Orthodox and Alternative Medicine: Politics, Professionalization and Health Care

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Mike Saks

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    Acknowledgements

    Acknowledgements go to the many colleagues, too numerous to name, who have discussed with me the various areas covered by this book over many years, in national and international conferences, symposia and other forums. Most of all, though, thanks go to my family – my wife Maj-Lis and my children Jonathan and Laura – who through their tolerance of my twilight activities as an author and researcher have made this book possible.

  • Conclusion

    The development of orthodox and alternative medicine, and the links between them, has now been examined over several centuries in Britain and the United States. The book has therefore run most of its compelling course. It has moved from studying the period when the distinction between these two spheres did not yet exist, to considering the time when they became very starkly polarized. It has also explored the most recent signs of some kind of rapprochement between orthodox and alternative medicine, following the emergence of a strong counter-culture. This volume has sought to highlight the political dimensions of this process, especially those related to self-interests – defined in this context in terms of advancing the income, status and power of the groups involved. The notion of professionalization based on exclusionary closure has been central to the analysis, given its key role in the marginalization of alternative medicine by medical orthodoxy and paradoxically now in the resurgence of unorthodox therapies. A number of associated issues have also been discussed. These include why orthodox medicine was initially able to professionalize, the reasons for the subsequent marginalization of unorthodox therapies, how far the deprofessionalization of conventional medicine is currently in train and the extent to which the professionalization of alternative medicine has occurred in the Anglo-American context.

    The analysis suggests that the further integration of orthodox and alternative medicine could bring great benefit to the consumer. In looking to the future, therefore, the Conclusion focuses on how this may be achieved. Such benefit is most likely to result if the best of the current range of orthodox medical practices are employed, along with the complementary strengths of the increasingly popular and even more diverse span of alternative therapies. As we have seen, the latter may be most helpful in dealing with areas such as chronic illness, in which orthodox biomedicine has less to offer, for all its other achievements. Moreover, although alternative therapies are often more labour-intensive – with consultations usually lasting considerably longer than those with primary care physicians – the costs of the remedies and technologies involved are typically much lower (Saks 1994). This lower cost represents an added advantage over orthodox medicine at a time when cost containment is a key issue. It was also noted earlier that some types of alternative therapies are attractive because of their comparative safety, reflecting their characteristic emphasis on the promotion of health rather than simply the treatment of illness (Fulder 1996). In all these respects, it is important that the forms of orthodox and alternative medicine for which there is substantial contrary evidence are discarded – and that the therapies for which there is the most significant positive support are embraced.

    Thus there is a need for decisions about ‘best practice’ to be underpinned by research. The concept of ‘evidence-based’ practice brings to the fore the question of what is to count as the ‘best’ of both worlds, especially given the methodological disputes that have long raged about the most appropriate means of evaluating alternative, as opposed to orthodox, medicine in Britain and the United States. These throw into focus the issue of how central the randomized controlled trial should be in assessing such therapies. This may not be easy to resolve, as they are often rooted in methodological assumptions incommensurable with biomedicine, based on the individual nature of the treatments given and with a greater emphasis placed on qualitative outcomes (Saks 1998a). As noted in the Introduction, it may therefore be necessary to go beyond rigid claims about the ‘objective’ scientific status of orthodox medicine and acknowledge that the rules of the methodological game are far from universal. Orthodox and alternative medicine could then be brought together in the most productive manner – taking into account not only the relative strengths and weaknesses of particular therapies, but also how they may be best delivered in practice.

    From the viewpoint of the delivery of such therapies in the Anglo-American context, there are many possible organizational frameworks. Leaving aside the employment of orthodox and unorthodox medicine on a self-help basis, these raise a number of important questions. Should specific alternative therapies be applied in mainstream health contexts, in completely separate settings, or as part of a new integrated service based on holistic health centres? Should physicians be the gatekeepers for alternative therapies or should orthodox and alternative practitioners operate as co-equals, working alongside each other? Should alternative practitioners generally seek the legally enshrined professional regulatory frameworks possessed by orthodox health professionals? Should all fields of unorthodox practice be at least minimally based on the establishment of codes of ethics and lengthy education programmes, even if they do not gain formal exclusionary closure? Should shared learning with conventional practitioners be encouraged, in order to enhance future collaboration, and if so at what level? How, moreover, should the development of an evidence base be supported for alternative therapies – by the private sector, the state, or both, as in the case of orthodox medicine? And who should pay for the therapies concerned – the consumer at the point of access, the insurance plans, or the state? While the resolution of such issues is in part value based, it must again be informed by research (Best and Glik 2000).

    Some of these issues were discussed at a specially convened conference held in 2001 entitled ‘Can Alternative Medicine Be Integrated into Mainstream Care?’, jointly organized by the Royal College of Physicians in Britain and the National Center for Complementary and Alternative Medicine in the United States. The very title of the conference suggests that one of the key difficulties in enhancing integration may be the interest of orthodox medicine in controlling alternative therapies. It has been emphasized in this book that it should not necessarily be assumed that professional groups serve the public interest, as opposed to their own self-interests, despite the prevailing ideologies of professions. While moves to incorporate alternative therapies into conventional medicine are now under way in both Britain and the United States, some contributors fear that these may result in a form of integration excessively skewed towards biomedicine. In this regard, Cant and Sharma (1999) note that ‘integration’ may become synonymous with the medical ‘appropriation’ of alternative therapies at the expense of the public. This threat is linked to the continuing dominance of medical interests in health care. Although this may have declined in recent years – albeit rather more in the United States than in Britain – it remains a significant issue for the future.

    In terms of balance, it is also important to note the potential detrimental impact of the competing interests of groups of alternative practitioners, who may themselves be seeking parochially to ensure their own ascendancy, in the face of the long-term dominance of medicine (Saks 2001). In this respect, it could be argued that a cautious approach to integration, placing it under the wing of orthodox medicine, is advisable to protect the public from undue risk. Such an approach may be justified if substantial harm is likely to be caused by alternative practitioners, particularly where they have little or no knowledge of biomedicine and/or the therapies that they are purveying. This danger is receding, though, with the growing professionalization of alternative medicine (Saks 2000b). On the other hand, the many orthodox health professionals whose patients do not feel sufficiently confident to tell them when they are using unorthodox therapies pose a threat to the public (Cohen 1998). So may orthodox health professionals practising alternative medicine who are trained to a lower standard than non-medically qualified therapists. There are also risks when such personnel lack the knowledge to make sensible referrals to alternative therapists (Cant and Sharma 1999). The extent to which doctors and allied health professionals can operate without sanction in the current manner may itself reflect ongoing medical hegemony.

    If entrenched professional interests primarily sustain the current position, major catalysts for change may be necessary for integration in health care to be enhanced in the Anglo-American context. One such catalyst in Britain has been the high-profile report on Integrated Healthcare, produced by the Foundation for Integrated Medicine (1997), under the sponsorship of the Prince of Wales. This was designed to prompt consideration of the way forward for the next five years as a spur to government action. It was based on the reports of four working groups that made sensitive and inclusive proposals for advancing the agenda in relation to research and development, education and training, regulation, and delivery mechanisms. In the United States, the direction of work on alternative medicine has also been positively affected by publications such as Manifesto for a New Medicine, produced by the first chair of the Advisory Council of the Office of Alternative Medicine (Gordon 1996). In the more devolved American political system, this book focuses on small-scale case studies that show how orthodox medicine can be synthesized with alternative therapies at grassroots level. Its aim is to provide a guide to healing partnerships and the wise use of alternative medicine, to facilitate more effective integration with biomedicine through the consumer.

    The intervention of the federal state, however, is now likely to have the most critical influence on this field. In this respect, two recent national initiatives in the Anglo-American context hold much promise in developing further the rapprochement between orthodox and alternative medicine. In Britain the driving force has been the report by the House of Lords Select Committee on Science and Technology (2000) on complementary and alternative medicine. Drawing on evidence submitted from many interested parties, this report makes a threefold distinction between complementary and alternative therapies. The first group delineated by the Committee is composed of acupuncture, chiropractic, herbal medicine, homoeopathy and osteopathy. These therapies are centred on individual diagnosis and treatment, and are seen to possess the most credible evidence base and the most organized groups of practitioners. The second group of therapies, exemplified by aromatherapy, counselling, hypnotherapy, massage and reflexology, are held to complement conventional medicine. The defining feature of the third group is felt to be that the therapies concerned have philosophical principles counterposed to those of mainstream medicine, as well as the weakest research base. This group encompasses such long-established health systems as Ayurvedic Medicine and Traditional Chinese Medicine, together with crystal therapy, iridology and radionics.

    On the basis of these distinctions, the report makes a number of recommendations to government, most of which have been well received (Department of Health 2001b). Among these are the following:

    • The National Health Service should ensure access to complementary and alternative therapies through medical referral where there is evidence of efficacy and/or robust regulatory mechanisms.
    • Single professional regulatory structures should be developed for such therapies, on a statutory or voluntary basis as appropriate.
    • Training in their practice should be linked to higher education, encompassing where relevant an understanding of research methods as well as biomedical knowledge.
    • Orthodox health professions should be more systematically familiarized with complementary and alternative medicine and draw up guidelines on standards for their members.
    • Research into complementary and alternative medicine should be extended, with pump-priming monies from government.
    • More information about such therapies should be made available to the public, not least through the National Health Service helpline NHS Direct.

    The document echoes some of the recommendations of earlier reports, including that of the British Medical Association (1993), while providing its own distinctive gloss. One key difference from the latter report is that it adopts a more eclectic view of research methods and argues for ring-fenced research funding for non-conventional medicine.

    Although the House of Lords Select Committee report has been criticized – not least for the apparent inconsistency of placing acupuncture in group 1 of its categorization, while locating Traditional Chinese Medicine in group 3 – it has undoubtedly moved the field forward in Britain. In America, its work has been paralleled by that of the White House Commission, which was established in 2000 by President Clinton to report on complementary and alternative medicine because of the high level of public interest in, and use of, unorthodox medicine (National Center for Complementary and Alternative Medicine 2001b). The Commission was tasked with making recommendations to the President of the United States to ensure that public policy maximizes the benefits of such therapies. The final report of the White House Commission on Complementary and Alternative Medicine Policy (2002) has now been published, following extensive consultation with many stakeholders. It includes such proposals as:

    • The Department of Health and Human Services should develop strategies for increasing consumer access to safe and effective forms of complementary and alternative medicine.
    • An office should be created to coordinate federal complementary and alternative medicine activities and facilitate their integration into the national health care system.
    • Insurers and managed care organizations should offer purchasers the option of health benefit plans incorporating appropriate complementary and alternative medicine interventions.
    • The education and training of both complementary and alternative medicine and orthodox medical practitioners should be designed to ensure public safety and improve health.
    • The dialogue between complementary and alternative medicine practitioners and conventional medical professionals should be strengthened.
    • The federal, private and non-profit sectors should support more research into complementary and alternative medicine, which needs a stronger research infrastructure.
    • The federal government and the states should ensure that accurate, useful and easily accessible information is available on complementary and alternative medicine.

    Leaving aside the references to the distinctive American political context, there are clearly many resonances with the recommendations of the report of the House of Lords Select Committee on Science and Technology (2000), on which the Commission explicitly draws.

    The importance of federal involvement in the development of alternative medicine in the United States, in addition to the efforts made to integrate it with orthodox medicine in individual states (Cohen 1998), is also highlighted by the progress that has been made through the National Center for Complementary and Alternative Medicine. This body, which is part of the National Institutes of Health, is anticipating further budget increases under the Bush administration from the $89 million it received in fiscal year 2001, following low-level beginnings in its previous form as the Office of Alternative Medicine in the early 1990s. Its high-priority areas of research range from investigating the mechanisms of complementary and alternative medicine to facilitating the successful integration of safe and effective non-conventional therapies into mainstream medicine (National Center for Complementary and Alternative Medicine 2001a). The Center also throws up a dilemma related to enhanced government involvement in complementary and alternative medicine – namely, that, as the level of investment rises, the field may be subject to ever-greater biomedical capture. This is in part because escalating federal funding provides interest-based incentives for orthodox doctors and medical researchers to enter this area, which may work to the prejudice of a balanced pattern of integration in health care.

    The experience of other Western countries also points the way to a more integrated future in health care. In continental Europe the contemporary growth in popularity of alternative medicine has broadly mirrored that in Britain. This has led to its expanding use by health professionals, as well as increasing support from the state (Fisher and Ward 1994). Unlike in Britain, governments in many other European countries adhere to traditional legal codes that restrict the practice of alternative medicine to registered medical professionals. However, in the light of increasing public interest in such therapies, a number of governments have allowed the expansion of practice beyond existing medical bounds. As early as 1970 in the Netherlands, for example, the State Commission on Medical Practice recommended that the medically unqualified should be prevented from practising alternative medicine only where public health was at risk (Fulder 1996). The extent of state interest in alternative therapies in Europe more generally is highlighted by the recent 5-year Cooperation in Science and Technology project on unconventional medicine, sponsored by the European Commission. This project involved researchers from Belgium, Croatia, Denmark, Finland, Germany, Hungary, Italy, the Netherlands, Norway, Slovenia, Spain, Sweden and Switzerland, as well as Britain. Its aim was ‘to foster international collaboration in research into the therapeutic significance of unconventional medicine, its cost-benefit ratio and its socio-cultural importance as a basis for evaluation of its possible usefulness or risks in public health’ (Monckton et al. 1998: 8).

    From a North American perspective, there has been progress towards integrated health care in Canada too. Kelner and Wellman (1997b) document how alternative medicine is flourishing alongside orthodox biomedicine – in a system where patients choose the type of practitioner that they believe will best help their specific problem. While there is variation between the provinces/territories in the official provision made for alternative therapies (Clarke 1990), at a national level increasing priority is being placed on people-focused services. The same priority is evident in the more consumer-oriented systems of managed care in Canada. As in the United States, therefore, growing attention has been given to integrating orthodox and alternative medicine for the benefit of the consumer – including by enhancing health information services, improving funding for health research, and supporting self-care and prevention across these fields (Best and Glik 2000). In this spirit, Health Canada established an Advisory Group on Complementary and Alternative Health Care in 1999 to identify crucial health system issues and propose a future strategy (Shearer and Simpson 2001). It also set up an Office of Natural Health Products to help ensure that alternative medicine is effective, safe and of high quality, while respecting the individual rights and diversity of Canada's population (De Bruyn 2001). However, as in Europe and the United States, such an approach will not bring about positive changes in the extent of integrated health care without multi-sectoral collaboration and bottom-up thinking (Best and Glik 2000).

    This point is underlined in countries in the East such as China and India, where therapies that are regarded as alternative medicine today in Britain and the United States are more strongly embedded as part of orthodox medicine, alongside biomedicine which has spread from the West (Saks 1997b). In China, for example, there are many hundreds of thousands of practitioners of the long-standing system of Traditional Chinese Medicine, and all hospitals have an outpatient clinic for traditional medicine (Fulder 1996). This contrasts with its relative marginality in the Anglo-American context. That said, even in China exponents of Traditional Chinese Medicine do not necessarily operate on a level playing field with their orthodox counterparts, given the current popularity of Western biomedicine. Indeed, they were formally banned in the past – as when Traditional Chinese Medicine, with its characteristic yin-yang philosophy, was suppressed in the 1920s by the Kuomintang, because it was seen as running counter to the modernization of China (Saks 1995b). Acupuncture, herbal remedies and other aspects of this form of health care, however, were revived following the Communist Revolution in 1949, and now both Traditional Chinese Medicine and biomedicine receive strong state support (Bray 2000). Thus the alternatives of today can become the orthodoxy of tomorrow – thereby underscoring the fluidity of the boundary between orthodox and alternative medicine.

    Given the impact of philosophies from the East on the development of the contemporary counter-culture in the West in the 1960s and 1970s, it is tempting to see the integration that is presently emerging primarily as a fusion of Eastern alternatives and Western biomedicine. In practice, though, the situation is much more complex. To be sure, Eastern philosophies have greatly influenced both Britain and the United States. Such influence is well exemplified by the books of Deepak Chopra, which have sold many millions of copies and aim to help readers to increase their energy levels using Ayurvedic principles (see, for instance, Chopra 1995). These principles underpin much of the traditional health care in the Indian subcontinent (Cant and Sharma 1999). They hold that individuals have varying body types with differing amounts of vata, pitta and kapha that influence, among other things, movement, digestion and the balance of bodily fluids. As we have seen, however, there are also many indigenous influences on alternative medicine in the Anglo-American context. These are illustrated by chiropractic and osteopathy, which were founded in the United States, and the distinctly British herbal heritage that runs alongside that of China and India (Fulder 1996). In addition, it should again be stressed that when therapies such as acupuncture have been adopted in the West, they have frequently been transformed into biomedical modalities that bear little resemblance to their ancient practice in the East (Saks 1995b).

    These international examples indicate that the future pattern of integration of orthodox and alternative medicine in Britain and the United States is likely largely to reflect the particular history and socio-political context of each of these societies (Saks 1997b). In Europe and North America the popularity of specific alternative therapies varies from country to country, partly related to cultural preferences. In France, for instance, the most widely used therapy is homoeopathy, whereas in the Netherlands it is spiritual healing and in Denmark reflexology (Fisher and Ward 1994). Interestingly, the latter two therapies do not figure as strongly in Britain as practices such as acupuncture and herbal medicine. In Canada, meanwhile, chiropractic is the most popular type of alternative medicine – with chiropractors now constituting the third biggest group of primary care practitioners after doctors and dentists. While there is a similar pattern in the United States, Canada is distinguished by the greater degree of prominence given to naturopathy (Clarke 1990). It should be noted that professional interests have also been important influences in shaping the terrain. In France, for instance, homoeopathy has flourished largely because by law its use is exclusively restricted to physicians (Fulder 1996), which has effectively eliminated competition and opened up the field for colonization by medical orthodoxy.

    This is a reminder that the nature and form of integration of orthodox and alternative medicine vary across nations – and that it is not always the non-medically qualified who are the standard-bearers for alternative therapies. It underlines too that the extent to which integration occurs is affected by a wide range of factors. These range from the degree of compatibility of the philosophies underlying particular orthodox and alternative therapies to ‘belief barriers’ in orthodox medicine about the acceptance of non-conventional health care (Cohen 1998). As has been indicated, the specific conjunction of occupational self-interests in the health field may well be one of the most significant ingredients in this equation. This has been a central theme of this volume, as part of the neo-Weberian analysis of the politics of professionalization in Britain and the United States. The author hopes that this analysis will enable the main field-breaking aim of this book to be realized – that is, to provide a rounded social scientific account of the historical, contemporary and possible future development of health care in the Anglo-American context, which recognizes that orthodox and alternative medicine are two seamlessly interrelated sides of the same coin.

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