., Layton, J. Bradley, “Social Relationships and Mortality Risk: A Meta-analytic Review”, PLoS Medicine, 2010;7(7).

26. Cacioppo, John T., Cacioppo, Stephanie, “Social Relationships and Health: The Toxic Effects of Perceived Social Isolation”, Social and Personality Psychology Compass, 2014;8(2):58-72.

27. Putnam, Robert D., Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York 2000.

28. Conrad, Peter, The Medicalization of Society, Johns Hopkins University Press, Baltimore 2007.

29. Moynihan, Ray, Cassels, Alan, Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients, Nation Books, New York 2005.

30. Welch, H. Gilbert, Schwartz, Lisa M., Woloshin, Steven, Overdiagnosed: Making People Sick in the Pursuit of Health, Beacon Press, Boston 2011.

31. Ioannidis, John P.A., “Why Most Published Research Findings Are False”, PLoS Medicine, 2005;2(8).

32. Starfield, Barbara, “Is US Health Really the Best in the World?”, JAMA, 2000;284(4):483-485.

33. Lane, Nick, Power, Sex, Suicide: Mitochondria and the Meaning of Life, Oxford University Press, Oxford 2005.

34. Wallace, Douglas C., “Mitochondria and Cancer”, Nature Reviews Cancer, 2012;12:685-698.

35. Picard, Martin et al., “Mitochondrial Psychobiology: Foundations and Applications”, Current Opinion in Behavioral Sciences, 2018;28:142-151.

36. Naviaux, Robert K., “Metabolic Features of the Cell Danger Response”, Mitochondrion, 2014;16:7-17.