John F. Roatch Global Lecture Series22 February 2013

THE IMPLICATIONS OF MARGINALITY IN THE MEDICAL

PROFESSION: THE CASE OF ALTERNATIVE MEDICINE

Professor Mike SaksProvost and Chief ExecutiveUniversity Campus Suffolk

RELATED EXPERIENCE

• Dean of Faculty of Health and Community Studies, De Montfort University, UK

• Chair of the Research Council for Complementary Medicine

• Adviser to government and professions on health and social care in the UK

• Recipient of major international funding for health projects in North America and Europe

• President of the International Sociological Research Committee on Professional Groups

• Author of thirteen books on professions, health and social care.

THE IMPLICATIONS OF MARGINALITY IN THE MEDICAL PROFESSION: THE CASE

OF ALTERNATIVE MEDICINE

1. Marginality in the Professions

2. Marginality and the Medical Profession

3. The Case of Alternative Medicine

1. MARGINALITY IN THE PROFESSIONS

THE MYTH OF SIMILARITY IN THE PROFESSIONS

It is often assumed that professions are similarly based – when there are considerable differences in how they are constituted and their position in society.

The notion of professions as communities of equals is a myth both in a single profession and in terms of the relationship between professions – on which this presentation focuses.

DEFINING PROFESIONS

Professions are defined in terms of exclusionary social closure – based on legal boundaries creating ranks of insiders (vs. outsiders) with associated privileges.

However, it is recognised that professions have different forms of social closure. Some occupations, moreover, have not effected full social closure and are in the process of professionalizing – governed by voluntary rather than statutory regulation.

MARGINALITY AND THE PROFESSIONS

The category of ‘marginalized professions’ and their relationship with dominant professions highlights the pecking order within professions. These have a less well accepted standing, typically reflected in different levels of income, status and power.

‘Marginal professions’ in contrast are professionally-aspiring occupations outside the state-supported orthodox division of labour.

THE IMPLICATIONS OF MARGINALITY IN THE PROFESSIONS

The marginal nature of professional groups can have many implications, not least for social inequalities – from patterns of geographical dispersal of practitioners to the number of practitioners in particular fields.

This issue becomes more politically charged if the position of marginal professions or marginalized professions does not relate so much to their expertise and the significance of the knowledge base for the wider society, but rather to interest-based politics.

2. MARGINALITY AND THE MEDICAL PROFESSION

MARGINALITY IN HEALTH CARE

The differentiation within professional groups and its impact, especially in terms of social inequalities, is now illustrated with reference to health care.

This then builds into the major case study of the marginalized field of alternative medicine.

CATEGORISING HEALTH PROFESSIONS

Orthodox health professions are divided by Turner (1995) into the following hierarchical categories:

• The dominant medical profession which stands at the pinnacle of orthodox health care in modern industrial societies.

• Limited health professions (eg dentists and opticians) which restrict themselves to particular parts of the body.

• Subordinated health professions (eg nurses and midwives) in the orthodox division of labour.

THE IMPLICATIONS OF MARGINALITY

This is a fluid categorisation – given, for example, the recent dilution of medical professional power related to the rise of corporatism and consumerism.

Nonetheless, these differences have significant implications in areas such as:

• The way knowledge is used in the division of labour (eg through referral structures)

• The quality of entrants to particular health professions in the pecking order

• Access to care through the public sector or insurance support.

THE POLITICS OF HEALTH MARGINALITY

The political debate about the reasons for marginality in the professions is also reflected in the health arena (Saks 2003):

• At one end of the spectrum, the medical profession is seen as being placed on a lofty pedestal as a result of possessing complex/esoteric expertise of vital importance to the public.

• On the other, medicine is seen as self-interestedly establishing its own exalted position in society at the expense of other health professions/occupations.

MARGINAL HEALTH PROFESSIONS

Despite the hierarchies, even marginalized health professions have official recognition and legitimation and a variety of associated benefits, such as protection of title, which has often been linked to enhanced income, status and power.

This marks out orthodox health professions from marginal health professions which largely stand outside formal state-endorsed frameworks and are based on the categorisation by Turner (1995) of ‘exclusion’ rather than ‘subordination’ or ‘limitation’ in the health care division of labour.

FURTHER MARGINALIZATION

Such marginal professions include aspiring health professions within the orthodox health care division of labour striving to professionalize.

The excluded also include occupations such as those in alternative medicine that are not yet fully professionalized with statutory underwriting, but have some form of voluntary self-regulation.

It is these variations from orthodox medicine which have the greatest implications for the health groups concerned and the wider public.

3. THE CASE OF ALTERNATIVE MEDICINE

(a) THE DEFINITION OF ALTERNATIVE MEDICINE

DEFINING ALTERNATIVE MEDICINE

Alternative medicine in the West is defined here in terms of its lack of power relative to orthodox health care:

Orthodox Health Care• Health care underwritten by the state• At present based on biomedical dominance• Focused heavily on drugs and surgery.

Alternative Medicine• Not widely supported by the state• Largely subordinated to biomedicine• Covers a great diversity of approaches, from acupuncture to reflexology.

TYPES OF ALTERNATIVE MEDICINE

• Acupuncture• Aromatherapy• Ayurveda• Biofeedback• Chiropractic• Crystal therapy• Healing• Herbalism

• Homeopathy• Iridology• Massage• Naturopathy• Osteopathy• Reflexology• Shiatsu• Yoga

Acupuncture

ALTERNATIVE MEDICINE AND POLITICS

In terms of the approach to professions based on the concept of social closure, the marginal position of alternative medicine is viewed as part of a political process creating insiders and outsiders.

Importantly, it is not seen simply as those therapies that lack available scientific evidence in terms of efficacy and effectiveness compared to orthodox medicine – which in itself may be contentious.

.

KEY POINTS ABOUT THE DEFINITION

In terms of this definition, it therefore follows that:

• Alternative medicine is not based on the intrinsic characteristics of such therapies, but their political marginality

• Depending on the balance of power, the orthodoxy of one period can become the unorthodoxy of another, and vice versa.

(b) ALTERNATIVE MEDICINE IN THE UK

PRE-INDUSTRAL HEALTH CARE IN THE UK

Pre-industrial health care in the UK was historically characterized by:

• A comparatively undifferentiated field

• The absence of a national, enforceable legal monopoly of medicine

• Difficulties in distinguishing practitioners:- Theories/practice- Training- Status/repute.

THE CREATION OF A MEDICAL PROFESSION IN THE UK

From the early nineteenth century, political power was used to create the medical profession through:

• A lobby for a unified profession, led by the Provincial Medical and Surgical Association (later the British Medical Association)

• A successful campaign to professionalize medicine, increasingly sustained by the

state by the ‘medical-Ministry alliance’

• Attacks by the emerging profession on rival health groups, through the medical media.

THE DEVELOPMENT OF THE MEDICAL PROFESSION IN THE UK

The rise of biomedicine was underwritten by the 1858 Medical Registration Act and subsequent legislation which led to:

• Differentiation from rival practitioners

• Reinforcement of medical dominance with:- An ever wider state market shelter- Growing paradigmatic unity- Advances in medicine- Subordinated health professions

• A highly privileged professional position in terms of income, status and power.

PROFESSIONALIZATION AS A POLITICAL PROCESS IN THE UK

It is claimed that the process of differentiation that began in the latter part of the nineteenth century in the UK was political rather than scientifically functional/justifiable at that time because, amongst other things:

• Medicine was classificatory (vs. curative)• Aseptic techniques had not been

introduced• Anaesthesia was not standard in

operations• Hospitals were seen as gateways to death.

THE INCREASING MARGINALITY OF ALTERNATIVE MEDICINE IN THE UK

Nonetheless, with the rise of orthodox medicine came the growing marginality of alternative medicine, as indicated by:

• Common Law rights, but no state legitimacy • Restrictions on claims to treat conditions• Medical ethics restricting collaboration• Intensified attacks in the medical journals• Informal medical colleague controls • Stifling the professionalization of alternative

medicine.

This led to a fall in use of alternative medicine and the numbers of alternative practitioners by the mid-twentieth century in the UK.

THE EMERGENCE OF A COUNTER CULTURE

However, there was growing public demand for alternative medicine from the late 1960s/early 1970s. This was linked in the UK to the development of a medical counter culture based on:

• Increasing awareness of the limits to medicine and the availability of alternatives

• A response to medical depersonalization and disempowerment

• A desire by consumers to exercise greater control over their own health care.

THE PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE UK

These trends are an important context to the professionalization of alternative medicine in the UK. This has been accentuated by the following political pressures:

• Growing medical incorporation of alternative medicine

• Disaffection with orthodox medicine• Greater receptivity of government to the

professionalization of alternative medicine• House of Lords Select Committee support• Lobbying for alternative medicine (eg

Prince Charles).

THE RECENT RESURGENCE OF INTEREST IN ALTERNATIVE MEDICINE IN THE UK

The development of this counter culture was the spur to the resurgence of interest in alternative medicine in the UK by the beginning of the new millennium with:

• More than 1/7 of the population using alternative medicine

• 60k+ alternative medicine practitioners in existence

• Increasing employment of alternative medicine in the National Health Service by medical and non-medical practitioners.

THE GROWING PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE UK

In consequence, there has been an increased move to professionalize alternative medicine:

• Alternative medicine has increasingly been based on education/training

• Ever more alternative medical practitioners like acupuncturists have voluntary regulation

• The General Osteopathic Council and the General Chiropractic Council were established in the 1990s with statutory

regulation

• Increasing numbers of alternative therapists are qualified health professionals.

THE FUTURE OF PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE UK

Although there have been obstacles to professionalization in the past, this is now becoming more of a direction in the UK.

This was addressed by the 2007 White Paper on Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century. This proposed, amongst other things:

• Ensuring regulation for alternative medicine proportionate to the risks and benefits

• Statutory regulation for certain groups (eg psychotherapists and counsellors).

THE STEERING GROUP FOR ALTERNATIVE MEDICINE

The 2007 White Paper led to a Steering Group exploring the regulation of acupuncture, herbal medicine and Traditional Chinese Medicine.

This reported to Ministers in 2008 on the statutory regulation of these groups – and prompted a consultation with key parties in 2009, the results of which were fed back in February 2011.

The consultation showed, amongst other things, that most respondents preferred statutory to voluntary regulation to protect the public in these fields and to enhance practice quality.

THE FUTURE PROSPECTS FOR ALTERNATIVE MEDICINE AS A MARGINAL FIELD IN THE UK

The future prospects for professionalization in the UK, though, are not that rosy:

• The Government is planning to statutorily regulate herbal and traditional medicine practitioners because of EU licensing issues

• Acupuncture, which has long lobbied for statutory regulation, does not look like it will be allowed to move in this direction at present

• The position is limited by current attacks on alternative medicine as non-scientific.

(c) ALTERNATIVE MEDICINE IN THE USA

PRE-INDUSTRIAL HEALTH CARE IN THE USA

Pre-industrial health care in the USA was similarly characterized as in the UK by:

• Great eclecticism, especially given the anti-corporatist resistance to monopolies

• The co-existence of a spectrum of practitioners from herbalists to homeopaths

• Difficulties in distinguishing ‘regular’ and ‘irregular’ practitioners in terms of remedies, education and other factors.

THE CREATION OF A MEDICAL PROFESSION IN THE USA

In the less unified system in the USA, state medical licensing systematically emerged in the early twentieth century – some five decades after medical professionalization in the UK. The formation of the medical profession largely resulted from:

• Lobbying from the increasingly influential American Medical Association

• Careful political positioning to ride the waves of the anti-monopolistic culture

• Attacks by the emerging profession on alternative health groups as ‘quackery’.

THE DEVELOPMENT OF THE MEDICAL PROFESSION IN THE USA

In the USA the rise of biomedicine was underwritten by a de jure monopoly (legally bounded) rather than a de facto monopoly as in the UK (with protection of title but where anyone can practice under the Common Law).

This led to differentiation from rivals and market privileges in the USA – and the reinforcement of medical dominance with:

• Growing biomedical unity• Ever greater specialism in medicine• Creation of subordinate health professions.

PROFESSIONALIZATION AS A POLITICAL PROCESS

The claim that the process of differentiation in the early twentieth century in the USA was political rather than scientifically justifiable is less convincing than in the UK as the move to professionalization came fifty years later.

At this time the scientific underpinnings of biomedicine in the USA were stronger. Even so, medicine could still not be considered to be rigorously founded at this time – with controlled studies only just starting and doubts over the general competence of medical practitioners.

THE INCREASING MARGINALITY OF ALTERNATIVE MEDICINE IN THE USA

Despite this, as in the UK, with the rise of orthodox medicine came the increasing marginality of alternative medicine in the distinctive USA context in particular as:

• It became illegal for the unlicensed to practice without their own licensing board

• There were tough legal powers against those practising without a license

• There were attacks on alternative therapists and other medical controls existed.

This also led to a decline in alternative medicine by the mid-twentieth century – even if by the1950s osteopaths were licensed in most states.

THE RISE OF A COUNTER CULTURE

Nonetheless, there was similarly growing public demand for alternative medicine from the late 1960s/early 1970s in the USA linked to the development of a medical counter culture.

This was exemplified in the USA by, amongst other things, the Boston Women’s Health Collective and the ping-pong diplomacy that excited interest in acupuncture.

This gave alternative medicine impetus in the USA in the back half of the twentieth century, with a medically incorporationist culture contrasting with the UK – linked to the more laissez-faire climate and more limited risk of legitimation of outsiders.

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THE PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE USA

As in the UK, these trends are a key context to the professionalization of alternative medicine in the USA. This has been accentuated in the USA by the following political pressures, amongst others:

• Growing medical incorporation of alternative medicine (eg with the establishment of the American Holistic Medical Association)

• On-going public disaffection with orthodox medicine

• Greater receptivity of local/federal government to alternative medicine

• Lobbying for specific alternative therapies.

THE RESURGENCE OF INTEREST IN ALTERNATIVE MEDICINE IN THE USA

In the USA the resurgence of interest in alternative medicine seems to have gone further and faster than in the UK. This is indicated by the fact that by the beginning of the twenty-first century in the USA:

• An increasing percentage (42%) of Americans reported using alternative medicine

• Out of pocket expenditure on alternative medicine had reached $27 billion

• More than 35% of physicians practiced at least one alternative therapy.

THE GROWING PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE USA

In consequence, as in the UK, there has been a further move to professionalize alternative medicine, as exemplified by the following:

• There are a myriad of associations representing the alternative therapists, with licensing typically based on graduation from accredited schools (eg in naturotherapy)

• Chiropractic, for long the bane of the American Medical Association, has gained widespread state licensure, as well as the right to reimbursement under Medicare and Medicaid.

THE FUTURE OF PROFESSIONALIZATION OF ALTERNATIVE MEDICINE IN THE USA

The professionalization of alternative medicine is now therefore becoming even more common in the USA, as in the UK.

This is accentuated by the establishment of the National Center for Complementary and Alternative Medicine in 1998 as part of the National Institutes of Health by the federal government to fund alternative medical research – with a $128m pa budget in 2012 that adds greater legitimacy to alternative medicine.

THE FUTURE PROSPECTS FOR ALTERNATIVE MEDICINE AS A

MARGINALIZED FIELD IN THE USA

The future prospects for alternative medicine professionalization in the USA, as in the UK, though, do have limits which highlight its on-going marginality:

• The degree of licensing varies for specific therapies from state to state – with medical control in some states

• Just as in the UK, the largest use of such therapies continues to be through self-help

• The position is restricted by on-going attacks on alternative medicine as ‘cultism’.

(d) A WIDER PERSPECTIVE ON ALTERNATIVE MEDICINE

IN THE UK AND THE USA

THE RELUCTANCE OF ALTERNATIVE PRACTITIONERS TO PROFESSIONALIZE

FURTHER

For all the developments in alternative medical professionalization in the UK and USA, such therapists have often been reluctant professionalizers:

• There was a considerable delay in forming voluntary/statutory organizations

• There are many outlying alternative therapists, even in professionalizing areas

• Some alternative practitioners continue to resist professionalization.

THE INDEPENDENCE OF ALTERNATIVE THERAPISTS

This is partly explained by the independence of alternative practitioners who often:

• Work in private practice• Operate outside state structures• Dislike bureaucracy and hierarchy• Regard individualism as sacrosanct• See a free spirit as essential to practice• Hold egalitarian philosophies • Do not collaborate within/across disciplines.

The term ‘herding cats’ has been applied to alternative therapists as this has undermined their unity in the politics of professionalization.

BROADER SYSTEMS OF POWER

However, the main reason for the limits to professionalizing alternative medicine seems to relate to the impact of broader systems of power, for example:

• The mainly negative response to the resurgence of alternative medicine by orthodox medicine

• The interlinked rejection by local/national government of certain individual therapy interest in gaining professional standing

• The pressures bought by other interest groups (eg the pharmaceutical industry and the private health insurers).

THE IMPACT IN A MARGINAL AREA

As with the marginalized health professions discussed earlier, this situation has impacted on alternative medicine through, for instance:

• The way knowledge is used in the division of labour – including through referral structures

• The quality of entrants to particular fields of alternative medicine

• Access to alternative medicine care through the public sector or insurance support.

ALTERNATIVE MEDICINE AS SELF-HELP

It has also impacted in the UK and the USA on the use of alternative medicine as self-help by:

• Limiting the range of consciousness about alternative medicine

• Increasing the use of alternative medicine as self-help where there is an absence of professionalized practitioners.

(e) THE IMPLICATIONS OF ONGOING MARGINALITY FOR ALTERNATIVE

MEDICINE IN THE UK AND THE USA

BENEFITS OF THE PROFESSIONALIZATION OF

ALTERNATIVE MEDICINE

The potential benefits to the public and practitioners of decreasing marginalization of alternative medicine through increased professionalization include:

• Stronger educational base• Certified knowledge/expertise • Evidence-based practice• Codes of ethics• Protection of the public• Increased public access• Security of practitioners• Enhanced income, status and power.

COSTS OF THE FURTHER PROFESSIONALIZATION OF

ALTERNATIVE MEDICINE

There are also potential downsides too that need to be acknowledged from the viewpoint of alternative medicine:

• Distancing from the client• Constraints on the scope of practice• More limited client accountability and

responsiveness• Potential economic costs • Dangers of professional tribalism• Barriers to integrated working• Lack of a sufficient evidence base in terms

of safety, efficacy and effectiveness.

A GLOBAL PERSPECTIVE

These costs and benefits should be seen in a global perspective in so far as other world systems (eg in Asia) have reversed the pecking order in the West – including in Canada and Western Europe as a whole.

This means that the relatively recently established orthodoxy of biomedicine is seen as more of a marginal practice as compared with other therapies that are considered alternative medicine in the West.

This is well exemplified in the East by the cases of China (where Traditional Chinese Medicine prevails) and India (where Ayurvedic Medicine is more of a force).

SOCIETAL VARIATIONS

This is not to say that there are not societal variations in alternative medicine as a marginalized therapy in the West, for example:

• In the USA practices like prayer, herbalism and meditation dominate

• In Canada chiropractic is the most popular type of alternative medicine

• In the UK therapies such as acupuncture and herbalism prevail

• In France homeopathy is the most broadly employed therapy

• In the Netherlands spiritual healing is the most widely used alternative therapy.

KEY QUESTIONS

However, these comparisons should make us think in the West very carefully in our own society in a recessionary world about:

• The alternative therapies that have the strongest evidence base• Their cost-effectiveness relative to orthodoxy• The methods that we use to form the evidence base (quantitative vs. qualitative)• The extent to which voluntary vs. statutory

regulation is desirable in particular cases• How far the practice is restricted to medicine• To what extent the self-help use of alternative

therapy should be limited.

The quality and cost of health in the UK, USA and elsewhere hinges on these questions.

POLITICAL ISSUES

To concretise this in the USA – not least with the implementation of the 2010 Affordable Care Act – there are some key political issues about the alternatives in an increasingly harsh financial climate in terms of individual rights:

• Which alternative therapies should be paid for through Medicare/Medicaid or private health insurers or customers at the point of access?

• What should be the threshold criteria of eligibility for federal/state/private health insurer funding of the alternatives?

• What are the implications of marginalization of alternative medicine for health care delivery in this context?

SELECTED REFERENCES

Kuhlmann, E. and Saks, M. (eds) (2008) Rethinking Professional Governance, Policy Press

Saks, M. and Allsop, J. (eds) (2013) Researching Health, Sage, 2nd edition

Allsop, J & Saks, M. (eds) (2002) Regulating the Health Professions, Sage

Saks, M. (2003) Orthodox and Alternative Medicine: Politics, Professionalization and Health Care, Sage

SEE ALSO... Kellner, M., Wellman, B., Pescosolido, B. and Saks, M. (eds) (2003) Complementary and Alternative Medicine: Challenge and Change, Routledge.

Saks, M. (1995) Professions and the Public Interest, Routledge.

Saks, M. (2000) “Medicine and the Counter Culture”, in Cooter, R. and Pickstone, J. (eds) Medicine in the Twentieth Century, Harwood Academic Publishers.

Saks, M. (2006) “The Alternatives to Medicine”, in Gabe, J., Kelleher, D. and Williams, G. (eds) Challenging Medicine, Routledge.

AND…

Saks, M. (2010) “Analyzing the Professions: The Case for the Neo-Weberian Approach.” Comparative Sociology, 9: 887-915.

Saks, M. (2013 forthcoming) “Marginalized Health Professions”, in Stevens, F. (ed) Encyclopaedia of Health, Illness Behavior and Society, Wiley-Blackwell.

Saks, M. and Kuhlmann, E. (2006) ‘Introduction: Professions, Social Inclusion and Citizenship’, Knowledge, Work and Society, 4 (1): 9-20.

Turner, B. S. (1995) Medical Power and Social Knowledge, 2nd edition, Sage.

Thank you for listening.

Any questions?