Knowing the history can disentangle the dueling among U.S. health care providers.
A recent legislative hearing in Alaska (May 2019) was yet another in a series of efforts to improve access to Naturopathic Medicine in America. There were similar events in Massachusetts, Pennsylvania, Idaho, New Mexico, and Rhode Island earlier this year and last. There are more of these gatherings these days, focused on either new or enhanced licensing for the naturopathic profession. The Alaska hearings were brisk. There, in early May 2019, a dozen or so medical doctors formed a queue to tell legislators that naturopathic doctors should not have their scope expanded. Naturopathic Medicine supporters felt that the presentations of the allopaths relied overly on anecdotal references and did not benefit from current data and information about the profession they were opposed to. Unfortunately, such tangling persists in the American health care terrain as we seek ways to overcome health crisis spikes such as opioid misuse, incidence of chronic disease, the persistence and growth of iatrogenic disease, the spiraling upwards of health care cost, and the dubious effectiveness of our current model.
Not only do the data indicate that Alaskan patients beg to differ about the role and importance of Naturopathic Medicine in choices available to American health care consumers, but so too do patients from the almost two dozen states in America which do credential Naturopathic Medicine doctors. At the root of the problem is that the sparring professional camps do not have enough bandwidth to study and understand the continuum of medical history in America. How did we get here?
Alaskan allopaths would likely welcome more historical as well as recent national and state-specific data about the qualifications, training, research, health outcomes, and licensing standards of the rapidly expanding fields of other professional groups providing health care, including Naturopathic Medicine. There is disruption all around for everyone. Even so, there is a way through. It may lie in giving more shelf space to history.
It is a challenge for conventional medical doctors to welcome new colleagues at the best of times, given the habits of authority of an established order. Biomedicine has had the control levers of health promotion and delivery for many decades. MDs and DOs when presented with objective, helpful information about the extraordinary shifts in holistic medicine knowledge content and efficacy of approaches in the last half century, are more interested in collaboration, with the patient at the center. Helpful in overcoming inertia too is that the “integrative medicine” initiatives in America welcome more new "old" ideas about nutrition, whole patient care, spirituality in medicine, and the danger of excessive reliance on pharmaceuticals. This complex terrain makes more sense if we make the effort to investigate what’s new, keeping historical context in mind. Surprisingly, what seems new may not be new at all; just new to certain groups. Let’s do the history.
The word “history” comes from the Greek, “istor”, meaning “eye-witness”. We often study history using a rear-view chronology, perhaps too often habitually assessing outcomes in terms of present status. When we calibrate our current tools for health from that perspective, though, we risk missing the facts before us. For example, there is little broad discussion or debate about disease caused by medical treatment, even though the numbers in the tens of thousands are outrageously and unacceptably high. As well, there is veiled understanding of the types of illnesses which caused death a century ago, compared to the statistics from today. Yet, well documented juxtapositions (historical, current) would be illuminating.
We risk needlessly reinventing wheels. As time passes and the tensions and emotions which affected judgment and action at one particular time dissipate, we also risk becoming fuzzy about how we got to our present circumstances, about where we have been, and why we sought the path we did. Contemporary historical scholarly inquiry, however, is increasingly multi-dimensional and nudges us to have a closer look at those “how’s, where’s and why’s”.
A quick look at the work of key historians such as Meszaros, Schmidt and Toynbee can help us with tools to get perspective on awkward questions such as the underlying simmer of unfair competition from biomedicine so inherent in the lineup of testimony in the Alaska hearings. Complicating the efforts of North American naturopathic medicine leaders to achieve recognition (translate: political legitimacy, making a living, social closure) is that holistic and reductionist practitioners alike yearn, like every small stream for an imagined faraway sea, for a time when respect for choice was less carved up by political entitlement, public policy and regulatory red tape .
American NDs face the distress of urgent, record levels of chronicity. Seeing no end in sight, they also often experience an ennui that they may have to give up precious values and principles from their past to have a place in the present. These forces affect their confidence and strategic direction as they confront current historical shifts, reminiscent, in fact of similar pressures a century ago. To avoid reinventing old wheels while everyone steams towards 2020, a look at how we have understood our own particular history can help. It is not a revisionist goal which contemporary historical scholars want to encourage. Rather, it is a clarifying intention which motivates, to see again, as if for the first time, what we have been doing during the last twelve decades to establish an alternative path to reductionist medicine. Even though Aristotle declared that history ranked below poetry and tragedy, a quick snapshot of the literature of our medical history, coupled with a parallel look at the structure of that history, can provide useful insights into what we should be doing next.
The study of the history of medicine, in any case, begs an understanding of the structure of that history. We can turn to the classical historical scholarship formats of brilliant thinkers such as Toynbee (1954). His definitions and classifications of civilizations, and his well known “laws” of genesis, and of growth, decay, death and reincarnation have given us a framework to understand the rhythms and cycles of historical phenomena in our own world. Using such tools we can understand our history more comprehensively. In the end, it is less helpful to lament the seeming glory days of the past, and rather to see the essential historical contents, contexts and structures of that past in order for our history to have a future that doesn’t feel and look like repetition.
Without our getting unduly distracted by the academic debate concerning the dialectic of history –vs- structure, let us reflect a moment on something Hegel called the “dialectical mediation” of logic and history. What the history of naturopathic medical education reveals is a tension in how we experience “history as narrative” (a running debate about what is ok and not ok about how and what educational objectives, outcomes, and methodologies have evolved?). Essentially, as Schmidt (2013) points out, we may well have forgotten to cut ourselves some slack. The frequently linear nature of our historical narrative doesn’t make room for a more holistic sense of our own history. Schmidt calls this a loss of “historical consciousness” (Schmidt, MIT Press, 2013).
Specifically, in our highly evolved era of commodity exchange (provider receives benefit back in exchange for a valued service, and competing providers jockey for control and advantage of their respective markets to get those benefits), and in an era which some historians believe to have reached a tipping point in capitalist enterprise (that is, when the exchange value does not have to address specifically any human need … only economic ones), we tend to separate out our knowledge and record of experience to do good in human society, from the sustained application of that knowledge in the marketplace. We divide our knowledge into didactic and clinical components which have not only utility and effectiveness as their measuring benchmarks, but also as political and regulated scope concerns in particular jurisdictions. These concerns arise as one group tries to control the marketplace and assert a particular point of view or “paradigm” and other groups expend their treasuries and their integrity to keep an oar in the race.
Thus, a strong link with our past in such a process has a dubious future unless the past is continually assessed in terms of present and near future criteria. As I listened to the Alaska testimonies I was uncomfortably aware of that dynamic. Mezaros put it this way: “… the investigation of the dialectical relationship between structure and history is essential for a proper understanding of the nature and the defining characteristics of any social formation in which sustainable solutions are being sought to the encountered problems. (Mezaros, 2011, p. ix)
This counsel is valuable, especially if taken in as a support and direction for strategic planning. Figuring out where we have fit, do fit, and will fit in the terrain of health care providers is fraught with the entire gamut of optimism, pessimism and places in between. There is, of course, an assumption in the very statement that we have to “fit” anywhere. Some would argue, why can we not just be who we are and other professional bodies can adjust to us? The realpolitik, however, is that the naturopathic medical system is a component of the larger, dominative U.S. taxonomy of systems. Hans Baer, a medical anthropologist, provided an analysis of this system of “systems” over two decades ago, that very depiction of an hierarchy of systems itself a reflection of what historical perspective we are assuming about the evolution of naturopathic medicine.
What we have to decide these days is to which perspective to anchor our planning. In this regard, there are five question clusters for planning agencies such as the AANP, the CAND, or the AANMC and its partner group, the NCC, to consider:
- Should we study more closely the specific history of the profession’s formation (accreditation, regulation, political status) or, instead, concentrate on regional differences as a platform from which to proceed? In practical terms, would this mean adopting a different legislation agenda in some states than in others?
- In considering differences in the profession’s location in civil society, might we examine scope, participation in clinical impact, research achievements or public understanding and awareness of the medicine before aiming at a particular legislative outcome? If the latter, from which “culture” should we proceed; for example, the functioning of naturopathy in an unlicensed jurisdiction such as Wisconsin, a modified licensed jurisdiction such as North Dakota, or a primary care platform such as Oregon or Washington?
- What broad patterns from the past of naturopathy are most useful going forward? Are those patterns deterministic, in the main, or can we isolate clear evidence of progress, confident that naturopathy as a medical system is unfolding as it should across the whole profession? Should we be trying to achieve homogeneity of standards of care, as the allopaths have done?
- What individual changes or patterns are evident which can guide us in terms of the strongest position to take?
- Where are we headed, really? What, in the most realistic, pragmatic sense, characterizes what we understand to be progress?
Hans Baer has long been interested in the study of heterodox medical traditions. He helps us with these complex, historical inquiries. His position is that despite the efforts of Lust and others, naturopathy has not articulated in a consistent or standardized way a philosophical foundation or a treatment taxonomy embraced by all factions. He does, as pointed out in the chart below, locate naturopathy among a category of "Professionalized Heterodox Medical Systems" (Baer, p. 43, 2001). Baer explains, “Biomedicine is unable to establish complete hegemony in part because elites permit other forms of therapy to exist, but also because patients seek the services of alternative healers for a variety of reasons, such as the bureaucratic and iatrogenic drawbacks of biomedicine as well as its therapeutic limitations.” (Baer, p. 44, 2001)
The American Dominative Medical System
Professionalized Orthodox Medical Systems
Biomedicine [allopathic medicine]
Osteopathic Medicine (a parallel medical system focusing on primary care)
Professionalized Heterodox Medical Systems
Chiropractic
Naturopathy [naturopathic medicine]
Acupuncture
Partially Professionalized or Lay Heterodox Medical Systems
Homeopathy
Herbalism
Bodywork
Body/Mind Medicine
Midwifery
Anglo-American Religious Healing Systems
Spiritualism
Seventh-day Adventism
New Thought Healing Systems (Christian Science, Unity, Religious
Science, etc.)
Pentecostalism
Scientology
Folk Medical Systems
European American Folk Medicine
African American Folk Medicine
Vodun
Curanderismo
Espiritismo
Santeria
Chinese American Folk Medicine
Japanese American Folk Medicine
Hmong American Folk Medicine
Native American Folk Medicine
(Baer, p. 43, 2001)
Kaptchuk and Eisenberg (2001) add to our understanding of these historical questions. They propose a "taxonomy of unconventional healing practices" which includes, like Baer, naturopathic medicine within a "professional system" category. Kaptchuck and Eisenberg point out in their model that "professionalized or distinct medical systems" are most readily recognized by lay persons and other professionals. They explain further:
Probably the most recognizable alternative healing practices are those that are organized into medical movements with distinct theories, practices, and institutions. Licensure as an independent profession is a goal if not always an actuality. Medical institutions, such as schools, professional associations, and offices with secretaries and billing procedures, are readily visible. An extensive corpus of technical literature helps guide therapy and practice and sharpens distinctiveness. (Kaptchuck and Eisenberg, 2001, p. 197)
Their taxonomy separates out professional medical systems from popular health reform activity in the health services and public domain healing practices of the period. They, in effect, take an historical perspective on these systems, rather than a political one. In their attempt to propose a taxonomy to describe unconventional healing within a "far-flung landscape of diverse practices" (p. 201) they conclude that "defining unconventional medicine by 'what it is' does not work" (p. 196). Citing Gevitz (1995), they contend that
… alternative medicine is an umbrella-like term that represents a heterogeneous population promoting disparate beliefs and practices that vary considerably from one movement or tradition to another and form no consistent body of knowledge. (Gevitz, 1995, p. 128)
This historical snippet outlines Kaptchuk, Eisenberg and Gavitz’s understanding of a "taxonomy of unconventional healing practices" which includes, like Baer, naturopathic medicine within a "professional system" category. Kaptchuck and Eisenberg point out in their model that "professionalized or distinct medical systems" are most readily recognized by lay persons and other professionals. They explain further:
Probably the most recognizable alternative healing practices are those that are organized into medical movements with distinct theories, practices, and institutions. Licensure as an independent profession is a goal if not always an actuality. Medical institutions, such as schools, professional associations, and offices with secretaries and billing procedures, are readily visible. An extensive corpus of technical literature helps guide therapy and practice and sharpens distinctiveness.
(Kaptchuck and Eisenberg, 2001, p. 197)
Essentially, then, paying attention to the larger historical filaments and aspects of what is going on for our profession is extremely important in fashioning strategy for expanded licensing, for expanded scope, and for expanded funding. We can get far clearer insights by knowing our history and by paying attention to those five question clusters every time we revise a curriculum, every time we frame legislation and seek a sponsor for it in state and provincial legislatures, and every time we focus precious resources on research. History may not have been as prominent in Aristotle’s taxonomy of intellectual pursuits, but it should rank very highly for us these days.
References
Baer, H.A. (2001). Biomedicine and Alternative Healing Systems in America: Issues of Class, Race, Ethnicity and Gender. Madison: University of Wisconsin Press.
Gevitz, N. (1995). Alternative medicine and the orthodox canon. Mount Sinai Journal of Medicine. 62: 127-31.
Toynbee, A. (1954). Vols. VII-X. A Study of History. London: Oxford University Press. 772; 732; 759; 422.
Kaptchuk, T.J. & Eisenberg, D. (2001). Medical pluralism in the United States. Annals of Internal Medicine. Vol. 135, No. 3: 189-195.
Schmidt, A. (2013). History Structure. Studies in Contemporary German Social Thought. Accessed December 30, 2013: https://mitpress.mit.edu/books/history-structure; subtext: https://mitpress.mit.edu/books/series/studies-contemporary-german-social-thought.
Meszaros, I. (2011). The Dialectic of Structure and History: an Introduction. Social Structure and Forms of Consciousness. New York: Monthly Review Press.