What Roszak told the baby boomers: watch out for the assimilators.

In his remarkable boomer book, The Making of a Counterculture (1968), Theodore Roszak warned us about "assimilation by the big guys", as did his contemporaries, Herbert Marcuse, Norman Brown, Alan Watts, Paul Goodman and others. The “trick”, they said back then, was to “clue in” when the dominant culture persuaded you, by various means, that your own efforts were really part of the mainstream after all. 

Or, seen from another angle, and as Voltaire put it a few centuries even before that, “Our species is so made that those who walk on the well-trodden path always throw stones at those who are showing a new road.” (Voltaire, Philosophical Dictionary). He also advised us at the end of Candide, in the part where he ignores Pangloss’s insistence that everything has turned out for the best, that we must in the end, “cultiver notre propre jardin” (we should just cultivate our own gardens). In a health care terrain where, “it is dangerous to be right in matters on which the established authorities are wrong,” (Voltaire, Philosophical Dictionary), it is very difficult to stick to our own garden when not only the marketplace cannot differentiate one garden from another, but also when we are having trouble doing the same.

Two terms from the computer industry, the “app” and the “backplane”, can help us figure out this mess. The issue: the expansion and accrediting of not only naturopathic and classical chinese medical education in America, but also the ensuing roles for graduates as professional clinicians. That strategy has been to accredit our programs and institutions for the mainstream higher education terrain, alongside continuous expansion of licensing. There is an accompanying drift to a more allopathic continuum of content, though, which has been worrying elders in the profession and disappointing newcomers at the same time. At the same time, the biomedicine industry barrels along, assimilating this and that, as new markets and new knowledge about what health is present themselves.

Back to our handy concepts to explore this concern. An “app”, as even old boomers know, is a kind of software dedicated to a specific task. Whatever the “app”, it runs inside an operating system. Some are single task; others, known as ‘integrated software’, can involve several applications all running simultaneously. Sometimes apps run on mobile devices; sometimes they run on desktops. The “backplane” of a computer is a kind of circuit board which has all kinds of elements: pci slots, usb connectors, ethernet connectors, headers, chipsets, memory slots, bridges and power sources.  All these and more components talk to each other in omnibus fashion, using parallel and bit serial connections to make up a complete computer system. Backplanes aren’t motherboards, I’m told, because they don’t include on-board processing. 

With these definitions in mind, may I suggest that in the design and delivery of naturopathic medical education, for example, we are at risk of defaulting to becoming an “application in the allopathic backplane”, rather than a profession with its own demarcated, codified knowledge and civil identity. This is also true for Chinese Medicine, which is understood often as a modality, rather than a medical system, when it shows up in what are known these days as "integrative medical clinics".

This pervasive symptom, that is the proliferation of “integrative medicine programs” and their corresponding “integrative medicine clinics” are occurring alongside the wholesale mixing and merging of content, learning outcomes, techniques, jargon and clinical definitions among natural medicine, naturopathic medicine and holistic medicine terminology, practices and certifications. The whole lot are spinning out there in the health care landscape, kicking up local skirmishes and eddies, invasive siroccos and regional tsunamis on occasion. Because we have to hold our ground amid the fuss, confusion and rush of services, territories, branding and claims, understanding why and how this is occurring is vital to knowing how best to prepare our doctors for clinical practice. As we move more and more confidently into that arena (five more states with licensing, registration or certification in the last decade alone), it’s the backplane of biomedicine we need to pay attention to most to keep our footing. That is, we process our activity [our app] increasingly through a device we do not control. The more we understand the biomedicine backplane, the more we avoid becoming just another app.

The allopathic profession and supportive industries have in recent years noted more commercial and clinical value in what we do [notwithstanding our having been formally doing what we do in the form of naturopathic medicine, under duress from these same interests, for over twelve decades and more in North America]. In keeping with the familiar practice which sees dominant, orthodox groups knocking off or assimilating the front edge products of competitors, the allopathic paradigm is corralling many of our modalities through the backplane of their powerful systems and through the turnstiles they rigidly control. 

Keeping to the fundamentals can help us keep out of the biomedicine backplane. There are numerous principles in naturopathic medicine which are not inherent in allopathic medicine and which we risk losing. These principles have to be embedded through the four years of naturopathic medical school and subsequent residency and continuing medical education. Allopathic schools and clinical settings are talking more about these of late, presumptuously and largely unaware that naturopathic medicine has held these spaces, under siege often, for many decades.

1.  Naturopathic and Classical Chinese Medicine have long affirmed the primacy of the relationship between the doctor and the patient. 
2. Naturopathic and Classical Chinese Medicine focus on the whole person and not exclusively on his or her pathology or presenting condition. 
3. Naturopathic and Classical Chinese Medicine are informed by evidence, the diagnostic skills, and the cumulative experience of the doctor or practitioner.
4. Naturopathic and Classical Chinese Medicine make use of every natural, therapeutic approach possible.
5. Biomedicine has not co-existed respectfully with the natural medicine professions, ever, in the North American landscape. Biomedicine defaults to assimilation within its paradigm.
6. Naturopathic and Classical Chinese Medicine have always encompassed the biological, psychological, social and spiritual dimensions of human health and illness.
7. Naturopathic and Classical Chinese Medicine have always emphasized the importance of the “vis” and "Qi", the body’s innate vital energy or force, and its capacity for healing.

 What is occurring more broadly in our time is the conjugating of such principles through the backplane of the allopathic establishment so often that they become assimilated. As Roszak pointed out fifty years ago, the mainstream orthodox professions will repeat messages to the extent that the assimilation of ideas, concepts and values is accomplished and eventually irretrievable as a counter-culture activity by those who had been nurturing them previously.

A further indicator of the convergence in the allopathic backplane of heretofore natural medicine services and products is the continuing move upward of access to and use of our sector. Earlier this decade, the 2012 NHIS key findings report (https://nccih.nih.gov/research/statistics/NHIS/2012/key-findings) about so-called “complementary health approaches” is very telling in this regard, as a case in point.  Specifically, for more than a decade one-third of U.S. adults have been using complementary health care approaches, coupled with an average of 12% of U.S. children from age 4 – 17 in the same period. Many naturopathic doctors, as a case in point, agree that the data are remarkable across many reporting dimensions. Not surprising, the NHIS report indicated U.S. adults reported that they were more likely to choose these complementary approaches (some 59 million of them) for preventive and overall wellness purposes, rather than as treatment for specific conditions.  These same adults were attracted to Fish Oil, probiotics and pre-biotics. They were drawn to mind and body approaches for therapeutic and overall wellness purposes.  In this sizeable market shift in the last two decades, Naturopathic doctors know that out-of-pocket spending on products and visits to complementary practitioners is growing, as reported by the NHIH, notwithstanding the prevalence of partial insurance coverages.

To prevent being conjugated as a profession through the assumptions and circuits of the allopathic backplane, then, we need to pay close attention to what professional formation entails at the end of the second decade of this new century. Referencing naturopathic medicine in particular, the necessity of accelerating its professional formation has never been greater. The complexity of professional formation lies in its dual imperatives. A group self-identifies within a demarcated body of knowledge and skills and at the same time as its members prepare to conduct lives of service and value to the community precisely because of those skills and in competition with those who might have similar resources to offer civil society, its members must carve out a moral and political development pathway for those eligible. (Boon, 1996; Biggs, 1989; Fox, 1989; Bucher, 1988; Gort, 1986; Freidson, 1985; 1984, 1970).  The goal of professional formation is to anchor members of such groups within prescribed requirements for entry and to equip them to navigate an inevitable landscape of competition. Eventually such groups achieve what scholars have called “social closure”, a term describing civil society’s acceptance of the defined roles and privileges of the group. Thus, the emphasis on state authority for the privileges accorded the “formed” group to protect its members from those who have not followed a similar foundational path.

Another variable in professional formation is the attention scholars give to the educational frameworks of emerging professions. Their attention is rooted, as suggested above, in the wish to describe those often institutionalized training arrangements as part of a larger understanding of how those groups take their place in civil society. The development of the naturopathic profession's medical education institutions has been inextricably bound up, then, with the professional formation of naturopaths and naturopathic doctors in this and a number of other ways, and by its quest to have one secure footprint in the nonprofit sector and another in the higher education world

Within this reality, every established, accredited naturopathic college or program within an institution of higher education in North America has found a niche just outside and parallel to the academic mainstream. This is invariably true, as well, for chinese medicine programming. That niche is also occupied by self-interested professional naturopathic and Chinese Medicine associations and groups who, just as the educational institutions which formed the foundation of their growth were finding their way, had been equally busy trying to establish themselves as a profession. It is in this complex interplay among the naturopathic medical or Chinese Medicine practitioner, the emerging naturopathic or Chinese Medicine academic, and the associations charged with scouting the terrain of professional formation and mapping a successful route across it, that the scholars of higher education and the sociology of the professions find much fascinating subject matter to explore.

There is a rich history of medical pluralism in North America, particularly in the United States, where medical historians, medical anthropologists and social scientists have written frequently about professional formation of mainstream groups such as medical doctors, lawyers and nurses, but much less about the alternative and complementary treatment modalities and therapies of such professions (Roth, 1976; Maretzki and Seidler, 1985; Maretzki, 1987; Gort and Coburn, 1988; Baer, 1992, 2001; Boon, 1996). This uneven attention has resulted as much from the small numbers in professions such as naturopathic medicine as it has from the so-called marginalization within regulated state or provincial frameworks of those professions in North America by the dominant, bio-medical, allopathic profession (Wardwell, 1951; Roth, 1976). The biomedicine monopoly has emerged most dramatically since Abraham Flexner’s 1910 report on medical education in which he emphasized the primacy of competency in basic sciences. However, the economic dominance of what Lust called in the early days “the Medical Trust” was an inherent motivator in the forming of western medicine as the dominant and orthodox system of medicine, especially in the United States. According to an early President of the Institute of Homeopathy, since the beginning decades of the twentieth century there has been an effort to thwart the professional formation of naturopathic doctors in the form of an "assault on traditional medicine" by the American Medical Association, long "bent on throttling everything which stands in its way for obtaining medical supremacy" (Wilcox, JAOA, 1914, p. 650).

The allopathic and the natural medicine professionals each look, touch and listen. Each has lab tests and instruments to do the work of physical and clinical diagnosis. Indeed, these similarities have been true from the days of Frederick Gates and William Osler who anticipated a time when all medicine, natural or scientific, could be "reduced to an exact science" (Bliss, 1999). Osler made it clear in his The Principles and Practice of Medicine (1892), though, that the rigour which must accompany scientific medicine was frequently not present in such fields as naturopathy, homeopathy and osteopathy.

Osler knew that "medicine must rest on science" (Bliss, 1999). Osler as a clinical physician wanted a scientific underpinning to "working at the bedside", focused on the "whole patient" not unlike the naturopathic physician who is trained to develop a relationship with the patient which includes a comprehensive awareness of the person's complete physical, spiritual and mental makeup. Boon (1996) and Gort (1988) before her have identified the contemporary manifestations of this tension between holistic and scientific practitioners, and indeed between holistic and scientific naturopathic practitioners. The holistic practitioner's spiritual and physical words are "not separate, but manifestations of a single life force" (Boon, 1996). Consequently, symptoms, whether physical or spiritual, command the same attention. Their scientific counterparts, however, practice based on a biomedical model, which reduces all pathology to a cellular or molecular level. For the latter, the scientific method is the route to curing a disease. For the former, environment and spiritual balance are key factors in a treatment protocol. 

As Schon reports (1994), "the greater one's proximity to basic science, the higher one's academic status". Professional schools of medicine, in such a context, would strive to train healers and socialize them as biotechnical problem solvers. Routinely, they would follow a sequence that immersed the student in medical science and then in supervised clinical practice. Glazer (1974) describes this approach as a "yearning for the rigor of science-based knowledge and the power of science-based technique". This fascinating polarity hugely influenced the development of naturopathic medical education in Canada. The existence of a distinct tension between professional orientation [itself not consistent across the profession and often regionally diverse] and student socialization has been discussed from a somewhat different perspective by Boon (1996) in her analysis of the scientific and holistic world views of both students and practitioners.

Gieryn's (1983) discussion about the practical problem of constructing some kind of boundary between science and "varieties of non-science" is an important theoretical discussion about the claims to authority which science insists upon. Naturopathic physicians and their teachers seem attracted to such a source of authority, but define their eclectic professional therapies inside and outside such boundaries. There are even continuing claims that the profession has not embarked on rigorous research about key modality areas in its repertoire such as individualized nutritional therapy (Vickers & Zollman, 1999) or chronic diseases in general (Haynes, 1999).  A persistent equivocation in the broader field of clinical practice and the continuing influence of practitioners on their educational institution's priorities have influenced the development of the profession and those very educational institutions.

A dimension of the problem is a persistent confusion among the public, elected officials, government policymakers, other professional health care providers, higher education administrators, academics and ministry officials about what naturopathy and naturopathic medicine actually are. Indeed, there is no current, modern and comprehensive textbook of naturopathic medicine which adequately assembles a synthesis and critical evaluation of the emerging constructs, clinical models and scientific foundations of contemporary naturopathic philosophy and clinical theory. Lindlahr’s 1925 text, Natural Therapeutics [four volumes] is considered by some as the earliest reliable reference in this regard. However, as Dr. Pam Snider points out (1996), “since Lindlahr there has been no textbook updating the underlying theory of naturopathic medicine, and no comprehensive guide to clinical practice and case analysis based on theory referenced to current research” (p.12). Within Pizzorno and Murray’s 1987 Textbook of Natural Medicine, a compendium of natural treatments for specific conditions referenced to research literature, there are two brief chapters on History and Philosophy and naturopathic clinical theory. 

I have found that the analytical tools and definitions of naturopathic medicine from Dower, Hough and O'Neil, in their Arkay Foundation report, Profiling the Professions: A Model for Evaluating Emerging Health Professions (September 2001) out of the University of California's Center for the Health Professions to be particularly useful in their breadth, inclusiveness and utility. The categories of definition encompassed in that work take into account the major aspects of institutional development which concern us here.  For example, the categories include, at the very least, government regulation and private sector recognition, the education and training of naturopaths, and a model for evaluation (Dower, O'Neil and Hough, 2001). Moreover, the comprehensive nature of the descriptions and definitions considers all those practitioners, regulated and otherwise, who find value in naturopathic modalities and therapies. The resulting breadth and objectivity are most helpful in sorting out the conflicting claims of philosophical, medical and even political positions taken by competing groups within the CAM community. As well, the inclusive nature of the Arkay Foundation work is particularly relevant to the circumstances which led to the creation of a naturopathic college in Ontario. Many groups from different corners of the CAM world played a part in the design, emergence and evolution of CCNM. 

In any case, beginning to paddle through these variegated waters I learn, as Myers, Hunter, Snider and Zeff (forthcoming, 2004) comment, that there is a “constellation of practices that form naturopathic medicine today in Europe, Australia and [North America].” Myers et al. (2003) conclude that its roots are in the “nature cure movement of the eighteenth and nineteenth-century Europe” (p. 50). This is an important element of any defining statement from a CAM group professing to be “naturopathic” in that rivals all insist on this least common denominator of origin, the “nature-cure movement”. In addition, there is another denominator in this debate. For example, there are those groups (such as the Thomsonians, early and modern chiropractors, acupuncturists, and the early eclectics) who assert the “belief that the physician merely supports the active self-recuperative powers of the human body” and that this principle and related understanding are “applied by modern naturopathy within the framework of modern scientific knowledge” (p. 50).

The University of California report referenced is recognized for its impartial and inclusive research design. The document provides a good starting point in that it constitutes an excellent framework for distinguishing among naturopaths, naturopathic doctors, naturopathic physicians and mainstream licensed primary care practitioners who select one of the naturopathic modalities for inclusion in their traditional scope (Dower, Hough, & O’Neil, 2001). Dower et al explain that, overall, three groups “have interests in sustaining naturopathic methods of practice” (p. 1). The authors specifically identify naturopathic physicians as those who have completed a formal curriculum of four years of study in schools recognized by an accrediting body called the Council on Naturopathic Medical Education, a non-government agency which I shall cover in more detail later in this thesis. The focus of naturopathic physicians (also called naturopathic doctors) is on “standardized entry to the profession as they define it, improving evidence-based research, and seeking formal recognition by state [and provincial] authorities” (p. 2). The second group they call naturopaths. They differ from naturopathic physicians or doctors in that the group “maintains the strictest definition of natural healing and does not incorporate surgical, non-natural pharmaceutical or obstetrical care into their practice” (p. 2). Theirs is a “much more varied set of pathways for entry into practice and training ranges from self-instruction and apprenticeship to formal courses of study” (p. 2). The third group identified in the Arkay study consists of licensed practitioners such as medical doctors, dentists or nurses who have added a naturopathic modality to their existing, regulated practice.

Meanwhile, parallel to the Arkay definitional scaffolding and critical to erecting early in this thesis an awareness of the complex and shifting ground of CAM providers, there are many related descriptions of what naturopathic medicine is, and of what naturopathy is. Individual scholars such as Newman Turner (1984), for example, suggest that “naturopathy is based on the recognition that the body possesses not only a natural ability to resist disease but inherent mechanisms of recovery and self-regulation,” forming the basis for “nearly all the techniques in complementary medicine” (p. 110). The U.S. Department of Labour, on the other hand, defines naturopaths in its Dictionary of Occupational Titles less philosophically and with more focus on what the practitioner actually does. The naturopath, in the view of the Department:

            ... diagnoses, treats and cares for patients using a system of practice that bases treatment of physiological function and abnormal conditions on natural laws governing the human body. Utilizes physiological, phytotherapy, food and herbs therapy, psychotherapy, electrotherapy, physiotherapy, minor and orificial therapy, mechanotherapy, naturopathic corrections and manipulations, and natural methods or modalities together with natural medicines, matural processed food and herbs and natural remedies. Excludes major surgery, therapeutic use of x-ray and radium and the use of drugs, except those assimilable substances containing elements or compounds which are components of body tissues and physiologically compatible to body processes for the maintenance of life.

                       (U.S. Department of Labor, 1991)

 As Myers et al. (2003) point out, this U.S. government definition emphasizes modalities rather than philosophy. In contrast, the American Association of Naturopathic Physicians commissioned in 1986 two naturopathic physicians, Pamela Snider and Jared Zeff to “create a unifying definition” based on a blend of philosophy and modalities. By November 1989 at Rippling River, Oregon, the following definition, arising out of wide consultation and consensus, was confirmed:

            Definition of naturopathic medicine

           Naturopathic medicine is a distinct system of primary healthcare: an art,  science, philosophy and practice of diagnosis, treatment and prevention of illness. Naturopathic medicine is distinguished by the principles which underlie and determine its practice. These principles are based upon the objective observation of the nature of health and disease, and are continually re-examined in the light of scientific advances. Methods used are consistent with these principles and are chosen upon the basis of patient individuality. Naturopathic physicians are primary healthcare       practitioners, whose diverse techniques include modern and traditional, scientific and empirical methods.

In an editorial in The Naturopathic and Herald of Health, Benedict Lust himself in 1902 explained that naturopathy was "purposely a hybrid word". Alluding to the therapeutic practices of nature-cure doctors, homeopaths and other health care practitioners such as Connaro (nutrition and fasting), Priessnitz (hydrotherapy), Woerishofen (the Kneippcure), Kuhne (Serotherapy), Macfadden (Physical Medicine), Willmans (Mental Science) and finally A.T. Still (Osteopathy), Lust proclaimed a "new medicine" whose scope would encompass every "life-phase of the id, the embryo, the fetus, the birth, the babe, the child, the youth, the man, the lover, the husband, the father, the patriarch, the soul." (Lust, 1902, p. 4). Lust had been especially interested in the hydrotherapy principles and practice of Sebastian Kneipp. However, Lust called his new and eclectic naturopathy the "medicine of the future".  Had he known about apps and allopathic backplane, he would not have wanted this new medicine to be affected by either concept.