Social changes and the advancement of CAM throughout the UK in recent years.

This piece is based on one originally written in March 2009 as part of the Open University’s course K221 “Perspectives on complementary and alternative medicine”. The nature of the course required a more balanced discussion than, with hindsight, the subject probably deserved. Nevertheless some of the points may be of interest when considering how, what we now refer to as, “Complementary and Alternative Medicine” (CAM) first emerged from the morass of primitive and brutal medical practices with origins in the middle ages (or even earlier), and why CAM has recently suffered such a dramatic increase in popularity in more recent times.

Introduction:

Although it has experienced a renaissance in the last half century, no discussion of the effect of social change on the use and advancement of CAM is possible without consideration of its origins at the start of the modern age. The debates surrounding the Medicines Act of 1858 which led to the enshrining of orthodox medicine and, arguably, the de-facto creation of “Complementary and Alternative Medicine” as a result, closely reflect modern arguments on the same topic, namely accusations of the political marginalisation of CAM and calls for its integration (or perhaps re-integration) into the mainstream.

Social and political developments in recent years can be seen as a mirror image of changes in the 1850’s as the great experiment is re-examined and given a contemporary gloss. Some attitudes in well-off western societies where public health and advanced medical care have transformed the average standard of living and, influenced by the development of communications technology and consumer culture, have begun to challenge the idea of purely science based medicine, increasingly perceived by some as being unable to cater for the patient as an individual with a need for choice in healthcare as in other areas of life.

Development:

According to authors sympathetic to the idea of CAM, such as Saks, until the Medicines Act of 1858 medical practitioners, although starting to emerge as a group and recognised by law in some areas, were often of low standing and competing in a pluralistic market with other, often self administered medical modalities whose origins lay in folk or religious practices (Book 1, pp. 62-64). Saks suggests that the introduction of the act was a political move by physicians in an attempt to exclude rival health groups (Book 1, p. 66) while maintaining the “income, status and power” of the emerging medical hierarchy (Book 1, p. 76). The act is described using language reminiscent of colonisation (Book 1, p. 76) and empire (Book 1, p. 36).

Other commentators, however have pointed out the disordered nature of what passed for the medical profession at the time leading up to the act and the need for consolidation. Roberts suggests that the drive for medical reform was an attempt to bring order out of the chaotic status quo of the day:

“This voice [of the majority of medical practitioners]… was currently stifled by the monopoly authority of the “medieval”, guild-based corporations of the profession, with their increasingly dysfunctional occupational demarcations into physicians, surgeons and apothecaries. Until these “Gattons” and “Old Sarums” of the medical nation were abolished, as rotten boroughs had been abolished,… no reliably effective expression of medical authority or purpose could emerge.” (Roberts, 2009, p. 39).

Thus it could be said that physicians, surgeons and apothecaries of the day were as much an obstacle to change as any other group.

Roberts further points out that professional authority rests not simply on professional assertion but requires cultural acceptance as well and the act, far from enshrining a monopoly of medical practitioners, had built into it the right of the individual to remain a free agent in a pluralistic medical market place.

It must also be considered when examining social change in 1858 that an increasingly scientific basis for medicine was emerging. This was seen for example in the introduction of basic hygiene and disinfection measures by Semmelweis, Lister and others in the 1840’s (Posfay-Barbe et al, 2007), the work of Florence Nightingale in the field of sanitation and statistics during the 1850’s (Audain 1998) and the pioneering epidemiological work of John Snow during the London cholera outbreak of 1854 (Snow, 1856).

Gradually, in response to growing public demand (Book 1, p. 65) and often in conflict with perceived wisdom from within and without its ranks, the emerging discipline of medicine was learning how to decide which treatments worked and which did not. CAM was emerging by default as society sought greater certainty and demonstrated, “a need for competitive self-improvement in a self-improving age.” (Roberts, p. 41).

Whatever its merits or motives, the enshrining of the act marked the beginnings of what is apparent today as the divide between “Orthodox” and “Complementary and Alternative” medicine. At that time the boundary was unclear and many orthodox practices of the age would not be recognised as such today, for instance the “doctrines of solids and fluids, humours and complexions” and the use of toxic medications such as mercury (Porter, 2001, p. 218).

In the century or so following, further legislation – notably the National Health Insurance act of 1911 and the introduction of the National Health Service in 1948 – served to consolidate the status of science based medicine and further marginalise the practices of CAM (Brunton, 2004, p. 140).

From the early 1900’s other changes took place which were to have a fundamental effect on society and its attitude to medicine.

Improvements in public health and disease prevention meant better lifestyle, increased longevity, greater disposable income and more leisure time (Self, 2008). Wars, empire and (latterly) a loss of job security meant that people were more inclined to travel. Towards the middle of the twentieth century technological advances such as the development of plastics, the transistor and electronic miniaturisation, the personal computer revolution and finally the advent of the world wide web meant that consumers had ever increasing and unprecedented access to new ideas and philosophies.

As a consequence society was becoming more aspirational. Tastes and lifestyles began to change giving rise to a desire for individuality and the beginnings of consumerism driven by increasingly sophisticated marketing (Book 1, p. 10). Lee-Treweek (2005) describes these changes as leading to a “pick and mix” approach to life as new consumers demanded greater choice in every area of life, including healthcare. Thus “Medical Pluralism” was born (or, possibly, re-born).

In the 1960’s the so called “counter culture” arose as an inevitable consequence of the coming together of these profound technological and social changes at a time when society was becoming disillusioned with authority; and post-modernist philosophy was taking root in the mainstream. The science which had brought such profound technological, social and medical benefits was now somewhat taken for granted. People were looking instead at the type of science which had brought us the atomic bomb, several lethal and ultimately fruitless foreign wars, thalidomide and all the technology and paranoia of the cold war, and this was engendering a not unreasonable suspicion of ‘the establishment’ and science in particular. Society was coming to realise that science did not have all the answers and that there was more to quality of life than technology; people wanted to reclaim the “spiritual dimension” (Book 1, p. 72-74).

In medicine this meant, among certain groups, a move to question the “old experts” – scientists and doctors, now regarded as hopelessly paternalistic and proscriptive, and the desire to look beyond “conventional” medicine and experiment with different modalities (Book 1, p. 18). Although unorthodox forms of healing had never completely disappeared they had declined in popularity up to this time. With the advent of communication technology and the marketing techniques that went with it however “unorthodox healing”, now rebranded as CAM, thrived in the “spiritual gap” felt by so many and consumers were persuaded that by adopting CAM they were regaining control of their lives (Book 1, p. 74).

Today, in an effort to treat patients as individuals, modern doctors are ethically obliged to be less paternalistic and more patient centred. No longer are they able simply to brush off patients with minor ailments or to make decisions on patients’ behalf regarding medical care without their full involvement (Book 1, p. 85), (General Medical Council, (2006)).

Paradoxically though, patients – now rebranded “consumers” in the healthcare “market” – have (not unreasonably) come to expect those things that a consumer expects by right – guarantees and predictable outcomes. So this new honesty on the part of doctors has inevitably become confused with uncertainty and doubt in the eyes of patients – not at all in keeping with the new consumer age. This has further accelerated the move to embrace CAM as people consult healthcare providers, often outside mainstream medicine where standards of training, regulation and ethics vary widely (Book 1 pp. 90-95), for the (albeit entirely fictitious) certainties that they feel entitled to.

At the same time it has never been easier for CAM practitioners to get their message across, with endorsements from celebrities and even Royalty in every magazine or daytime TV program, and the world wide web offering a platform for any medical opinion or claim, no matter how implausible or nonsensical. This “healthcare hard sell”, regardless of supporting evidence is more in keeping with the merchandising of cosmetics than medicine and simply plays into the hands of sceptics, confirming their worst suspicions about the ethics and morals of CAM.

Conclusion:

Despite the best efforts of its supporters and its popularity with consumers in this post-modern age, CAM remains set apart from prevailing orthodoxy. Whether this separation persists as a result of political prejudice or genuine establishment concern about CAM’s suitability seems to be largely a matter of perspective. It may even be that this separation, originating in the anti-establishment movements of the 1960’s is the main factor which actually defines CAM and its unique identity – “for some groups of CAM practitioners, the growth of ‘integrative medicine’ represents an undermining of counter-cultural values” (Book 1, p xii). Some would say that CAM practitioners are as backward looking and resistant to change today as the old guilds of physicians, surgeons and apothecaries were in the 1850’s.

It could be argued that the question of the status of CAM will never be settled to the satisfaction of either its proponents or detractors until the fundamental issue of safety and efficacy is addressed. If CAM is to be regarded as more than just “feelgood” and achieve the credibility that many of its proponents seek then it must compete for mainstream status on an equal footing with orthodox treatments. And this will never happen until CAM moves from the realm of “opinion based” to that of “evidence based” medicine. In some situations where this has happened, “the overriding conclusions are that some forms of CAM are… supported by evidence and… have a place in modern healthcare” (Ernst et al 2006, p. xiii).

References:

Audain, C. (1998) Florence Nightingale Biographies of Women Mathematicians http://www.agnesscott.edu/Lriddle/WOMEN/nitegale.htm [Accessed 21-3-09].

Brunton, D. (2004) ‘The emergence of a modern profession?’ in Brunton, D.,(ed) Medicine transformed: Health, disease and society in Europe 1800-1930: A source book [online], Manchester University Press http://books.google.co.uk/
books?id=iFWASHAZH9gC&printsec=frontcover#PPA140,M1 [Acessed 21-3-09]

Ernst, E., Pittler, M.H., Wider, B. (Eds) (2006) The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (second edition), London, Mosby.

General Medical Council, (2006) Good Medical Practice (2006): The duties of a doctor registered with the General Medical Council [online], http://www.gmc-uk.org/guidance/
good_medical_practice/duties_of_a_doctor.asp [Accessed 21-3-09].

Lee-Treweek, G. (2005) ‘Changing Perspectives’ in Heller, T., Lee-Treweek, G., Katz, J., Stone, J., and Spurr, S., (eds) Perspectives on complementary and alternative medicine, Milton Keynes, The Open University.

Open University (2005), K221, Perspectives on complementary and alternative medicine, Book 1 Perspectives on complementary and alternative medicine, Milton Keynes, The Open University.

Posfay-Barbe K. M., Zerr D. M. and Pittet D. (2008) ‘Infection control in paediatrics’, Lancet Infectious Diseases, vol. 8, pp. 19–31.

Porter, R. (2001) ‘Quackery’, in Lee-Treweek, G., Heller, T., Spurr, S., MacQueen, H., and Katz, J. Perspecives on complementary and alternative medicine: a reader, Oxon, Routledge/Milton Keynes, the Open University.

Roberts, M. J. D. (2009) ‘The Politics of Professionalization: MPs, Medical Men, and the 1858 Medical Act’, Medical History, vol. 53, no. 1, pp. 37–56. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2629176 [accessed 19/3/09]

Self, A. (ed) (2008) Social trends No. 38, 2008 edition, Basingstoke, Palgrave MacMillan/Office for National Statistics [online] http://www.ons.gov.uk/ons/rel/social-trends-rd/social-trends/no–38–2008-edition/social-trends-full-report.pdf [accessed 8-7-13].

Snow, J. (1856) ‘Cholera and the water supply in the south districts of London in 1854’, London: printed by T Richards, 37 Queen Street, reprinted from the Journal of public health for October 1856 [online] http://www.nlm.nih.gov/exhibition/cholera/pdf/101216228.pdf [accessed 21-3-09]