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[The following paper was originally published by Sociological Research Online. To cite the article, use the following information: Gil-Soo Han (2002) 'The Myth of Medical Pluralism: A Critical Realist Perspective' Sociological Research Online, vol. 6, no. 4, <http://www.socresonline.org.uk/6/4/han.html>. The article is archived here in compliance with the copyright notice on the Sociological Research Online site, which, in part, reads as follows: "All work published in Sociological Research Online is subject to copyright and may not be reproduced, in whole or in part, in any manner or in any medium without the written consent of the Management Board unless no charge is made for the copy containing the work or the excerpt, and the author's name and place of first publication appears on the work or the excerpt" (emphasis added).]

The Myth of Medical Pluralism: A Critical Realist Perspective

By GIL-SOO HAN

Abstract

It is widely assumed that there is a high level of medical pluralism in contemporary society. For example, both orthodox and non-orthodox medicines are simultaneously available to the public. What forms the boundaries that demarcate orthodox medicines from non- orthodox ones? These issues arise when examining medical pluralism from a critical realist viewpoint. The aim of the paper is to argue that: firstly, orthodox and non-orthodox medicines reflect political economic aspects of the social context in which they are located. They do not exist in a social vacuum ensuring their ontological distinctiveness. Secondly, there are more similarities between orthodox and non- orthodox medicines than distinctly different features. In contemporary capitalist societies the key structuring/generative mechanism affecting the form and content of medical systems derives from the commodification of health care. This pervades both orthodox medicine and its various alternatives. Thus the reality of medical pluralism is illusory.

Keywords:

Alternative Medicine; Biomedicine; Complementary Therapy; Critical Realism; Medical Pluralism; Modes Of Production; New Age Medicine; Political Economy; Social Formation; Traditional Medicine

Introduction

1.1

Part of my intellectual curiosity about medical pluralism started with the empirical question: Why have the Korean immigrants in Australia, for the last two decades, been utilizing both orthodox and non-orthodox medicines including herbalism, massage, and acupuncture? Why are there not conflicts in using the supposedly different kinds of medicine (see Han, 1997; 2000; 2001)? Also relevant here is the burgeoning boom of a variety of New Age medicines. Are they really providing 'better' or alternative treatments? What is behind all these phenomena? As a way of unveiling the myth of medical pluralism, this paper examines the relationships between modes of production, social formation and medical systems whose effects are implemented in the nature of 'medical pluralism' at a structural level as well as at the level of the agent. This paper intends to be a theoretical endeavor to reveal the extent to which orthodox medicine is different from, or similar to, non-orthodox medicine, which has been explored in some empirical studies (e.g., Cant and Sharma, 1999; Han, 2000).

1.2

On the surface, it may appear that dominant and subordinate relations of Western (orthodox) and East Asian (non-orthodox) medicine in Australia are struggles of different ethnic groups or scientific and non-scientific medicines. However, these are simply masking other realities. Orthodox medicine sometimes systematically destroys non-orthodox medicine, and preserves it at other times. In many cases, a destruction strategy is adopted (see Chowka, 1995). Medical journals, institutions and media carry out obvious methods as a strategy. When non-orthodox medicine is preserved within ethnic groups, this may appear to be supporting or encouraging multiculturalism. Again, this may be masking the underlying mechanism of the phenomenon.

1.3

What is orthodox medicine or Chinese medicine/ non-orthodox medicine/ complementary therapies? For example, Chinese medicine in China today is not only different from that in China at different times in the past, but also from that in Australia today in a number of ways. Since Chinese medicine has many facets, it is indeed inappropriate to select one of these and call it 'Chinese medicine.' Such a concept entails the idea of a system of beliefs, knowledge, practices, facilities and resources related to medical care and illness intervention that have been developed, or adapted from elsewhere, and practised in China and overseas over a long period of time. The necessity of operating within a historical perspective also applies to other medicines including orthodox medicine. This is because a medical system not only reflects but also contributes to prevalent socioeconomic, political, and ideological relations of production and because medicine is articulated within a specific mode of production. In this respect, we cannot speak of medicine in general; rather, we need to speak of primitive medicine, feudal medicine, capitalist medicine or communist medicine (Navarro, 1983, p. 184).

1.4

Some writers argue that complementary therapy is the alternative to the 'troubled' or unsatisfactory biomedicine and so prefer to call this field 'alternative medicine' or 'alternative therapy.' Others argue that the term 'complementary therapy' is more appropriate as it is hoped to complement biomedicine rather than replace it (cf. Cant and Sharma, 1999). This also signifies the acceptance that complementary medicine can work together with biomedicine (British Medical Association, 1993). Both of the terms, complementary and alternative medicine, are problematic. Behind the concept of complementary medicine is the idea that a combination of biomedicine and complementary medicine forms holistic medicine. The concept is still open to debate. In addition, the term 'alternative medicine' assumes that we have an alternative therapy to biomedicine, which is clearly not true. One problem with categorizing all these complementary therapies under the one umbrella is that this tends to group together both largely accepted health practices, such as acupuncture, and more controversial practices such as laetrile or the Grape Cure (Gray, 1998, p. 56). This article uses only two broad categories: biomedicine or orthodox medicine on the one hand and complementary therapy or non-orthodox medicine on the other.

1.5

The level of acceptance of a therapy or a medicine to the broader society is of the utmost importance for the relevant practitioners and consumers. Therefore, medical pluralism is more than a phenomenon of the mix of traditional and modern medicine; it is rather, a function of political economy and cultural hegemony (Elling, 1981; Myntti, 1988, p. 520) and a result of complex factors within medical and other systems which are intertwined. A major issue often discussed in the study of medical pluralism is the role of the State. In the Third World, State support for non-orthodox medicine tends to encourage anti-imperialist feeling. However, when members of the upper class require serious medical attention, they seek help from orthodox care (Frankenberg, 1980, p. 198). In pluralistic medical systems, a set of signs is liable to multiple interpretations, and different sickness labels. As Young (1982, p. 270) mentions, '[s]ocial forces help to determine which people get which sickness. ... Symbols of healing are simultaneously symbols of power ... and medical practices are simultaneously ideological practices' (cf. Blane et al., 1997; Davey Smith et al., 1990; Shaw et al., 1999). Irrespective of whether or not non-orthodox medicine receives necessary financial and legal support to survive, both from the government and the public, the State's interest is to keep it alive, so that non-orthodox doctors take some burden off the orthodox ones (Young, 1986).

1.6

More generally, the prosperity of non-orthodox medicine in capitalist countries is dependent upon acquiring support from members of decision-making bodies who are seeking solutions to the contradictions of capitalist-intensive medicine and/or by patients who demand forms of treatment neglected by orthodox medicine (Baer, 1992).

1.7

Medical pluralism is more readily observable in some societies than in others. How can this be explained? While the role of the State has been considered significant in the phenomenon of medical pluralism, attention has not been given to the ways in which non-orthodox medicine is linked to entrepreneurial activities as well as to the continuing process of capitalism in which the exploitation of labour is a necessity. This process is what brings about similarities between biomedicine and complementary medicine.

Conservative Cultural Explanations

2.1

According to cultural explanations which stress cultural factors, patients may consult non-orthodox healers because they do not always agree with unfavourable comments made about them by orthodox medical doctors. Non-orthodox healers may be more easily accessible geographically and financially (Rahaman et al., 1982; Young, 1981). People may be interested to take up any health services available in the hope that they may provide relief (Durkin- Longley, 1984; Janzen, 1978). What makes medical pluralism possible from the viewpoints of cultural explanations? According to Weisberg (1982, p. 1513),

... the [medical] plurality is related to the freedom of choice that serves to place the patient in control of his environment, to give him options to strike what seems the best course for himself.

2.2

There is little doubt that individuals have options to choose from to a certain degree. However, Weisberg (1982) neglects the fact that medical systems are also shaped by social factors such as pervasive relations of production. Thus, individual patients from low class backgrounds are virtually left with much more limited options. In fact, individual use of health services is enabled as well as restrained by pervasive socio-political factors.

2.3

Postmodernism challenges the key assumptions of the dominant modernist/humanist cultures, including the idea of an autonomous human subject/agent, the idea of accumulative progress as well as the notion of universally valid objective knowledge. Regarding complementary therapies, postmodernists are centred around 'particular, as opposed to universal, truths', and focus on 'encouraging the articulation of perspectives on health care practices besides those of the dominant biomedical approach' (Gray, 1998, p. 70). Although postmodernists would encourage a high level of medical pluralism in terms of health care services, whether it is possible, and how, is open to debate. The ultimate problem with conservative cultural approaches as well as others which include postmodernist and poststructuralist approaches is that they often serve to justify the status quo. Those views tend to downplay the fact that influential social factors are not always immediately observable, but they are real and functioning.

Political Economy Explanations

3.1

Other studies have tried to broaden the scope of understanding by analyzing the mutual links between local practices and socioeconomic and political factors in the national and international contexts. According to this perspective, the ways in which orthodox medicine becomes the dominant medicine in most capitalist nations derive from underlying changes in social and economic relations. Coward (1989), for example, argues that the prevalence of economic rationalism has reinforced a climate whereby society is not to blame and individuals are to care for their own health needs.

3.2

For another example, among Tswana groups in Botswana and South Africa, while class divisions become clear between agrarian and urban-industrial capitalist sectors, traditional principles of social stratification tend to be subsumed by that of capitalist society and traditional relations of production become dominated by capitalist ones. This leads people in upper social and economic levels to become more confined to orthodox medicine both in ideology and practice, even though they may continue to use non-orthodox medicine as well (Comaroff, 1981; 1982). Similarly, Frankenberg (1981, p. 115) argues that allopathic medicine in India maintains a dominant medical power under the support of the middle and upper classes whose influence in 'the legitimation and reinforcement of capitalist power' is significant. He also points out the close link between elite commitment to orthodox medicine and an ideological system characterized by 'an urban, male, technological, curative and individualistic world view' (p. 115). In this regard, non- orthodox healers may end up serving only those people for whom such an ideology or 'cash nexus' is least relevant (Adams, 1988; Turner, 1977).

3.3

Whilst political economy perspectives prove to be fruitful they seem to overlook individual agents' views or hermeneutics or interpretivist views. However, a skillful synthesizing of the two broad schools may lead to a valuable result. Critical realism is one way to achieve this goal.

A Critical Realist Understanding of Medical Pluralism

4.1

How can we best understand people's use of both orthodox and non-orthodox medicines without conflict? The consumers' level of education has not been an appropriate explanatory factor (Miller, 1988; 1990). Understanding the phenomenon could be sought at least from two levels: individual and societal (or structural). No doubt, the two levels are closely linked. Neither individualist voluntarism nor collectivist reification of social entities provide a satisfactory perspective. This is because society does not exist independently of individual human agency. Following critical realism, I argue that patient health seeking behaviour is enabled and constrained by medical systems in the social context, but the action, in turn, reproduces or transforms the medical systems.

4.2

Critical realist epistemology relies on the thesis of naturalism, the argument which advocates the essential unity of method between the natural and the social sciences (Bhaskar, 1978; Sayer, 1992). That is, it is possible to apply the natural science model to the study of social reality. Realists assume that reality in both the natural and social sciences has ontological depth; that is, it is structured in a hierarchical fashion. Observable events constitute 'surface phenomena and reflect the realization – at the level of the actual – of generative mechanisms located at the level of underlying relations' (Watson, 1986, p. 8). Generative mechanisms refer to the causal powers of entities, aspects of their nature which cause them to act in particular ways.

4.3

There are three levels of reality: firstly, the empirical, which comprises experienced events; secondly, the actual, which consists of all events, irrespective of whether experienced or not; and thirdly, the causal, consisting of generative mechanisms (Porter, 1996, p. 219). For example, a study of a chemical reaction involves at least two levels of observation: firstly, surface phenomena, and secondly, the scrutiny of generative mechanisms or causal powers located at the level of underlying relations. The surface level of phenomena does not exist independently of deeper underlying factors. Realists argue that a similar method applies to the social sciences where 'tendencies' are the equivalent of generative mechanisms and refer to the emergent natures of particular social relations. These underlying relations for Marxists are 'inner relations' and the observable phenomena at the level of the actual are known as the phenomenal realization of these inner relations (Azevedo, 1998; Watson, 1986, pp. 8-9).

4.4

The major difference between the natural sciences and the social sciences is the ways in which generative mechanisms are understood. In natural science, mechanisms can be apprehended in terms of closed systems so that empirical regularities can be studied through manipulation, repetition of experiments, and so on. However, in social science, mechanisms need to be understood in terms of open systems (situations) because the realization of the mechanisms in contingency and the nature of social events in open systems is indeterminate. Generative mechanisms may be appreciated under the construction of closed systems. However, within the social sciences, this is usually impossible. This is the limit of naturalism. Therefore in the social sciences, the study of the mechanisms is dependent upon 'historical and comparative analyses and/or practical interventions in basically open systems' (Watson, 1986; cf. Collier, 1994).

4.5

Regarding the relationship between concepts and reality in the social sciences, realism can be distinguished from positivism/empiricism and those strands of theory often called conventionalism/interpretivism/hermeneutics (Benton 1977; Collier 1994; Keat and Urry 1975; Sayer, 1992). Realists share the natural thesis with positivists but they reject two particular aspects of positivism. Positivism does not make a distinction between generative mechanisms and observable surface phenomena. Therefore, observable or empirical regularities are the only real phenomena. That is, ontology is reduced to epistemology; 'what is to what can be known' (Lovell, 1980, p. 11). In addition, positivists see abstractions as only heuristic intentions rather than concepts which refer to real entities. Thus positivists reject the ontological depth of social reality and operate 'with a flat ontology' (Watson, 1986, p. 10).

4.6

Conventionalists maintain that all knowledge is theory laden and that therefore it is not possible to have independent access to the real. The inevitable result is relativism: knowledge depends on how we look at reality. A conventionalist position argues against the basic realist assumption about an independent and knowledgeable world. However, defending their position, realists acknowledge that knowledge may be 'theory laden' or socially constructed, but it is not 'theory determined' (Sayer, 1981; (1992). The real world 'cannot be reduced to language or theory, but is independent of both, and yet knowable' (Lovell, 1980, p. 17).

4.7

To sum up, realism is both an ontology and an epistemology. It makes assertions about what the nature of the real world is (ontology) and the way the real world can be known on the basis of the ontology. The observable empirical world is causally connected to 'deeper' ontological levels, and it is through these causal connections that we can use sense-data, experience and observation in formulating knowledge of the structure and processes of the real. These casual connections, Lovell (1980: 22) argues,

cannot themselves be understood through experience, because neither the underlying structures nor the connection between these structures and the empirical world are themselves experienced. The connection can only be reconstructed in knowledge. But these connections are vital for the realist theory of knowledge.

4.8

Critical realist epistemology combines the realist perspective and historical materialism which emphasizes the significance of the modes of production of life which determine the social, political and intellectual life process in general. It is not the consciousness of the people that makes their being, but on the contrary, their social being determines the consciousness. The mode of production is critical for our understanding social reality because of our necessary transaction with nature in producing and reproducing our physical existence. This is also the reason why productive involvement (i.e., work) is proposed as a significant mediator in understanding the juxtaposition of biomedicine and traditional medicine (Han, 2000).

4.9

Every social phenomenon is produced in the continuing relationship between social structure and individual action. Prior to the occurrence of any individual action, social structure pre-exists. Thus individual action is enabled and restrained by the pre-existing societal conditions (Bhaskar, 1989).

4.10

Giddens' (1984) structuration theory shares some common features with a critical realist view: the former stresses the autonomy of social actors, but the latter carefully notes the pre-existence of social forms, thus acknowledging a stronger ontological grounding of structure (Bhaskar, 1978, 1983; 1989; Porter, 1993, p. 595). In the study of both orthodox and non-orthodox medicine (e.g., amongst Korean immigrants in Australia), understanding the structure of the medical system is crucial. Of course, part of the structure is partially formed by the cultural elements Koreans have been bringing with them to Australia since the early 1970s. Again, this does not imply that individual health care utilization is predetermined by the medical structure to which patients are readily exposed. Rather, health care seeking behaviours will be influenced by the social position of individuals, in that social position provides them with the means, media, rules and resources (e.g., past experiences of family members, relatives, and friends) to enable or encourage their actions (Bhaskar, 1989, pp. 3-4). This does not mean that, in a place where a diverse range of health care services is available, every patient will necessarily utilize all the available health services. Indeed, every individual action entails the nature of open social systems. For instance, when an individual falls ill, the person's major interest in seeking health services is to recover from illness. The kinds of services available for a person to pursue depend upon the resources at the personal level as well as at the societal level which pre-exists the personal. In seeking the services, the client is involved in reproducing existing health systems based on the principles of the dominant mode of production.

Modes of Production, Social Formation and Medical Pluralism

5.1

There are two terms to be defined now. First of all, what is a medical system? Medicine or a medical system is not just a thing; rather it refers to,

the constellation of beliefs, knowledge, practices, personnel, and facilities and resources that together structure and pattern the way members of a sociocultural group obtain care and treatment of illness (Fabrega and Manning, 1979, p. 41).

5.2

Secondly, what is medical pluralism? It could generally mean one of two things. The first meaning refers to the co-existence of various health care systems such as orthodox medicine, chiropractic, acupuncture, herbal medicine, osteopathy, bonesetting, and so on. Consumers have a right to choose from the pool of various types of therapies, each of which is unique in its own right. The second kind of meaning refers to pluralism within a particular system. For example, with orthodox medicine, a client has a choice to go to a private or public hospital or to a doctor practising in a village, or a town, or a distant city, or overseas. This paper is concerned with the first kind.

5.3

Why is it important to discuss modes of production in understanding medical pluralism? All aspects of social life are closely influenced by what is required by the work process (Clement and Myles, 1997; Laurell, 1979, p. 545; Scambler, 2001) and the relations of production. To put this differently, the basis of any society is what is produced, how it is produced and how it is distributed. Production is a critical factor in social formation and in the reproduction of society and its social phenomena, including health and disease. An extraction of surplus value at the site of production leads to fatigue and stress, that is, expropriation of health. The change of means of production has led to the intensification of work, the introduction of new forms of organization and new kinds of risks for health. As Palloix (1980, cited in Navarro, 1982a, p. 7, his translation) has written:

To transform the world, that is, to transform the mode of production, through the process of class struggle is to change, among other moments, the mode of organization of production and the process of work. Otherwise, all process of change can be in vain, because it is the mode of organization of production and of the process of work where we find the roots of the division of social classes, the class struggle, and where capitalism is reproduced and reborn.

5.4

What makes up knowledge, ideology and social institutions cannot be understood without looking at the social formation and historical period out of which they grow (Berliner and Salmon, 1979, p. 32). Contemporary society is often characterized by large-scale monopoly capitalism. Most individual activities and social- political institutions reflect a capitalist mode of production. As Pierre-Phillipe Rey (cited in Soiffer and Howe, 1982, p.178) has mentioned, '[a] mode of production is a process of production that reproduces itself. It is thus defined by the area of class struggle at the core of the linked pair of exploiter and exploited, determined by specific relations of exploitation' (their translation).

5.5

Pointing out the significance of modes of production is not to imply that all social relations are class relations, or that every social phenomenon is explained by what happens at work. What happens in other phases of society such as exchange and consumption and what happens on other levels such as ideological, economic and politico-juridicial maintains a relative autonomy of its own. There is a mutual influence between production and various phases and levels of society, but the latter are constructed and articulated within a whole, that is, a social formation or society which is most significantly characterized by production.

5.6

A medical system is not an exception. Why were naturopathy and nursing not worthy of an academic degree in the past, but are both worthy now (Ellicott, 1994; cf. Martyr, 1995)? These are examples of articulation of medicine in the context of modes of production. In most societies, today, various kinds of medicine co-exist. Some evolved a few thousand years ago; others evolved as recently as a hundred years ago and many more are continually meeting to co-exist. Various kinds of medicines undergo changing processes for their survival. Whilst they still maintain the legacy of other kinds of modes of production out of which they grew in the past, they are articulated and re-articulated in the interaction of different modes of production. Therefore, the complex relations between different kinds of medical systems or the juxtaposition of so-called orthodox and non-orthodox medicines cannot be explained simply by looking at the dominant and subordinate relations of one group of health workers over another involved in different medicines.

5.7

According to Marx (1973, p. 99, cited in Navarro, 1982, p. 81), production, distribution, exchange, and consumption are parts of an organic whole, the mode of production. But it is the relations of production which determine what, how, and why products are produced and exchanged. I mean, by relations of production,

those relationships which are established between the owners of the means of production and the direct producers in a definite process of production, relationships which depend on the type of ownership, relation, possession, dispossession or usufruct which they establish with the means or production (Harnecker, 1977, cited in Navarro, 1982b, p. 82).

5.8

Marx suggested two major types of relations of production, which depend on forms of ownership of the means of production: relations of exploitation and relations of reciprocal collaboration. The former may be observed when one group of people (the owners of the means of production) live off the exploitation of the labour of the direct producers. They include relations of slavery whereby the master owns the means of production as well as the labour power (the slave); relations of servitude whereby the master owns the land, and the servant relies on him and has to offer free labour for a certain number of days every year; and finally, capitalist relations whereby the capitalist owns the means of production and the workers must sell their labour power in order to live. Relations of reciprocal collaboration come into being when there exists a social ownership of the means of production and no group of people lives off the exploitation of another group. They include the relations between members of primitive societies, or the relations of collaboration that, according to Marx, characterize the communist mode of production (Navarro, 1982b, p. 82; Navarro, 1983, pp. 183-184).

5.9

A few different modes of production may exist within the same social formation. Most contemporary capitalist societies, for example, simultaneously contain some aspects of the feudal mode of production, the petty commodity mode of production, and the capitalist mode of production simultaneously. In petty commodity production, the worker owns the object of work and the means of work and has control over the labour process. In large-scale industrial society, there is a complete separation of the labourer from the object of work, from the means of labour and from his/her own skills, knowledge and fellow workers, and the capitalist controls both the means of production and the labour process (Navarro, 1982a). These different modes of production within the same social formation are closely related to each other, that is, dominating and dominated relationships. The most dominant mode characterizes the mode of social formation (e.g., feudal, capitalist).

5.10

Likewise, today's capitalist societies are composed of at least a few kinds of medical modes of production. Some of these are: a home mode of production, a petty commodity mode of production, and a monopoly-capitalist mode of production. A home mode of production is one whereby the purpose of medicine is to heal family members only; a petty commodity mode of production is one whereby a medical skill (e.g., diagnosis, cure) takes the form of a commodity and its sale becomes the means of livelihood for some individuals. And lastly, a monopoly-capitalist mode of production is one whereby on the one hand, the private producers of a health commodity control its production which is highly centralized and concentrated (Berliner, 1982), and who employ the majority of health workers on a salaried basis in large scale health care organizations, and on the other hand, State-provided medical services offer a range of treatments partly on a commodity basis, partly 'free', and subsidized through taxation.

5.11

The complete dominance of one kind of medical mode of production over another could lead to the latter's disappearance for a certain period or forever. However, in general, most medicines are embedded in a broader context marked by a mixture of modes of production and are constantly articulated under the influence of the dominant mode of production (Frankenberg, 1980) in that particular society that is not static or going through change. For example, Chinese medicine in Australia undergoes a changing process for its survival or expansion.

5.12

The penetration of orthodox medicine into a traditional society is sometimes more abrupt than at other times, depending on the type of interaction between the host and the incoming mode of production. For example, in the feudal Malay peninsula, although Western pills and potions are prescribed by the bomoh (medicine man or shaman), they do not replace native herbs or non-orthodox medical practices. Government-trained midwives were well accepted, but had not replaced non-orthodox ones and mothers had no preference. They had not taken advantage of surgery, however, since it is against the doctrine of Kor'an to cut or mutilate the body in any way (Wolff, 1965). What Wolff's study argues overall is that the technology has been accepted but not the ideas behind it. Whether this kind of thesis is sustainable over a long period of time is doubtful. Now, thirty five years since Wolff's study, it would be safe to say that there has been much change in the links between different kinds of medicine there. This change would take place, unlike as Wolff (1965) argues, not through either 'the Malayanization of Western cultural elements' or 'the Westernization of Malay culture', but by both.

5.13

In explaining medical pluralism, Berliner's (1982) work on medical modes of production and Berliner and Salmon's (1980) work on the emergence of holistic health practices are helpful. By holistic health practices, they mean those practices basically counter to scientific medicine which attempt to view the patient as an integration of body, mind, and spirit (Berliner and Salmon, 1980, p. 144). In the following discussion ideas shall be drawn from their work. And the terms, 'holistic' and 'non-orthodox medicines' will be used interchangeably.

5.14

As Berliner and Salmon (1980) indicate, it would be an oversimplification to group holistic medical practices together in one category. Their origins are as diverse as the names of practices show: transpersonal psychology, parapsychology, folk medicine, herbalism, nutritional therapy, massage, homeopathy, yoga, meditation, and parts of the martial arts. Indeed, there are numerous kinds of herbalism itself. Nevertheless, there seem to be at least two basic characteristics central to the anti- 'scientific medicine' kinds of healing method: firstly, there is an assumed unity of mind, body and spirit, which implies that illness is other than just physical; and secondly disease is supposed to have reasons and dimensions not emanating from the purely biological. These imply that health is a process of everyday life rather than an outcome. Therefore it must be an important part of the daily understanding of individual and community activities.

5.15

The mind/body dualism remains a central philosophical critique of orthodox medicine, and the eradication or underestimating of the mind as a major part of the disease process has been considered as one of the most conspicuous achievements of orthodox medicine. These critiques of orthodox medicine form the primary reason to advocate holistic medicine. The main direction or thrust of the movement is a direct confrontation against the fundamental principles of orthodox medicine.

5.16

Consequently, the holistic health movement has attempted to prove the potential power of the 'mind' over the 'body' in the treatment of various diseases, as practices such as meditation, biofeedback, autogenic training, and hypnosis become popular. The probing of psychic matters (e.g., clairvoyance, telepathy, precognition, psychokinesis, and extra-sensory perception) may bring out a new perspective on pathophysiology and health maintenance. Other practices such as yoga and some forms of the martial arts are publicized as a means of forming an integrated concept of the health of individuals and a greater health consciousness.

5.17

The popular use of holistic medicine since the 1970s is a part of the movement to challenge basic theories of orthodox medicine (Goldstein, 1999). Therefore, utilizing holistic medicine is a means to participate in the movement. The value of each holistic therapy may become established through practice and scientific investigation. The use of one or more kinds of holistic health services does not always imply the individual's total rejection of 'scientific' medicine. This enables the possibility of the juxtaposition of orthodox and holistic medicine (Cant and Sharma, 1999).

5.18

There has been ample evidence of why, in the West, a holistic view of health was submerged by the coming of 'scientific' (or orthodox) medicine in the late 19th century. However, having enjoyed a period of dominance in health services for a long time, orthodox medicine is now under attack by the holistic health movement, due to the broader economic crisis. This attack has been pervasive in the West since 1970 and in other parts of the world at various times depending on the socioeconomic and political context of local areas.

5.19

Let me now turn to why the holistic health movement has become prevalent. First of all, there has been a question about the level of effectiveness of modern medicine in alleviating the disease patterns in advanced capitalist society. The health sector in the West, now consuming about 10 per cent of the GDP, has become a leading growth industry. The cost of health care services for the poor and aged and other affiliated health costs such as environmental and occupational safety requirements and the purchasing of health insurance have been financial burdens for both corporations and the State. Whilst health care expenditure is blamed for limiting capital accumulation, reducing inflation in health costs has been a corporate strategy, which includes replacement of costly, high-technology medicine with cheaper, anti-technological therapies, and the promotion of new modes of healing. A variety of self-help treatments and holistic medicine practices have been promoted and they tend to foster 'individual responsibility' for disease especially in the context of the decline of the welfare state (Crawford, 1977; Han, 2000).

5.20

In addition, while it is true that the problem of mind/body duality of orthodox medicine bears an extensive limit in curing disease, it is also true that work conditions under the capitalist mode of production are significantly different from those of previous modes. The level of work intensity and alienation is high. Under the capitalist medical modes of production, health is referred to as a capacity to work. When a person falls sick, a significant matter which concerns the person is whether s/he can go to work. Work-related stress appears to be the primary cause of some diseases (such as heart disease and cancer) resulting in high levels of mortality. People who are supposed to be responsible for their own health have no options but try all the available health services. This is not a process of the individual taking an active part in sustaining his/her own health, but a process to maintain one's health in its best condition so as to be able to sell labour power, which provides the primary source of living. This could change the nature of some non-orthodox medicines which were both preventive and curative-oriented, in the past, into largely preventive. Of course, the curative nature of some non-orthodox medicines would remain effective against some diseases regarding which orthodox medicine has showed only limited efficacy. The extent to which the use of non-orthodox medicines resurges and becomes popular depends upon the social settings. Of those, the availability of access to orthodox medicine would be an influential factor.

5.21

Now, let me look at holistic health practices more closely. Holistic health services need to be put under investigation prior to acceptance. There is a tendency for the holistic health movement to appear to be politically conscious and to take up the banner of social medicine which calls for the control of social factors to fight and prevent disease. However, in fact, it has been at best apolitical. Indeed, the holistic health movement shares much similarity with orthodox medicine in its organizational and social pattern. It is: 'solo, fee-for-service entrepreneurial practice; knowledge of skills sold to 'consumers' in commodity forms; elitist and sexist behavior on the part of practitioners; and a clear separation between practitioners and those who are served' (Berliner and Salmon, 1979, pp. 44-45; cf. Sharp and O'Leary, 1991). As in scientific medicine, the focus of treatment is on the individual rather than a larger social class. While promoting the concept of a unified whole of mind, body and spirit, holistic health practices continue to leave aside the external world in their healing process (i.e., the role of social class, economic, social and political relations). Thus, helping the individual to adjust to a socially pathological circumstance is a major goal.

5.22

In a study of the history of Chinese medicine, Unschuld (1975; 1987) finds many parallels in the ways in which the ontology of Chinese medicine (which has been steadily growing or reviving in some Asian countries and in the West) and Western medicines has developed while they have mutually influenced each other over the period of a few millennia. For example, it is argued that

An ontological approach, in China as in Europe, tends to neglect the individual patient because it focuses on a fight against the disease or against the pathogenic agent, rather than on restoring a function or a system of functions. The Chinese ontological approach to illness has, therefore, conceptualized 'diseases', has sought for their very specific causes, and has developed standard treatment procedures regardless of the individual patient. The fact that bacteriology was quickly adopted in China and found a large number of adherents may, aside from its tangible effects, also result from the fact that all the conceptual pre-conditions for the introduction of bacteriological concepts were present in China for two millennia already (Unschuld, 1987, p. 1026).

5.23

Let me now elaborate on the above mentioned similarities between orthodox and non-orthodox medicine in more detail.

Common Features between Orthodox and Non-orthodox Medicines

6.1

Firstly, there are always carer- patient (or doctor-patient) relationships in providing health care. The carer maintains expertise or qualifications obtained through traineeship. The social backgrounds of health seekers do not affect the relationship of one party providing care based on the specialty and the other receiving care as a patient. This carer-patient relationship is also historically specific. The relationship is much more distinct in a market society, compared to that of primitive and feudal society.

6.2

Secondly, medical service is a commodity to be sold and bought. All the medical services involve a period of traineeship, advertising, special tools to be used for treatment and drugs. The reason people pursue a kind of medical training is because they see the possibility of finding a place of employment. This applies to complementary therapies, too (Huisman, 1989; Sharma, 1992). The supply of necessary tools and drugs implies the involvement of pharmacists, drug manufacturing companies and distribution. In addition to structural factors which influence health seeking behaviours, what kind of health care a patient would pursue is partially the patient's, that is, consumer's choice. This leads medical providers to advertise. Although Judeo-Christian tradition once regarded medical service as a form of charity (Turner, 1987, pp. 20, 27), there has been an increasing trend toward consumerism in the provision of health service (Goldstein, 1999; Reeder, 1972). This trend is similar to consumerism in other aspects of society in which customers shop around according to information about the services available to them. This orientation is more prevalent in the middle and upper classes than among the socially and economically disadvantaged (Cockerham, 1986, p. 100).

6.3

Anthropologists report that few charlatans are found among non-orthodox healers because they are not full-time medical practitioners and they have other sources of status and income (Leslie, 1980, pp. 192-193). It might have been possible to observe the avocational practitioners in some tribal societies whereby the influence of the national and international political economy has been minimal. However, as each society becomes closely interlinked to a wider structure of economy or to the process of globalization, being avocational medical practitioners becomes nearly impossible under the present modes of political economy. Research shows that complementary medicine, as private medicine, heavily influences the characteristics of complementary practitioners' practice (Cho, 2000; Johannessen, 1996; Sharma, 1992). Some traditional medicines, such as Ayurvedic and Yunani medicines in India (Leslie, 1976a, p. 364) and Hanbang in Korea, maintained a relatively low level of professionalization until the Second World War. However, being backed up by the State educational system and establishing professional associations, they have since become highly professional and consequently commercially oriented (Brass, 1972; Coward, 1989; Leslie, 1973; 1976a). To be brief, the medical sector as an economic enterprise is well documented (Alubo, 1990; Ben-David, 1968; Foster, 1995; Fox, 1976; Unschuld, 1976, p. 301).

6.4

This is not to imply that every medical service is based on the principle of fee for service. Free State-provided medicine is a case in point. However, the State's intervention in the health of the public is generally a way of control over providing adequate labour power so as to reproduce the dominant mode of production (Aumeeruddy et al., 1978).

6.5

Thirdly, medical service takes place usually in the clinic. If a patient is unable to come to the clinic, the health worker may visit the client. Providing the service in an established clinic is a consequence of the professionalization and commodification of the medicine. As long as the patient is in the clinic, surgery or hospital, carer-patient relationships tend to persist. The more institutionalized a medicine is, the more impersonal and alienating the relationship is in its treatment setting.

6.6

Fourthly, health workers tend to medicalize the disease which is a socially constructed reality. Recently, as a method of curing disease, some health services, especially those offering psychiatric treatment, have utilized social scientific knowledge and socioeconomic factors concerning the client. However, the diagnosis and treatment by health workers are primarily based on physiological knowledge. Disease is the central concern of health workers' competence and they tend to shun the relevant social issues and illness experience. This tends to dehumanize factors causing illness, and consequently to mystify social reality. In this process, health is considered to be closely related to the ability to work, or a means to an end rather than an end in itself.

6.7

Fifthly, there is always competition, not only within each medical tradition to better appeal to, or treat, the clients, but also between different medical services in order to enhance each of its reputation against other kinds (Unschuld, 1975). The latter kind increases the level of particularism of each institution. That is, whilst different health care systems share many common features rather than differences, they compete for superiority over, or fair recognition by, others (Worsley, 1999). This competition is also closely tied to winning or maintaining acceptance by the public and consequently to receiving financial reward. There seems to be a tendency to stress that non-orthodox health workers are more prone to internal conflicts. For example, it is argued that the professionalization of chiropractors has been hampered not only by physicians but also by conflicts among themselves caused by different methods of treatment (Cockerham, 1986, p. 114). However, such conflicts should not be over-emphasized to suggest that conflicts among chiropractors take place more often than among physicians. It goes without saying that orthodox physicians, like any other health workers from different medical traditions, are also bound to have disputes among themselves over a number of issues. For example, it is this ongoing process of fighting over the better financial reward that misleads the public into thinking that medical pluralism is well and truly pervasive.

6.8

Sixthly, despite the claim of authority by orthodox doctors, other health workers still attract a significant proportion of patients both in the East and West. The fact that orthodox medicine has gained an ever-increasing proportion of any nation's medical system has to do with coercive factors of various kinds rather than to do with natural development and demands from the population (Unschuld, 1975, p. 303). Orthodox health workers may argue that they enjoy much higher respect from the public than their counterparts. In interviews with 1,123 patients of non-orthodox healers in an African urban suburb of Lusaka, Frankenberg and Leeson (1976) found that two-thirds of them had first been attended by orthodox medicine despite the fact that there were about 30 non-orthodox doctors in private practice, one government clinic and sub-clinic in this community of 80,000 people. Leslie (1980, p.194) has identified several structural reasons for such high regard for cosmopolitan medicine and its orthodox physicians.

6.9

However, patients also consult 'alternative' therapies. Increasing popularity of complementary medicine in recent years is in part due to people's dissatisfaction with biomedicine (Baer et al., 1998) and thus poses a very real challenge to it (Sacks, 1994). This is a clear indication of some of the gaps within conventional medicine. Research suggests that the users of alternative medicines are not only aware of biomedicine's inability to cure many illnesses, but also they are not always satisfied with the biomedical treatments offered (Daykin, 1996). Moreover, biomedicine is seen as insensitive to the needs of individual patients and that it does not appropriately handle the social and experiential aspects of illness (Coward, 1989; Goldstein, 1999; Sharma, 1990, p. 132). Complementary therapists are often more friendly and more accessible than their biomedical counterparts; their holistic approach integrates the patient's and family's experience of illness in a thoughtful manner; their method of cure also contains 'demonstration effects'; and the majority of them maintain symbols of power like stethoscopes, motorbikes and wristwatches. In India and Korea, the non-orthodox medical systems are backed by formally recognized colleges, hospitals, research institutes, pharmacies and clinics. Other countries have a lower degree of professionalization in non- orthodox medicine, but in many Asian, African and Latin American countries, professional associations of traditional practitioners exist; training and practice take place in clinics; and commercial companies take care of the manufacturing and advertising of indigenous medicines (Leslie, 1980, p. 194).

6.10

Lastly, a high level of professionalization process is observed both in orthodox and non-orthodox medical services (Cant and Sharma, 1999). The providers of health services try hard to maintain well-organized professional associations, through which the control over the required qualification is achieved. The associations maintain close links with higher education sectors (e.g., medical schools), health planning agencies, public health agencies, insurance companies and hospital administrators (Cho, 2000, p. 124). The maintenance of professional organization by health workers is often part of a market enhancing strategy by occupational groups in a competitive market society, which continues to contribute to the medical profession's current trends toward managerialism and consumerism in health care (Wilkinson and Kitzinger, 1994).

6.11

Why are these similarities observed between orthodox and non-orthodox medicine? In brief, there is no such thing as 'traditional' medicine in contemporary society. A particular medicine might sustain some characteristic traces of a few modes of production, but it largely reflects the dominant mode of production (i.e., capitalist) as a result of articulation and re-articulation under the influences of different modes of production. To put this differently, every medicine, irrespective of its time of appearance, changes and takes on the features of the broader social formation or generative mechanism and its dominant element. Consequently, we are left with capitalist medicines today. In this respect, celebrating medical pluralism is simply an illusion.

Summary

7.1

As already mentioned, according to Pierre-Phillipe Rey (1977, p. 122, cited in Soiffer and Howe, 1982, p. 178), '[a] mode of production is a process of production that reproduces itself.' Transformations from one mode of production to another have been achieved by enforcement of violence such as conquest, enslavement, robbery under the support of the State or other social institutions (Soiffer and Howe, 1982, p. 180). Types of medical modes of production, knowledge and ideology grow out of historically specific social formations.

7.2

The present juxtaposition of orthodox and non-orthodox medicine which has grown out of different social formations, but which has been articulated at various stages of their existence, can be understood only when considering the ways in which contradictory modes of production, which co-exist for a long time, are articulated under the dominant mode of production. Of course, in the process of the articulation of modes of production, the State, despite its supposed relative autonomy, takes a critically significant role in favouring the development of capitalist mode of production. Although the capitalist mode of production is largely in control of economic superstructures in contemporary society, it does not always solidly dominate other modes of production. They are in the continuing process of articulation for their survival. Some features of traditional or domestic modes of production are preserved or integrated into the capitalist mode of production, and some are destroyed. For example, sometimes 'traditional' or non-orthodox medicine is sold in a ready for consumption or tablet form. This involves the establishment of factories to produce the relevant instruments. Whilst non-orthodox medicine changes many of its features both passively and actively, its commodity nature remains solid. To be more general, the fewer conflicts between various kinds of medicines grown out of different social formations, the more chances of the mere appearances of medical pluralism.

7.3

Therefore, it is crucial to note that one medical system consists of a few different modes of medical production. For example, any non-orthodox medicine today contains not only some components reflecting the capitalist mode of production but also contains legacies which reflect the pre-capitalist mode. Nevertheless, orthodox and non-orthodox medical systems share many more similarities than differences. The differences are indeed often 'of emphasis rather than absolute' (Frankenberg and Leeson, 1976, p. 233; cf. Worsley, 1999).

7.4

Biomedicine and non-orthodox medicine concentrate on the individual body and neither biomedicine nor non-orthodox medicine actually consider social origins and constraints on health and well-being. Both rely on medication, rather than on social, political and economic change to bring about improvements in health and well-being. Both individualize health problems. Although biomedicine and non-orthodox medicine share differences as well as similarities, a notable concern of the users of medicine is whether or not they could afford it, and if they would benefit from it, or whether it will maintain their health, that is, the primary capacity to work under the pervasive capitalist mode of production (Goldstein, 1992; 1999). While the users of health care attempt to fully utilize any available health care, orthodox or non-orthodox, the providers of health care in pursuit of profit also look for the best possible ways to meet the needs of the consumers (Cant and Sharma, 1999; Han, 2000).

7.5

Many kinds of alternative medicine are booming in many developing and developed countries. Indeed, many of the complementary or folk medicines that were strongly discredited under the dominant influence of biomedicine have revived or regained a certain level of credibility in many parts of the world over the last few decades. Most research on alternative therapies often involving cultural explanations has not been satisfactory. For example, a cultural explanation for the persistence of traditional medicine in Malaysia was that biomedicine is impersonal and mechanistic, whereas traditional medicine tends to be personal and supportive (Heggenhougen, 1979). Such a perspective tends to underestimate similarities between biomedicine and alternative medicine and is unable to explain the dominance of biomedicine. Further, cultural explanations decontextualize health, illness and health care choices and neglect relevant political-economic aspects or underlying mechanisms (e.g., Bhopal, 1986; Brainard and Zaharlick, 1989).

7.6

The popular use of alternative medicine in part reflects the increasing awareness of the limit of biomedicine or frustration with scientific approaches to health and illness. However, in seeking an explanation for the pervasive demand for and supply of alternative health care, it is not only important to go beyond the culture of each kind of health care itself but also to examine the changes occurring at a societal level as well as to examine consequential individual response to the changes (Cant and Sharma, 1999). There are some relatively new social conditions that influence the choice of diverse health care methods such as herbal medicine, health foods and what are loosely called New Age therapies. The transformations in the labour market and the global effects of the restructuring of work have led to decreases in job security, work-related stress and pressures on household budgets. These have contributed to broader cultural changes, transformations in subjectivity and a pervasive attitude of 'look after oneself', which reiterates the importance of an underlying mechanism in understanding the recent booming of complementary medicine (Worsley, 1999).

7.7

Finally, critical realism explores, and is able to reveal, the close relationship between observable events and generative mechanisms of a social phenomenon and offers a real possibility for dialogues between biomedicine and non-orthodox medicine that share many similarities. Such dialogues are likely to benefit the public to a large degree. However, innovative critical realist research is yet to be undertaken before we can see any notable contribution to the society.

Acknowledgements

Much of insight of this paper has derived from conversations with Professor Rachel Sharp, formerly at the University of New England, Australia. I am indebted to Carmel Davies and anonymous reviewers for their critical readings and constructive comments on earlier versions of the paper.

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