Sarah Cant & Ursula Sharma. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
Introduction
Whilst biomedicine has achieved a position of preeminence in the health-care systems of ‘advanced’ societies, it has never been the only mode of health care open to sick people in modern times. Biomedicine emerged as the favoured partner of the state in most Western countries in the middle or late nineteenth century. The professional privilege recognized by the state has taken various forms: state registration of the medical profession, along with a high degree of professional autonomy; direct provision or funding of biomedical services for the populace (as in Britain and many other European countries); regulation or organization of insurance schemes covering biomedical but not (until recently) other forms of health care; heavy reliance on the biomedical profession’s advice on all public issues relating to health and the body.
This privileging has been associated with what sociologists have called the ‘medicalization’ of society—referring both to the way in which more and more conditions become defined in terms of medical models of disease, and to the process by which the biomedical profession achieves practical power over patients and over other kinds of health-care professional (see, for example, Stacey 1988). In many Western countries (such as France) the practice of healing by persons without a medical qualification was illegal. In a few (like Britain) the practice of non-biomedical forms of healing was permitted, but the title of doctor was protected by law from its use by persons not biomedically qualified.
However, even in those countries where biomedicine was most strongly privileged by the state, other forms of healing still flourished. Rural populations and some of the urban poor never had good access to biomedical care and used folk systems of curing either out of necessity or preference, as also have some ethnic minorities, (see, for instance, Kirkland et al. 1992, Vaskilampi 1993). While biomedicine was beginning to take its modern institutional shape, many other important forms of healing grew in the context of the intellectual and social ferment of the nineteenth century (Cooter 1988; Gevitz 1988). Homoeopathy was one of the earliest, at times rivalling conventional medicine in popularity in some parts of Europe (Faure 1992; Nicholls 1988). Chiropractic and osteopathy developed in, and spread from, the United States in the late nineteenth century (Baer 1984; Wardwell 1992).
Of these modes of healing, many that survived into the twentieth century experienced a period of decline or stagnation during the interwar period, but nonbiomedical healing never actually went away. Many forms have reemerged into greater popularity since the 1960s, becoming the subject of more research and seeing increasing professionalization of their practitioners. This period also saw the emergence or importation of modes such as aromatherapy, reflexology, etc.
Alternative medicine, considered as a category of health care, is therefore not new, although some specific forms may be novel. Increased interest in the 1960s manifested itself first among the educated middle classes (especially women), but is not now confined to those groups. A summary of data from Europe published in 1994 indicates a range between 20 per cent (The Netherlands) and 49 per cent (France) of the population using some form of alternative medicine, with a steady increase during the 1980s being evident where statistics have been available over time (Fisher and Ward 1994: 309).
In the absence of survey data from an earlier period, we cannot easily assess the role which nonbiomedical forms of healing might have played before the 1960s. Evidence of bitter medical opposition to specific therapies suggests that some individual forms presented real threats to biomedicine. However, by the late 1960s a public debate had developed which defined alternative medicine as a generic issue and which focused on the general role and legitimacy of nonbiomedical forms of healing.
This debate has had various forms and levels. At state level, some governments have been moved to reconsider restrictive legislation (as in the case of The Netherlands), provide funds for research into roles and efficacy (United States, The Netherlands, Switzerland, Denmark), or consider state registration for the more professionalized alternative therapies (Great Britain, Australia). Doctors are increasingly asking questions about the possibility of cooperation with alternative practitioners, and many models of collaboration exist in spite of the continued antipathy expressed by many professional medical associations. If the public are voting with their feet in favour of a more diverse system of health care, does this imply a loss of status and legitimacy for biomedicine (even science in general), or perhaps a less disease-orientated revision of popular conceptions of health, well-being, and responsibility for the body? Is medical dominance declining in favour of a more pluralistic provision—does the new role of alternative medicine constitute a significant challenge to biomedicine (Saks 1994)? Or is this apparent pluralism a new dispensation over which biomedicine still exercises a presiding role, keeping the power to define what is and what is not charlatanry? How is the new role for alternative medicine defined in different kinds of health-care systems (market-oriented, state-organized, etc.)?
Much work on alternative medicine has considered the issue principally in terms of ‘rejected knowledge’—rejected, that is, by the biomedical and scientific establishment. The relationship between biomedicine and alternative medicines is nowadays very complex. As we shall see, medical attitudes range from outright rejection to incorporation. However, it remains a matter of the utmost political importance and, in any given country, plays a crucial role in shaping the opportunities for alternative medicines to gain greater legitimacy and security.
However, these opportunities are also shaped by patient perceptions. The use of alternative medicines has grown rapidly, and in many Western countries it can be assumed that as much as a third of the population has had some experience of them. Users share their information about, and perceptions of, alternative medicine through patients’ self-help groups, consumer groups, and informal local networks. The patient, considered as consumer, cannot be ignored when we consider the present situation and likely outlook for alternative medicines.
The therapies themselves have not stood still. The ‘lay’ therapy groups that emerged or reemerged in the 1960s look different today. Most have professionalized to some degree and become politically much more sophisticated, and many have engaged with biomedical knowledge in different ways. Within the biomedical camp, doctors who practice alternative medicines have become more confident and vocal in promoting these therapies within medicine, and some have started to enter into closer relationships with ‘lay’ therapists practising the same therapy.
Such a revolution in health care was bound to have implications for policy and the state. In some countries there has been a demand for a radical reform of the statutory position on nonbiomedical therapies. In practice, the changes to the legal position of alternative therapies have usually been very limited, but even where the letter of the law is restrictive with respect to the practice of healing by anyone who is not a doctor, there has been a noticeable relaxation in attitudes. In many countries those responsible for national health policy have shown a degree of interest in integrating some alternative therapies into whatever health-care provision is funded directly or indirectly by the state.
In this chapter we consider the contemporary position of alternative medicines from these four points of view: those of patients, doctors, therapists, and the state. We recognize that this does not exhaust the possible angles from which the debate may be studied. One could, for instance, examine the ways in which insurance companies have increased the number of alternative therapies for which they will reimburse patients, or the attitudes of the pharmaceutical companies to ‘natural’ medicines. It is unfortunate that there is not space here to deal at length with the relationship between alternative therapies and the nursing profession. However, the four perspectives we discuss are of crucial importance in framing both the opportunities and the problems that alternative medicines face at the present time. We are aware of the problems of a generalizing approach and hope that this overview will do justice to the complexities and diversities of the situation in different ‘Western’ countries.
The very label ‘alternative medicine’ is contentious. Some prefer the term ‘complementary’ medicine, recognizing that many patients and doctors use these forms to complement biomedical health care rather than to replace it. Some healing modes which are ‘alternative’ or ‘complementary’ in one country are virtually incorporated into the biomedical canon in another, and where doctors themselves practise nonbiomedical healing, the boundaries between alternative and orthodox medicines are increasingly hard to define. Nonbiomedical healing practices are a highly heterogeneous category everywhere; osteopathy, as practised in Britain today, probably has more in common with biomedicine than it does with spiritual healing or crystal therapy.
Various other terminologies can be used to refer to the healing modes under discussion (‘parallel,’ ‘gentle,’ or ‘holistic’ medicines) and all have their advantages and disadvantages. We have continued to use the term ‘alternative medicine(s)’ simply because it, or its equivalents in other languages, are the most widely used. We are aware of the conceptual problems in defining and naming nonbiomedical forms of healing, and refer the reader to Fulder (1996) for a helpful discussion.
Users of Alternative Medicine
Alternative medicine can no longer be considered a marginal health-care option. Studies in many countries suggest that increasing numbers of people have consulted alternative practitioners, although it is not always clear whether the survey instruments are quantifying one off consultations or consistent use over a period. Such methodological ambiguities inevitably make comparisons difficult (see Cant and Sharma 1999), but the available evidence suggests that at least 20-25 per cent of populations across the Western world have used an alternative practitioner in the past year (Eisenberg et al. 1993; MacLennan et al. 1996; Menges 1994; Sermeus 1987). Despite the massive growth in the number of available therapies, it is still a relatively small number that attract the greatest support, particularly osteopathy, chiropractic, homoeopathy, herbalism, and acupuncture (Fisher and Ward 1994; NAHAT 1992). In America, relaxation therapy and therapeutic massage are also very popular (Paramore 1997).
What do we know about the characteristics, health beliefs, and practices of those who consult alternative practitioners? Does use of alternative medicine represent a radical alteration in the health behaviour of the lay populace, and do users share demographic and attitudinal characteristics? There is some evidence that middle-aged and middle-class women make up the largest category of users, although this need not surprise us when we note the usage patterns of biomedicine (Verbrugge 1982). The increase in the use of alternative medicine over time has not been matched by an even spatial patterning; for example, there are more practitioners and consequently greater accessibility of services in the south compared with the north of England (Cant and Sharma 1999). Studies in Australia (Lloyd et al. 1993), Britain (Furnham and Bhagrath 1992), and Germany (Furnham and Kirkcaldy 1996) also suggest that users are more health conscious, concerned with healthy living, and sceptical of biomedicine, although such differences can vary according to which therapy group is studied. For example, users of acupuncture were found to be more sceptical of biomedicine than a similar sample of osteopathic patients (Vincent and Furnham 1996).
Evidence of scepticism towards biomedicine does not mean that users of alternative medicine are opting to reject orthodox medical care. On the contrary, the majority of patients see their general practitioner before they seek advice from an alternative practitioner and then rarely abandon biomedicine totally (Ooijendijk et al. 1981; Thomas et al. 1991). It is likely that users of alternative medicine are high consumers of health services generally (not just alternative medicine), especially as many are sufferers of chronic illness. However, more detailed studies (Sharma 1995) have revealed that there are a variety of patterns of usage. Some users are very discerning and knowledgeable in their choice of practitioner. In particular, with increased knowledge about the services that the alternative practitioner can provide (as in the case of those whom Sharma terms ‘stable users’), there is evidence that the individual will shop around among practitioners, continuing to use the biomedical practitioner for particular complaints. Similarly, in America it has been shown that as users increase their understanding of chiropractic, they are likely to consult these practitioners as a health-care option of first resort and treat them as primary practitioners (Sawyer and Ramlow 1984). These examples of ‘demarcated use’ thus show us that patients may undergo trajectories of experience that, in time, enable them to use services selectively, but even this active choice of alternative medical services has not occurred at the expense of biomedicine, as few patients completely reject orthodox care. These patterns of use suggest that we may be seeing the development of plural and complementary medical services.
The Value of Alternative Medicine to Users
These new health practices can tell us an enormous amount about what it is that patients desire from health care. Clearly, patients want efficacious treatment (Sharma 1995), but the decision to use alternative medicine does not appear to be driven by this consideration alone. In the first place, it has been shown that many users of alternative medicine express concerns about the side-effects associated with biomedical interventions (Sharma 1995) and prefer to use what they regard as more ‘natural’ treatments. (This does not mean that biomedical services are not deemed to be efficacious, nor that alternative medicines should be viewed as ‘risk-free.’)
Second, qualitative differences in the therapeutic encounter are an attraction to the users of alternative medicine. The amount of time spent by the practitioner is perhaps the most important. Consultations can last more than an hour and provide the opportunity for patients to discuss their medical problem in depth and explore their underlying anxieties. This attention to the holistic nature of health and disease means that a person’s spiritual and emotional well-being is as important as their physical symptoms. It necessitates a highly individualistic approach to treatment and the need to extract detailed information from the patient about the nature and personal significance of his illness. Consequently, the patient is treated as ‘expert’ having valuable knowledge about him/herself, and is afforded a sense of consumer control over the health-care programme. Qualitative studies show that patients respond positively to being treated as an equal and desire a more participatory relationship with their practitioner (Hewer 1993). Of course this more mutual and sharing relationship can bring ambiguities. For example, patients were sometimes confused about how to treat their practitioner—as friend or expert? (see Cant and Sharma 1998.) There may also be limits to the level of expertise the patient is in a position to exercise. All of the patients in Cant’s study of users of homoeopathy believed that they had a role to play in the consultation, but the majority were not at all informed about the medication they had been prescribed or indeed about homoeopathy in general. Only one respondent claimed to have tried to read up about the remedy that he had been given.
I never know what the remedy is—I did read and go to lectures. I got hooked really, but he (the homoeopath) discouraged me and told me to think that it is all magic. (Cant and Sharma 1999: 42)
It appears that patients do not all desire full equality in terms of health knowledge. Certainly it has been shown that practitioners want only to encourage a certain degree of participation and may withhold information, partly no doubt to maintain their own professional distance and boundaries of expertise (see Cant and Sharma 1996a, 1996b). Nevertheless, patients generally feel that they participate more actively in the alternative medical encounter. The fact that most alternative medicine is still only available on the private market means that users are more likely to have made autonomous decisions about whom to consult rather than depending on the advice of a biomedical practitioner. This active participation in the choice of both therapy and practitioner, and the perceived involvement in the consultation itself, suggests a shift in power relations between user and practitioner, the former taking the role of ‘consumer’ rather than ‘patient.’
Alternative medicine may also offer more satisfactory ways of interpreting illness experiences that move beyond reductionist accounts and resonate with ideas held by the patient. We know that the lay public has a wide range of frameworks of meaning which are used to make sense of illness episodes (Stacey 1988), and that these are not generally drawn upon by the biomedical doctor. In contrast, alternative medical practitioners usually spend a long time questioning the patients about their family, their lifestyle, and their environment. Indeed questions can be so probing and wide ranging that new patients may feel perturbed about their relevance. But, there is evidence that some patients do feel that alternative medicine helps them make sense of their situation even if it is by simply linking their health problems to those of their family (Sharma 1995). On the other hand, not all therapists spend extended time with their patients; with chiropractic the average consultation may last no more than 15 minutes (Cant and Sharma 1994). Some patients may consult because they hold particular health ideologies, require a different relationship with their practitioner, or are concerned about the safety of biomedicine, but others may be more pragmatic, desiring no more than the relief of a particular symptom. We should therefore be cautious about giving too much emphasis to the pursuit of meaning.
Use of alternative medicines may be connected with changing understandings of the body. Many alternative practitioners view themselves as educators as well as healers, and try to help patients achieve a better understanding of their bodies and health and well-being. Quantitative data certainly seem to suggest that users themselves are more concerned about preventative health care and are less likely to smoke or drink alcohol than nonusers (Lloyd et al. 1993). It is argued by sociologists that the body has become a ‘project’ (Shilling 1993), one that is increasingly seen as unfinished, to be shaped by lifestyle choices. Perhaps there is a link between the attraction of alternative therapeutic practice, with its emphasis on holistic health care, and increased concerns about the ‘healthy’ body. Furnham and Kirkcaldy (1996) showed in their quantitative study that users were more knowledgeable about their body than nonusers, and Cant’s qualitative study demonstrated that users were very aware of, and concerned to monitor, bodily changes and to ensure that they worked actively to maintain ‘good’ health. Such body monitoring was often encouraged by therapists, who asked their patients to keep a diary of how they were feeling and to chart any bodily changes they experienced. Respondents felt that this had transformed their perceptions of themselves.
It has done something to me—what am I trying to say, my body tells me what is happening all the time. My body leads me now…. if the psoriasis starts I know now that I am emotionally stressed… I make the connection between emotional and physical signs. I don’t check my body all the time but I do monitor it. (Cant and Sharma 1999: 44)
Others talked about how they had become more preoccupied with their good health and made sure that they did all possible to ensure that a state of such ‘good health’ was maintained.
Such comments can explain the continued use of alternative therapies by individuals, but they also illustrate the connection between alternative medical practice and what Crawford has called ‘healthism’ (Crawford 1980)—a belief in the perfectibility of health and the individual’s responsibility for maintaining that health. This cultural emphasis can be interpreted as empowering, offering individuals the opportunity to know themselves (Busby 1996), or as disciplining, placing more responsibility on the individual and operating as a surveillance function (Braathen 1996). Crawford (1980) would favour the latter interpretation, arguing that holism does not empower the individual, for it does not provide effective social and political analysis of the causes of ill health. Alternative medicine seems to de-medicalize personal health by encouraging the individual to be less dependant on biomedicine, but paradoxically it then re-medicalizes life, bringing all areas of a person’s emotional and spiritual life under scrutiny (Lowenberg and Davis 1994).
The changes in lay health-seeking practice which we have discussed may signify a change in the power balance within health care generally. Patients appreciate greater equality in their relations with their practitioners, and biomedicine may need to become more patient-orientated if it is to retain support. The greater scepticism towards biomedical knowledge and treatment regimes may also serve to displace trust and question the authority of orthodox doctors. The biomedical profession well aware of such threats, has been concerned to understand the attraction of alternative medicine (BMA 1986), and, as we shall see in the following section, has attempted to exclude, limit, or subordinate alternative medical practice.
Relations with the Medical Profession
Given the social power of biomedicine, the situation of alternative medicine is bound to be influenced by the attitudes of doctors. Whilst alternative therapists have been more conscious of medical hostility than of other dimensions of the relationship, the influence of biomedicine has been positive as well as negative.
Some forms of alternative medicine are widely practised by doctors, and even among doctors who do not claim to practise any form of alternative medicine there is a widespread interest in knowing more about it. According to a study by Goldszmidt et al, 68 per cent of a sample of Canadian general practitioners claimed to refer patients to nonmedical alternative practitioners (Goldszmidt et al. 1995: 31). A British survey found that 93 per cent of a sample of GPs and 70 per cent of hospital doctors claimed to have suggested referral for alternative medical treatment (Perkin et al. 1994: 524). A comparison between Canadian and US survey data also suggests substantial rates of referral (Verhoef 1996), although both this survey and that of Perkin suggest that GPs perceive themselves as under some pressure from patients to refer. Therefore, it is not clear how far any trend towards referral to alternative practitioners is driven by doctors’ own conviction of the value of alternative medicines, and how far it is a rather reluctant response to perceived patient demand.
In the United States, Great Britain, and a number of North European countries we are seeing more and more instances of the integration of biomedicine and alternative medicines at various levels. This can take place through various kinds of collaboration between medical and alternative practitioners in the context of local initiatives and the establishment of multidisciplinary, holistic health-care teams. Pietroni (1992) has categorized ways in which alternative medicine could be integrated into general practice. His typology is based on the possibilities contained in the British health-care system, but (with some modification) would be widely applicable elsewhere. The opportunities listed include: (a) appointment of alternative practitioners as ancillary staff funded by the family health service authority; (b) sharing of premises by GPs and privately practising alternative practitioners, with referrals by the GPs; (c) provision of services by alternative practitioners located in the GP practice centre but funded by charities and voluntary contributions; (d) referral centres funded by local health authorities and enabling a group of local GP practices to access the services of alternative practitioners without actually sharing premises. None of these models departs from the ‘traditional’ relationship between GP and alternative practitioner, in which the GP retains clinical responsibility for the patient. However, Pietroni also proposes a more radical and experimental model in which both doctors and alternative practitioners share ownership of, and jointly manage, health centre premises and resources, share equally in any profits made by the centre, and share medical accountability as a corporate group. Patients would register with the practice and not the GP, and would have the option of going directly to an alternative practitioner within the group rather that through the ‘gatekeeper’ GP. However, this would require doctors to cede more authority to alternative practitioners than most would probably be prepared to countenance as things are at present.
At the level of research training, we find collaborative schemes like the ‘Munich Model,’ a university project for the integration of naturopathy into research and training at the Maximilian University in Munich (Melchart 1994). There is increasing inclusion of modules on alternative therapies in the education of undergraduate medical students in the United States, Britain, and other countries where forms of alternative medicine such as homoeopathy, acupuncture, or manipulation had not hitherto been any part of the medical curriculum (Pavek 1995). There is also enormous interest in alternative modes of healing among some other health-care professions, notably nurses and mid-wives (Rankin-Box 1993).
However, the collective voice of medicine has not always been so kind, and national medical associations have often offered stiff resistance to any move to legitimate alternative medicine. The modern biomedical profession sees itself as practising a form of healing which, in contradistinction to other practices, is based on scientific enquiry and experimentation, and it legitimates itself largely in these terms. The accusation that nonbiomedical healing lacks scientific proof is the main plank of the modern critique of nonbiomedical healing (BMJ Editorial, 1980: 2). Some medical critics have claimed that the re-emergence of alternative medicine represents a return to magic, superstition, and unreason (Glymour and Stalker 1989: 27).
Such negative attitudes cannot be lightly dismissed given the strong influence that the organized medical profession has had on the government policy of individual countries. For instance, the British medical profession managed to block repeated attempts by osteopaths to achieve state registration in the interwar years (Larkin 1992). Of course this influence is very uneven; in Sweden the medical profession has, in spite of a public oppositional stance, been able, at most, only to delay legislation favouring the legitimation of alternative medicine (Eklof 1996).
The Case of Chiropractic
The case of chiropractic may serve to illustrate some of the different ways in which the medical profession can deal with therapy groups that threaten its privileged position. Chiropractic depends largely on forms of spinal manipulation, and was founded by Daniel David Palmer (1845-1913). It spread very rapidly in the United States and was licensed in almost every state over the 50 years following Palmer’s death. Patients evidently regarded it as a form of legitimate medical practice that avoided some of the things they disliked about conventional medicine, especially heavy reliance on drugs, and they seem to have approved of its eclectic practice. They certainly did not share the medical profession’s view that chiropractic was a deviant form of healing (Cobb 1977: 18). Conscious of this, legislators were prepared to override medical objections that it had no scientific basis when the inclusion of chiropractic under Medicare was an issue. Paradoxically, in spite of chiropractic’s rejection by the medical profession, licensure helped to effect convergence between the knowledge bases of chiropractic and conventional medicine through the requirement for the inclusion of much biomedical knowledge in the curriculum. Legitimation was therefore something of a mixed blessing from the point of view of the chiropractic purist (Baer 1984: 158).
By the 1970s chiropractors had gained enough confidence to bring a lawsuit against the American Medical Association and ten other medical organizations on the grounds that they had breached antitrust laws in conspiring to effect a monopoly over health care and to constrain licensed chiropractors from competing. The court upheld the case of the chiropractors and, in addition to imposing damages, insisted that an interprofessional research institute be set up to promote cooperation between chiropractors and the conventional medical profession. Since this event, the AMA has muted its collective opposition to chiropractic and has attempted containment rather than elimination (Gibbons 1980). It has not yet offered to chiropractors the place within its fold which it extended to American osteopaths.
In some other countries the story was similar. In Australia, chiropractors faced vehement medical opposition, often taking the form of malpractice suits brought against individuals (Fulder 1996: 103). However, when in 1974 the Ministry of Health established a committee to look into the usage of chiropractic, it concluded that chiropractic filled an important gap in the Australian health-care system. Manipulative Therapy Acts have since been passed by individual states offering registration to chiropractors and osteopaths despite continued medical opposition (although some Australian doctors would not object to state licensing for chiropractic if their practice were limited to back pain (Easthope 1993: 294)). On the other hand, in Britain the 1994 Chiropractors Act was passed with active support from the medical profession; the more limited scope of chiropractic practice in Britain meant that it did not constitute a threat to the overall position of medicine, as it had done in the United States. Indeed, it was regarded as helping to relieve back pain, a major issue for both the GP and the orthopaedic specialist. Chiropractors were not asking for parity with the medical profession and could be admitted to a legitimate, although adjunct, role with full medical support.
The case of chiropractic demonstrates that whilst national medical associations have, in general, taken a hostile stance to alternative medicine, their positions have varied over both space and time according to whether they see a particular modality as a major threat to their dominant position or as a possible adjunct to their own practice, capable of being accommodated without major redefinition of their own legitimate and legitimating role in the medical division of labour. But it also shows that doctors can no longer be confident that their objections will be heeded by governments conscious of the popularity which some forms of alternative medicine enjoy with the electorate.
National medical associations will find it harder in the future to maintain blanket opposition to alternative medicine. In some cases the tension between the collective stance and the individual practice of doctors is very evident. In Britain, the 1986 BMA report on Alternative Therapy was generally dismissive of the claims of alternative medicine and stressed the lack of scientific proof in the form of randomized controlled trials for most alternative interventions (BMA 1986). That the tone of this report was generally out of tune with the temper of the public, and indeed the temper of many of its members, became apparent in the debate that followed its publication. A further report was commissioned, and published in 1993. This second report (BMA 1993) took a completely different line, placing much less emphasis on scientific credentials and more on professional training, evidence of competence, and accreditation.
However, if collective medical opposition to alternative medicine is being toned down, it must be recognized that doctors’ acceptance of, say, acupuncture or chiropractic in a particular country does not mean that the same doctors are likely to accept the claims of, say, herbalism or kinesiology. There are considerable national variations as to which therapies doctors find acceptable. Homoeopathy, acupuncture, osteopathy, and chiropractic are the most widely accepted by doctors in most countries, but whilst reflexology is taken seriously by doctors in Denmark, in Britain it does not have a high status in the eyes of the medical profession, although the modesty of its practitioners’ claims render it unthreatening.
It must also be remembered that conventional biomedicine is not a static system itself. In practice, it is more eclectic than its scientific language and professional rhetoric would suggest. It has always been able to incorporate new ideas, and is probably not immune to the influence of patient demand. Possibly opposition is more explicit and more focused where doctors compete with alternative medicine in something near to an open market situation, but the adaptability of medicine in all kinds of health-care systems is a general feature. It remains to be seen how relations between alternative medicine and biomedicine develop. There is much evidence of cooperation and some convergence of knowledge bases. However, biomedicine is still the most powerful single health-care profession and is unlikely to cease to be so; those forms of alternative medicine that have been most successful in terms of gaining greater public recognition and legitimacy are, on the whole, those which have had the approval of a sizeable section of the medical profession.
The Rejuvenation of Alternative Medicine
In this section we look at the ways in which the therapy groups themselves have changed in the post-war period in terms of their professional organization and therapeutic aspirations. The 1970s saw the revival of alternative medicine across the Western world (Sale 1995; Willis 1989). However, there have been national differences in the types of therapies that have become more favoured in the course of what Baer calls their ‘rejuvenation’ (Baer 1992). For example, in Denmark alternative therapies became more popular from the 1970s (Staugárd 1993), but this was especially the case for reflexology. In contrast, in Iceland (Haraldsson 1993) and The Netherlands (Fisher and Ward 1994) there has been an exponential increase in the use of spiritual healers, and in France acupuncture and homoeopathy have become very popular (Traverso 1993). In the United States therapies such as chiropractic, osteopathy, and naturopathy (Baer 1992) maintained a stronger presence throughout the century but did experience further rejuvenation in the 1970s. Consequently, although we will sketch a general story here, it should be recognized that there are spatial and temporal differences. There are also clear variations across Europe when the training and academic background of the practitioner is examined. In countries with more restrictive legal systems, such as Belgium and France, the expansion of therapies has been confined to doctors or other recognized and biomedically orientated professionals such as physiotherapists.
Even within national boundaries we see that each therapy group has a specific history and distinct perception of their role in the healthcare market. In Britain alone it is estimated that there are at least 160 therapy groups (BMA 1993) which are all different in the way that they are organized and in their views of what they can and cannot treat (see Pietroni, 1992, for a useful typology). Some, more ‘radical’ therapy groups see themselves as separate from biomedicine, while others prefer a collaborative and complementary position in the health services. Even within therapy groups, the role and scope of the therapy may be the subject of debate, such differences being compounded by the ever-increasing number of therapists. For example, in the United States it has been projected that the per capita supply of alternative medical clinicians will increase a further 88 per cent by 2010 (Cooper and Stoflet 1996). The number of professional associations is also increasing. Within reflexology in the United Kingdom there are more than 100 schools training practitioners and fourteen professional associations (Cant and Sharma 1994) There are also multiple umbrella associations that purport to represent the therapy groups. Nevertheless, it is possible to outline some general trends.
The 1970s revival of alternative medicine was an unplanned and radical movement, promoted largely by individuals who were not medically qualified. For example, whilst homoeopathy has been practised by some doctors in the United Kingdom since the eighteenth century, the 1970s saw the development of homoeopathy taught and practised by non-medically-qualified practitioners, many of whom also shared spiritual beliefs (i.e., Druidism). Homoeopathic training, in this context, was characterized by a lack of structure, the teaching took place through ad hoc seminars, and there was no curriculum or credentials. The teachings were very radical, proposing that homoeopathy would replace biomedicine in time, and to this end instruction was made available to anyone who was interested, irrespective of their background or qualifications (Cant 1996; Cant and Sharma 1996b).
The initial revitalization of alternative medicine was largely characterized by the direction of energy to the spread of the therapies and defence against the attacks of biomedicine rather than the stringent formulation of syllabi and professional credentials, but the late 1980s were witness to far-reaching changes, at the level of both organization and ideology, which have transformed the ‘official’ content and practice of alternative medicine, that is, that which is promoted by professional organizations.
In the first place there have been conscious attempts to structure the way that alternative medical knowledge is codified, transmitted, and accredited, with the establishment of formal training colleges. The timing of this process varies by country and depends on where the therapy first became popular. In Canada, for example, colleges of chiropractic emerged in the 1960s (Biggs 1992), whereas in the United Kingdom the shift from apprenticeship and unstructured teaching of chiropractic to a more formalized programme took place later in the late 1970s and 1980s. Even where colleges had a longer history, concerted efforts to achieve accreditation, and particularly degree status, began in the mid-1980s. Elsewhere similar developments took place; the first colleges of naturopathy emerged in the United States (Baer 1992) and Canada (Gort and Coburn 1988) in 1978.
These developments signalled a dramatic growth in student numbers. Baer (1992) shows that within 10 years (by 1988) of the first college of naturopathy opening in the United States, at least 130 students were being trained per year, compared with the original intake of three students. In the United Kingdom, if we take just two of the fourteen professional associations that represent reflexology, we see exponential growth. For example, the Bayley School (albeit one of the largest) estimated in 1994 that it had trained more than 3000 reflexologists. The Association of Reflexologists had 480 full members and 1560 members overall in 1994, and suggested that twenty new members joined every week. This is phenomenal growth when we consider that in 1984, when the Association was inaugurated, there were just ten members.
The 1980s saw the rapid multiplication of colleges for training in various forms of alternative medicine. During this period another nine colleges of naturopathy emerged in the United States. In Britain, although the scale varied by therapy, there was also a significant increase in the number of colleges. For instance, within chiropractic three separate colleges had emerged by the end of the 1980s, in homoeopathy there were twenty by the early 1990s, and in reflexology, at the time of writing, there were more than 100 schools that had been established, with no evidence that the expansion had run its course.
The ‘pluralization’ of colleges has not simply altered where training takes place but has had implications for the content of the curricula and the qualifications awarded. Many therapies now require at least 4 years of training in addition to supervised clinical practice. Increasingly, there have been moves to link the courses to nationally approved credentials. At present, in the United Kingdom, it is possible to read for degrees in chiropractic, osteopathy, homoeopathy, and herbalism. Aside from degree status, all colleges in the United Kingdom have made stringent attempts to identify the necessary prerequisites for a competent practitioner and to produce a core curriculum that covers these requirements. In some cases there have been European and International agreements upon what this core curriculum should contain, signifying a serious attempt to codify knowledge so that it can be passed on in a formal and structured way (see Cant and Sharma 1999).
Second, there are many instances where the therapy groups have tempered their original radical ideas. For example, within chiropractic it was believed by a section of the profession that the manipulation of the spine had the potential to cure the whole range of mechanical and organic problems. In Britain, the Druidic homoeopaths stressed the dangers of biomedicine and the capacity of homoeopathy to deal with all medical problems. Yet, the 1980s saw the gradual curtailment of such radical claims. For example, the main associations for the non-medically-qualified homoeopaths have now decided to stop advising patients to reject immunization for infants, although some members still believe that vaccination can account for forms of ill health (Cant and Sharma 1996b). In some cases this curtailment has been accompanied by the expansion of other skills. For example, in the United Sates osteopaths and nat-uropaths have acquired skills of general practice (Baer 1984).
Significantly, the professional associations that represent the various therapies in Britain publicly state that their practice should not be regarded as ‘alternative’ but as ‘complementary’ to biomedicine. This represents a conscious modification to the type of knowledge that is deemed acceptable and the type of public messages that the practitioners wish to convey. Some therapies now define their scope very modestly indeed. For example, in Britain the professional associations that represent reflexology have defined their therapy as supplementary to medical practice, helpful for relaxation and general healing but with no claim to diagnose or even cure (Cant and Sharma 1996a).
Third, we can identify consistent efforts on the part of professional organizations to relate ‘complementary’ knowledge to the orthodox scientific paradigm, at least in public (notwithstanding the misgivings of many individual members). For example, colleges in Britain and elsewhere (Baer 1992) have incorporated medical science into their curricula and conceive of biology, pathology, and physiology as constituent parts of their knowledge system. Such a move has been recommended by the British Medical Association (BMA 1993), which has argued that such an education will ensure that practitioners know when to refer patients back to a biomedical practitioner. The groups also increasingly make reference to orthodox scientific ideas to explain why their therapy works. This has been attempted in a number of ways, either by drawing directly on biomedical science or by criticising medical science and claiming to use a different scientific paradigm such a quantum physics (see Sharma 1996). There has also been more openness to the use of scientific research methods, particularly randomized controlled trials, to examine the effectiveness of specific treatments (Meade et al. 1990; Reilly et al. 1986).
Finally, alternative medical groups have attempted to draw boundaries around their therapeutic knowledge in order to support their claims of expertise. This has been effected through higher entry requirements, longer training programmes, and the establishment of registers of qualified practitioners.
In summary, there has been a general shift throughout the alternative medical sector to more professional forms of organization and to a more controlled dissemination of knowledge. This has been accompanied by the inclusion of more biomedical knowledge about health, disease, and the body in training curricula. The expansion of therapy groups has taken place in a context that has required that the teachings and practices conform, to some degree, to an established paradigm and one that still places biomedicine in a position of authority, providing a model to be copied.
The Role of Government
The preeminence of biomedicine in the healthcare systems of the Western world has been a product of the policies of government. In some countries, such as France, healing by nonmedically-qualified therapists is illegal. Elsewhere, alternative medicine has been tolerated but not supported by state funding or licence. For example, in Britain therapists may practice as long as they do not call themselves doctors, and in Germany ‘heilpraktiker’ may practice if they pass examinations to show certain competencies. Even where (as in India) other systems of healing are recognized and supported by the state, biomedicine still has a privileged position in the medical division of labour (see Last 1990 for a full typology of medical systems). The strength and universality of biomedicine’s special relationship with the state has led some to suggest that the biomedical profession is an agent of the state (Navarro 1978). Certainly biomedicine has had an important say in the allocation of public health resources, with the consequence that most state health-care funding has been committed to biomedical provision.
However, the recent and rapid increase in alternative medicine has meant most governments have been called upon to regulate an expanding and diversifying health-care market. The general trend has been towards greater tolerance, even in countries with very strict laws of licensure, particularly for those therapies that have standardized their training and defined an area of competence. We are starting to see divisions in health-care systems not just between ‘legitimate’ biomedicine and ‘illegitimate’ alternative medicine, but between therapies legitimated through state regulation and those without such recognition. On the other hand, greater tolerance cannot always be assumed. For example, three non-medically-qualified homoeopaths were arrested in Belgium in 1996 in a climate of apparent acceptance. Nor does governmental support necessarily lead to greater availability of a given therapy for the general public, especially if funding is not forthcoming.
Where governments have shown greater tolerance, this has taken various forms. For instance, in the United States, the National Institute of Health was instructed by Congress to open an Office for Alternative Medicine and provide funds for research (Pavek 1995). The Labour government in the United Kingdom is exploring a similar possibility, although it is not clear whether funds will follow. The clearest form of support has been through the granting of state registration or, in the United States, licensing laws—although these vary from state to state (Sale 1995). It is important to note that attempts at state registration have been made by therapy groups throughout the twentieth century (Larkin 1992), but have only started to prove successful in more recent years, especially the last decade. Chiropractic has now received state regulation in Switzerland, Norway, Finland, Sweden, the United Kingdom, and the United States.
Why have governments shifted their focus and what are the implications for alternative medicine, biomedicine, and the shape of the health services? In the first place, fiscal crisis and escalating health costs, especially with the increase in chronic and intractable health problems, have prompted governments to re-evaluate their health spending. Second, there is evidence in some countries, especially the United States (Baer 1984), that the support of certain therapies has been in response to shortfalls in the supply of biomedical personnel. Third, it is likely that governments have felt compelled to respond to vocal lay interest. Certainly in the United Kingdom, patient groups have proved to be effective lobbyists. There is also evidence that some governments have become increasingly suspicious of powerful and monopolistic professional groups. For example, in Australia the government has become less likely to offer carte blanche support for the medical profession (Willis 1989). Similarly, in the United Kingdom, since 1979, there has been a general move to curtail professional monopolies, enhance the power of the consumer, and increase competition, in particular through the encouragement of the private sector (Klein 1995).
Whilst governments have appeared more favourably inclined towards alternative medicine there may be limits to how far the support will extend. For example, it is the case that only certain therapies have attracted governmental support, and these are the ones that have undertaken the changes described in the previous section, altering their organizational structures and limiting their medical claims. As a result, it is a small number of therapies that have been able to secure statutory regulation. For example, in Britain only osteopathy and chiropractic have been successful to date. This is not to understate the importance of registration; it signifies that the government is prepared to endorse certain therapies and provide users of these services with some guarantees, but at the present time it appears that only those therapies that have limited their therapeutic claims and practices can hope to gain this endorsement, and only those therapies that are the least threatening to the biomedical paradigm have attracted support. Government support has, on the whole, not included bringing the services of non-medically-qualified alternative practitioners directly into state funded health care. There are few opportunities for patients to receive financial help with fees. Private insurance companies increasingly cover chiropractic and osteopathic services. In the United Kingdom, biomedical GPs have been able to use their budgets to purchase alternative practitioners’ services on behalf of their patients. However, a recent study (Thomas et al. 1995) shows that these powers of GPs are under-used. In any case, this arrangement still places the GP in a position of control over both the patient and the alternative medical practitioner.
Overall we have seen some changes to the practices of government in relation to alternative medicine, in particular in making decisions about where the boundaries between legitimate and illegitimate health care lie. There has been some encouragement of a plural medical market, but one where providers have to conform to certain regulative criteria and where biomedicine still holds a dominant position. There has been a restructuring of expertise rather than a radical transformation of the system of health-care delivery.
Conclusion
Nonbiomedical forms of healing, never entirely absent, have come to occupy a more prominent and acknowledged role in the health-care systems of Western countries since the 1960s. As Cobb has shown in the case of chiropractic, the means by which a mode of healing may be legitimated are diverse: licensure or registration laws; government funding for research; academic support; the professionalizing efforts of therapists themselves; social movements, which directly or indirectly support alternative healers; and popular demand, as conveyed through opinion polls or other media to doctors and politicians (Cobb 1977). The process of legitimation has been very uneven and has everywhere taken place in the face of opposition from some quarters. There is much local variation as to which modes are most popular or most readily legitimated. Efforts to integrate alternative health care into the formal health-care system have often been ad hoc and unsystematic, depending on who has been prepared to support which therapies locally.
We have looked at this process of legitimation and acceptance from the point of view of four constituencies, all of which are playing a crucial role in this revision of the social relations of health.
Patients. A major driving force has been the evident popularity of alternative medicine among patients of chronic disease, often associated with a critical stance towards certain aspects of modern biomedicine and a more ‘consumerist’ approach to health care in general. Some patients clearly find that alternative medicines offer them a more participatory role in their own healing, and that they offer ways of understanding illness in terms of personal meaning rather than impersonal disease categories. Neither doctors nor governments have been able to ignore this. We can see this as a postmodern rejection of the absolute authority of medical science (Easthope 1993: 293). Alternatively, we could regard it as evidence that lay views on health care were never completely medicalized in the first place, and that we are simply seeing a resurgence of health seeking behaviour which was ‘normal’ before the large-scale provision of biomedical care funded by the state. Without more research the evidence is hard to assess.
The medical profession. It has always been the case that some doctors have practised certain forms of alternative medicine (such as homoeopathy, hypnotherapy, osteopathy), but more and more doctors (especially GPs) are now aware that alternative therapies are popular with many patients and may be helpful in dealing with certain chronic conditions, or at least in providing patients with the emotional support and counselling that GPs are ill-trained to provide. Those who see such scope are, in many countries, still outnumbered by those who perceive only a threat to their monopolistic position from therapists who (from the medical point of view) are not properly trained and who conduct treatments whose efficacy has not yet been demonstrated scientifically. On the whole, outright principled rejection of all kinds of healing which are not biomedical has ceded to acceptance that (whether doctors like it or not) many patients will continue to use alternative medicines. Therefore, a more realistic stance is cautious endorsement of those therapies which seem to be efficacious and cost effective in biomedical terms, or which offer relief from symptoms that biomedicine has not been successful in treating.
Alternative practitioners. Where alternative practitioners have succeeded in gaining professional legitimacy, it has generally been at the cost of a tempering of distinctive theory and practice, and a degree of convergence with biomedical theories of pathology, anatomy, and treatment. In forming their own professional associations, practitioners have had to confront the need to provide clearer ways of delineating their knowledge bases, defining professional competence, and achieving agreement on the claims that they can make for their particular therapies. Patients may reject the meta-narrative of biomedicine, but medical authority creeps in by the back door when homoeopathic or acupuncture colleges are obliged to include much biomedical knowledge in their courses, or when practitioners modify their claims so as to facilitate acceptance by the medical profession and the public at large.
The state. Governments have been unable to ignore the popularity of alternative medicine among the populace, and its increasing use by articulate and vocal members of the public who have pressed for relaxation of the laws against nonbiomedical practice where these have been in force. On the whole, whatever reforms have taken place, governments have not wanted radical disturbance of the relationship between biomedicine and the state, and have permitted the medical profession to act as advisors to government on matters concerning alternative medicines. On the other hand, accommodating some popular and successful forms of alternative medicine is compatible with an agenda (in some countries) of trying to contain the power of a large monopolistic medical profession. Furthermore, the presence of forms of healing which appear less costly than biomedicine and have a less expensive technological base has probably been significant in a period of crisis for public health-care funding.
It is likely that the expansion of alternative medicine will not continue indefinitely, if for no other reason than that it will encounter the same kind of funding constraints as bio medicine and run up against the same public realization of the limitations to its claims to efficacy. Whilst the demand for health care appears to be boundless in Western countries, the extent to which either governments or insurance companies or individual patients can pay for it is restricted. In the short run, alternative medicine appears to offer treatment that is inexpensive compared with many biomedical treatments and/or to provide the holistic approach, which is the (often unattained) ideal of good biomedical primary health care. As such, it is likely to occupy a limited, but nonetheless important, role in the total healthcare systems of Western societies.