David Schleich, PhD
When I first joined the naturopathic medical education field, Pat Wales, DC, ND, a longtime leader of the profession in Canada, was coaching me about the emerging preferences of new NDs. She cautioned that the schools and their recent grads were inadvertently complementing the hegemonic power of biomedicine. She worked hard to help me understand the theoretical and empirical inconsistencies in the biomedical model. It was from Dr Wales, for example, that I first learned how worried NDs were about recurrent educational and clinical issues against which the profession had to struggle in their communities and in their careers, such as the abandonment of nutrition, the medicalization of pregnancy and childbirth, the creation of widespread community drug dependence, and an epidemic of iatrogenic diseases.
Dr Wales also taught that the permeation of most areas of medicine by molecular and cellular biology and genetics was not just a philosophical but also a curriculum matter that the schools had to take care with over the years. She said that there was a tsunami of didactic and clinical knowledge under way that by the early 1990s was already slamming into naturopathic medical education. She went on to say, “There was a time when medicine was not so focused on individual organic pathology and brilliant, patient interventions were the order of the day.” Dr Wales meant the word “patient” as an adjective and as a noun. She said, too, that the “inclination of young naturopaths” to “be more like the allopaths and less like themselves” had to be countered by good curriculum that “keeps our roots strong and the old ways vibrant.” And, in another conversation some years later when we had established the new college in Toronto (Canadian College of Naturopathic Medicine, Ontario, Canada) to drive the growth of the naturopathic profession, it was Dr Wales who first acquainted me with the notion of the “sick man” (to which I will allude herein) that was at risk of disappearing from even the naturopathic universe. She and numerous other mentors, such as Dr Don Warren and Dr John Matsen, helped me understand soon enough that the naturopathy of Lust’s and Lindlahr’s day had transformed considerably already and was still transforming. Today, the fuss and enthusiasm about “integrated medicine” or “integrative medicine” that Drs Oz and Weil and others pitch on popular TV are part of what Dr Wales was warning me about.
Some years later, Dr Paul Mittman, president of Southwest College of Naturopathic Medicine and Health Sciences (Tempe, AZ), and others described how conventional, complementary, and alternative medicine “met” in naturopathic medical education (Poorman, Kim, & Mittman, 2001). Shortly thereafter, Coulter (2003) alerted us to the practical difficulties that would accompany what looked like an inevitable clash between so-called integrative medicine (a term coined by Andrew Weil) and the dominant biomedicine paradigm. However, there is another and larger collision course possible, and it affects the future of our naturopathic college programs as they work diligently to prepare graduates for the occupational boundary work and medical borders ahead. The challenge for Association of Accredited Naturopathic Medical Colleges naturopathic programs is to reflect on whether the elements of naturopathic medicine that find expression in CAM are, as Coulter and Baer explain, “simply being co-opted into the biomedical paradigm at the level of therapy but not at the more philosophical level” (2008, p. 337).
For a while, “complementary and alternative medicine” purported to function outside of but alongside biomedicine. With healthcare costs spiraling wildly (Bueckert, 2004), one hears at gatherings, such as the recent March 2011 Integrative Health Symposium in New York City, that integrative medicine combines the best of both biomedicine and what was formerly called CAM. There are social scientists (always count on them, and not on media personalities such as Dr Oz and Dr Weil, to drill down to the actual patterns under way) who have argued that biomedicine is becoming unrelentingly more holistic. Hans Baer (an astute observer of medical systems) suggests, along with his colleague, that it is not as much a matter of theoretical or ethical intention so much as market forces that propel integrative medicine to subtly absorb, even co-opt, CAM (Coulter & Baer, 2008). As they report, naturopathic medicine’s challenge to the “bureaucratic, high-tech, and iatrogenic dimensions of biomedicine” coincides with the recognition by biomedical and osteopathic physicians, as well as by nurses, in a wide variety of jurisdictions of the “limitations of their conventional approach to illness” (Coulter & Baer, 2008, p. 331). There is little doubt that what Coulter and Baer call the “amorphous category and biomedical construction” that we know as CAM is shifting into new terrain (2008, p. X). What is the best response of our naturopathic education programs to equip our graduates for this landscape? Dr Wales would say love your roots; grow your roots.
Sharma explains this inevitable phenomenon as follows: “Official medicine tends to colonize ‘fringe’ areas of medicine once they are successful” (1995, p. X). Hollenberg (2006) describes this kind of “colonizing” or “co-opting” with less deference to the dominant biomedicine profession. Allopathic physicians, Hollenberg (2006) explains, deliberately exert their professional dominance in stages by the following 4 strategies:
- Seeking to monopolize patient charting, referrals, and diagnostic tests
- Appropriating certain CAM therapies from CAM systems
- Relegating CAM practitioners to specific therapeutic tasks
- Using biomedical jargon as the principal vehicle of communication
If we accept that the gathering energy of integrative medicine needs to be understood not only as an accumulating acceptance of natural medicine modalities by mainstream biomedicine but also as a dangerous usurping of those naturopathic modalities, we had best generate early and deep discussion about these epistemological challenges to integrative medicine as they affect our curricula. Scholars like Hollenberg and Muzzin (2010) and Coulter and Baer (2008) are watching this phenomenon through an experienced lens. They point out, collectively, that “biomedicine and CAM are being combined in myriad healthcare settings; select medical curricula are incorporating CAM while new ‘integrative’ physicians are graduating; and wide-scale health policy on CAM is being created by such organizations as the World Health Organization” (Hollenberg & Muzzin, 2010, p. 34).
This is serious business. Social scientists (Hollenberg & Muzzin, 2010), not MDs or NDs, are alerting orthodox and heterodox health professionals that the current momentum has the following 3 potentially alarming outcomes:
- The devaluing of non-biomedical health knowledge
- The acceptance of only biomedical evidence
- The creation of a biomedical monolithic worldview
There are some who would argue that these factors are already in play. There are others who would say that they are not final.
This same tectonic shift, whatever stage it is at, is accompanied by another kind of mountain-forming geosyncline, described in 2009 by N. D. Jewson. Jewson’s thesis is as follows:
The sick-man may be said to have disappeared from medical cosmology in two related senses during the period 1770-1870. Firstly, as control over the means of production of medical knowledge shifted away from the sick towards medical investigators the universe of discourse of medical theory changed from that of an integrated conception of the whole person to that of a network of bonds between microscopical particles. Secondly, as control over the occupational group of medical investigators was centralized in the hands of its senior members the plethora of theories and therapies, which had previously afforded the sick-man the opportunity to negotiate his own treatment, were replaced by a monolithic consensus of opinion imposed from within the community of medical investigators. (2009, p. 19)
The early NDs and recent leaders have argued that what defines biomedicine is essentially a reconfiguration of relations among the state, clinicians, laboratory-based researchers, and industrial corporations. The sick man so central to naturopathic philosophy, principles, and practice is lost in this equation. Healthcare experts in North America and globally seem to be content with this status quo. However, especially in America, politicians and economists and those responsible for administering health expenditure are questioning the sustainability of a system that (1) rewards highly profitable pharmaceutical and paramedical industries (including the insurance sector) and (2) gives leadership for primary care to biomedicine professionals who willy-nilly are co-opting therapies, modalities, and even philosophies that the naturopathic profession has kept safe for decades in one of its most important mandates (an almost “hidden curriculum” of the naturopathic profession), which is to limit the medicalization of life. As biomedicine scurries hither and yon “making the labels of ‘healthy’ and ‘unhealthy’ applicable to more and more aspects of human existence” (Hallam, 2003, p. X), an inexorable collaboration within biomedicine (the dominance of the laboratory over the clinic) has occurred. Gaudilliere (2002) argues in the “Au Miroir de l’Amerique” section of his remarkable analysis of L’Invention de la Biomedicine that this dominance has had “substantial consequences for our understanding of what the ‘patient’ is and how healthcare should be structured in the industrial world” (p. 373). Essentially, Gaudilliere explains it thus:
The sick man has little role to play here. Instead, human pathology in its various guises is invariably taken into the laboratory and isolated from its complex environmental contexts—as has been the case with modern medical approaches to breast, colorectal and other common forms of cancer. Secondly, the rise of biomedicine has encouraged a widespread belief among both lay and professional parties that there is a pharmacological fix for almost all human ills. (2002, p. 254)
Another factor in this stew is what Hallam (2003) emphasizes when he writes about the future sustainability and the paradox of diminishing returns of modern scientific biomedicine even though health expenditures more than doubled between 1960 and 1998 in member countries of the Organisation for Economic Co-operation and Development; he writes that “relative and increasing ineffectiveness of health care interventions” (p. X) puts that dominance into question. Thus occurs, some would argue, the “colonizing” of anything that moves that might work better. Hallam’s assertions are familiar to naturopathic students, who absorb the admonitions of the elders about healthcare in a biomedicine universe. Hallam insists that statistical data pertaining to life expectancy and infant mortality “demonstrates that there is not a clear relationship between increased health expenditure and improved health outcomes” (2003, p. X). He adds that “we are reaching the limits of what biomedicine can deliver for improved health” (Hallam, 2003, p. X) and further confirms his warnings by indicating that new and incurable diseases are emerging and that “old infectious diseases, including tuberculosis, cholera, malaria, and diphtheria are making a worldwide comeback” (p. X).
Back in 1976, Ivan Illich had already written extensively about the “expropriation of health” by biomedicine. In his book Limits to Medicine, he warned of how essential social services, such as medicine, schools, and transport, have become (through over-industrialization of these very services) commodities or products that are harmful to humankind. Illich warned about the growth of iatrogenic capacity in modern medical systems. The naturopathic principle that eschews the notion of a pharmacological solution for every presenting condition is only part of what Dr Pat Wales was attempting to communicate to me over a decade ago.
Regarding the 2006 changes to the curriculum at Harvard Medical School (Boston, MA), Jules Dienstag recently wrote a fascinating and event-prescient curriculum response to the pervasiveness of the integrative medicine model that is lurking at the periphery of natural medicine:
Isolation among disciplines has already begun to change, and many medical schools have added new departments of systems biology, which focus on this complexity and the interdependence and interaction among different body systems. A sick patient does not represent a biochemistry problem, an anatomy problem, a genetics problem, or an immunology problem; rather, each person is the product of myriad molecular, cellular, genetic, environmental, and social influences that interact in complex ways to determine health and disease. Our teaching, in both college and medical school, ought to echo this conceptual framework and cut across disciplines. (2008, p. 221)
The rapid inclusion of “narrative medicine” curricula in many American medical programs is another marker of the pervasiveness of the integrative medical model as it chunks out and describes systematically what it wants from naturopathic and other traditions. Based on the early work by Rachael Naomi Remen (1996) and the later research and curriculum development by Greenhalgh and Hurwitz (1999), so-called narrative medicine carves out a role not only in the diagnostic encounter but also in the therapeutic process. In the former, narratives encourage empathy and promote understanding between the patient and the physician. In the latter, narratives encourage a holistic approach to patient management with therapeutic and palliative implications thrown into the mix. Naturopathic physicians have been doing narrative medicine forever. Remen (1996) reminds those who would adopt narrative medicine that the very scientific objectivity that protects the physician who is trying to resolve the pain of the patient from taking on the pain of that patient can interfere with creativity and self-reflection on the part of the clinician. These conversations are intensely familiar to the ND, whose way of practicing has been all about patient-centered medicine for more than a century. There are some scholars who have described “patient centered” using other terminology, focusing not only on biology but also on psychology and sociology.
George Engel (1977 and 1980), whose work in “biopsychosocial medicine” reverberates immediately with any ND who encounters it, also raises a red flag or two about what is occurring. Smith (2002) quotes an explanation by Engel: “The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness” (p. X). Integrative medicine, which purports to provide a blueprint for research, a framework for teaching, and a design for action in the real world of healthcare, may well be on its way to co-opting even biopsychosocial medicine. Engel’s model set the stage for this movement, prescribing “a fundamentally different path from the still-guiding biomedical model: to be scientific, a model for medicine must include the psychosocial dimensions (personal, emotional, family, community) in addition to the biological aspects (diseases) of all patients” (Smith, 2002, p. 309).
In any case, we may wish to look formally and urgently at just what so-called integrative medicine is becoming. Such an understanding can inform our curriculum design (classroom and clinic) and the positioning of graduates in the coming years. We may wish to keep in mind Hallam’s observations as we generate these discussions, recalling the words of Hallam:
It is also abundantly clear that biomedicine’s dominant position in the health care field reflects the long political process by which it was imbued with social and cultural significance. Indeed, the history of medicine through the eighteenth, nineteenth and twentieth centuries makes it clear that if it were not for the extensive political maneuvering by the profession in accordance with its own visions and goals, it is extremely doubtful whether biomedicine would occupy the position it does today. (2003, p. 14)
Hallam also cautions us about the following:
These tactics include exclusion, reformulation and incorporation. Exclusion is a strategy of occupational closure that seeks to keep alternative practitioners out of the healthcare market by defining them as ‘menacing and dishonest.’ Reformulation is an attempt to broaden medicine to account for social and environmental factors while still seeking to achieve occupational closure through ‘sound science.’ Incorporation, in turn, involves embracing the practice of some alternative therapies by conventional medical practitioners. (Hallam, p. 2003)
It seems that integrative medicine is a continuation of the assimilation of natural medicine principles and practice, where convenient, into biomedicine. To assure that our graduates have an “identity” to declare as they open their clinics or join the healthcare landscape in other ways, it is very important that we include courses on the history of medicine and the philosophy of naturopathic medicine prominently in our curricula, taught not by adjuncts but by committed professional naturopathic medical academics who can see trends and patterns for what they are. As well, we will want to emphasize practice management techniques and strategies that can celebrate the modalities that our graduates are highly skilled in. Our graduates simply have to leave our colleges with confidence that the potential of naturopathic medicine to exist as a heterodox medical system, evolving into an orthodox medical system, is grounded in the following very real such trends and patterns out there:
- There is definitely a large market for naturopathic medical services; revenue streams for our graduates can be guaranteed with a few legislative changes.
- There is increasing scientific and anecdotal evidence of efficacy.
- The safety profile of naturopathic medicine makes possible considerable cost savings not only from reduced delivery costs but also from litigation and medical insurance.
One elder from the profession said recently that the latest “hijacking of our medicine” by the integrative medicine proponents reminded him of the purposes behind the development of Codex (http://www.codexalimentarius.net/web/index_en.jsp) and global moves to take over the alternative medicine industry with respect to access to natural medicine products. The integrative medicine proponents are already busy dispensing advice on diet and supplements and publicly acknowledging the link among diet, nutrition, and chronic diseases. We need to remind ourselves, our graduates, and our colleagues once again, as if for the first time, that these are messages that have long been the forte of naturopathic medicine and historically denounced by biomedicine. Those clever rascals.
David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Previous posts have included appointments as vice presi-dent academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd), and the University of Toronto (PhD).
References
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