Alternative and Bio-Medicine in Israel: Boundaries and Bridges 9781618110749

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ALTERNATIVE AND BIO-MEDICINE IN ISRAEL: BOUNDARIES AND BRIDGES

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ISRAEL: SOCIETY, CULTURE, AND HISTORY Series Editor: Yaacov Yadgar, Political Studies, Bar-Ilan University Editorial Board: Alan Dowty, Political Science and Middle Eastern Studies, University of Notre Dame Tamar Katriel, Communication Ethnography, University of Haifa Avi Sagi, Hermeneutics, Cultural studies, and Philosophy, Bar-Ilan University Allan Silver, Sociology, Columbia University Anthony D. Smith, Nationalism and Ethnicity, London School of Economics Yael Zerubavel, Jewish Studies and History, Rutgers University

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ALTERNATIVE AND BIO-MEDICINE IN ISRAEL:

B O U N DA R I ES A ND BR IDGE S

Judith T. SHU VAL E mma AV ER BU CH

With Contributions from Yael Ashkenazi Eran Ben-Arye Moshe Cohen Jonathan Davies Revital Gross Sky Gross Yael Keshet Nissim Mizrachi Leora Schachter

Boston 2012 —3—

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Library of Congress Cataloging-in-Publication Data: A catalog record for this title is available from the Library of Congress. ISBN 978-1-936235-86-5 Copyright © 2012 Academic Studies Press All rights reserved Book design by Adell Medovoy Published by Academic Studies Press in 2012 28 Montfern Avenue Brighton, MA 02135, USA [email protected] www.academicstudiespress.com

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Dedicated to the memory of

Professor Revital Gross Esteemed scholar Devoted collaborator Much-loved friend Who made a major contribution to this book

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Table of Contents1

Preface

9

Authors and Contributors

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Part I. OPENING Chapter 1. Introduction Chapter 2. Health, Health Care and CAM in Israel Chapter 3. Theoretical Background Chapter 4. Historical Perspective: Unconventional Medicine in Israel – Moshe Cohen

15 17 29 38 49

Part II. CASE STUDIES Chapter 5. A Decade of Co-existence of CAM and Bio-Medicine in Israel Chapter 6. “We Own the Truth”: Boundary Making During BioMedical Encounters – Nissim Mizrachi Chapter 7. The Integration of Knowledge: Physicians Practicing Homeopathy Chapter 8. Nurses Practice CAM—Spatial Separation Chapter 9. Midwives Practice CAM: Feminism in the Delivery Room – Judith T. Shuval and Sky Gross Chapter 10. Integrative Medicine in Family Practice – Judith T. Shuval and Revital Gross Chapter 11. To Regulate or not to Regulate: The Perspective of Policymakers on Integrated Care – Revital Gross, Yael Ashhkenazi and Leora Schachter

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Part III. PATIENTS Chapter 12. Patients’ Views: Cultural and Health-care Pluralism in Northern Israel – Yael Keshet and Eran Ben-Arye

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Unless otherwise specified, the chapters are written by Judith T. Shuval and Emma Averbuch. —7—

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Part IV. SUMMING UP Chapter 13. Theoretical Conclusions: Boundaries and Bridges Chapter 14. Medicalization and CAMification

219 221 230

Epilogue

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Appendices A. Israel—Summary of Demographic and Health Data B. Legal Aspects of Complementary Medicine – Jonathan Davies

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References

257

Index

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Preface

As sociological observers, we cannot but be impressed by the striking growth in the spread of alternative and complementary medicine in Western societies and in Israel. Despite the vast achievements and dramatic successes of conventional bio-medicine, remarkable numbers of people seek alternative health care. Many visit an alternative practitioner even before they see their conventional family doctor. In most cases, they do not abandon conventional medicine, but turn to alternative medicine as an additional mode of care. While the National Institutes of Health in the United States have provided scientific evidence for the effectiveness of some forms of alternative care, many of the widely used methods have never been scientifically scrutinized or have not passed rigorous tests for efficacy. The lack of scientific evidence hardly troubles users of alternative medicine: what counts for them is the fact that in many cases it works—they have little interest in how or why. Failures are largely ignored while success is touted. What is no less striking is the fact that increasing numbers of physicians and other health-care professionals not only refer patients to alternative practitioners but themselves seek treatment from them. Indeed, some of these sophisticated, bio-medically trained professionals have decided to study and practice alternative forms of health care, often in conjunction with their conventional clinical work. A small number have shifted to a predominantly alternative form of practice. As sociologists, we have been intrigued by these phenomena—which in effect challenge the undisputed hegemony of the medical profession. It is not surprising that major efforts have been invested in defending the turf of medicine and in trying to ensure its traditional dominance. We have been especially fascinated by the confrontation between different approaches to healing and the apparent inconsistencies among them. At first glance, it is hard to believe that some physicians trained and experienced in the context of scientific medical practice can accept the very different assumptions and methods of alternative medicine. Yet, a remarkable number of bio-medical professionals not only work —9—

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in “mixed” settings, but express enthusiasm for the integration of biomedical and alternative modes of health care. The “contenders” in this confrontation are markedly unequal: the well-established, richly endowed, politically-advantaged medical profession and its health care system are confronted by a broad variety of loosely organized alternative practitioners with few material or political resources at their command. Indeed, their knowledge base can scarcely contend with the scientific and technological infrastructure of modern medicine. Despite this inequality, the weaker contender has attained remarkable popularity and has gained widespread legitimacy. This is true in Israel, as it is in many other countries. It would seem that these social changes in the field of health care are not ephemeral, but are likely to continue in one form or another. Indeed, alternative medicine has become an unmistakable component of the health care system. One of the most interesting innovative approaches is that of integrative practice, in which certain physicians and other bio-medical practitioners who have broadened their knowledge base to include alternative methods utilize approaches and techniques selected from both bio and alternative medicine such as to provide people with maximum benefit from a variety of modes of health care. These professionals are confident that this form of practice will be seen more and more frequently in the future. The book seeks to examine the ways in which bio and alternative medicine have developed modes of co-existence in Israel. In analyzing these patterns, we hope to make a modest contribution to a deeper understanding of the social processes involved in this important transformation in the structure and functioning of health care. The book presents the results of over ten years of research by the authors. Judith T. Shuval initiated the research and Emma Averbuch worked along with her during the entire period; Nissim Mizrachi and Sky Gross were active in selected portions of the work part of this time. We decided to enrich the text by inviting four additional Israeli scholars to contribute chapters which deal with relevant research of their own: Moshe Cohen, Revital Gross, Yael Keshet and Eran Ben-Arye. We are grateful to this very special group of researchers and friends for their enthusiasm and dedication in writing special chapters for the book. Taken together, the authors represent three generations of Israeli sociologists. The senior author, Judith Shuval, started her professional — 10 —

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career in Israel in the 1950s, shortly after the founding of the state of Israel. The youngest of the contributors are sociologists who completed their advanced degrees in the last few years (Ashkenazy, Averbuch, Cohen, S. Gross, Keshet). And the “middle generation” is made up of well-established sociologists whose careers have spanned over ten years of creative research (R. Gross, Mizrachi). Two physicians—both experienced specialists in CAM and integrative health care in Israel—provided important contributions to the book (Ben-Arye, Schachter). The major core of the research was done at the Hebrew UniversityHadassah, Braun School of Public Health and Community Medicine in Jerusalem. Our research has been generously supported by a number of funds and organizations: The Louis and Pearl Rose Fund for Research in the Sociology of Health, the Tannenbaum Fund for Research in the Sociology of Health, the Israel Academy of Sciences, the Israel National Institute for Health Services Research. We are grateful to all of these bodies. Thanks to The King’s Fund, London, for permission to quote in Appendix A from Global Emerging Leaders Network, Israel Profile. We are grateful to Jonathan Davies for the text written for Appendix B on the legal status of CAM in Israel. We are indebted to Sky Gross for her creative field work, and meticulous editing of the manuscript and her insightful comments. Thanks to Liat Milwidsky for her skillful and sensitive interviewing of nurses and midwives. Nahum Steigman undertook the translation of some of the text from Hebrew to English. We are grateful for his very competent work. The book could not have been completed without the dedicated encouragement of both of our families. Hillel Shuval, that pillar of unswerving support over the years, has been no less devoted and loving during this most recent undertaking. His many years of living with a sociologist have rubbed off on him so that his critical reading of the manuscript has been creative and invaluable. Emil Averbuch and the children, always patient and helpful, pitched in enthusiastically to make the project possible. Judith Shuval Emma Averbuch Jerusalem Oct 25, 2011

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Authors and Contributors

Authors Judith T. Shuval Ph.D. in sociology, Harvard University. Professor Emerita at the Hebrew University of Jerusalem where she holds the Louis and Pearl Rose Chair in the Sociology of Health. Founded the Programme in the Sociology of Health at the Hebrew University of Jerusalem and directed it from 1980-1994 . Served as Chair of the Israel Sociological Association. Received the Israel Prize for the Social Sciences for her pioneering research on the mass immigration to Israel in the 1950s. Her first book, Immigrants On The Threshhold, published in 1963, was republished in 2006 by Transaction Press as “a classic of the 1960’s”. Henrietta Szold Prize in public health. In 2006 the European Society for Health and Medical Sociology awarded her its prize for her life’s work. Served as Visiting Professor and Visiting Scholar at the University of Michigan, Brandeis University and Harvard University. Emma Averbuch Ph.D. in sociology, Hebrew University of Jerusalem, 2010. Dissertation entitled: Boundary-Spanning Physicians—The Liaison of Bio-medicine and Alternative Medicine. Her academic interests focus on the social determinants of health and health inequalities, cultural diversity in health care and health services research. She coordinates  programs regarding coping with inequality in the Israel Ministry of Health and  teaches sociology of health at the Braun School of Public Health, Hebrew UniversityHadassah Medical School in Jerusalem. Contributors Yael Ashkenazi MPH, Braun School of Public Health, Hebrew University-Hadassah Medical School in Jerusalem. Researcher, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem. — 12 —

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Eran Ben-Arye M.D., Hebrew University-Hadassah Medical School. He has dual training in family medicine and in complementary medicine including herbal medicine, clinical homeopathy and anthroposophic medicine. Dr. BenArye is the co-founder and director of the Unit of Complementary and Traditional Medicine at the Department of Family Medicine, and the director of the Integrative Oncology Program within the Haifa and Western Galilee Oncology Service, Lin Medical Center, Clalit Health Services. Moshe Cohen Ph.D. in Science, Technology and Society, Bar-Ilan University. Member of the Executive Committee of the Israel Society for History and the Philosophy of Science (ISHPS). Jonathan Davies LLB, LLM Tel Aviv University, Specialty in Medical Law, Senior Partner at Davies—Korn Law Offices, Jerusalem and Tel Aviv. Chairman of the Council of Presidents of the World Association for Medicine and Law (WAML). Fellow of the American College of Legal Medicine and Fellow of the Royal Society.  Lecturer in forums and workshops of physicians in the Israel Medical Association (IMA) on the issue of the "Medical Expert". Revital Gross (deceased 2011) Ph.D. in sociology, Bar Ilan University. Senior Researcher, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem. Associate Professor of Sociology, Department of Social Work and Department of Management Sciences, Bar Ilan University. Sky Gross Ph.D. in sociology and anthropology, Hebrew University of Jerusalem. Lecturer in humanities and social sciences at Tel Aviv University School of Medicine. Yael Keshet Ph.D. in sociology, Haifa University. Senior Lecturer and chair of the Sociology of Health and Wellness sub-department in Sociology and Anthropology Studies at the Western Galilee Academic College.   — 13 —

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Nissim Mizrachi Ph.D., in sociology, University of Michigan, Ann Arbor as a Fulbright grantee. Research Fellow, Harvard University. Senior Lecturer in sociology, Tel Aviv University. Leora Schachter M.D., Founder and Medical Director of the Complementary Medicine Services of HMO Maccabi. Founder and Director of the “Meirav” school for complementary medicine professional caregivers, currently affiliated to the Open university. Head of Pain Management in HMO Maccabi.

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Chapter 1

INTRODUCTION

Goals Israel is known for the high level of development and sophistication of its medical and health care system. The National Health Insurance Law of 1995 provides universal, comprehensive health insurance which includes curative and preventive care as well as hospitalization. Thus, health care is available and accessible to the entire population. Conventional bio-medicine has played a central and creative role in this development, which assured it the place of dominant player until the late 1980s. Following that period, complementary and alternative medicine gradually entered the field of health care, attracting a growing number of consumers and practitioners over time. In 2007 there were 1,750,000 visits a year to alternative practitioners—or 146,000 a month (http:// Business Data Information COFACE). In 2007, 12% of the adult population of Israel reported using an alternative practitioner at least once during the previous year—an increase of 100% since 1993. 37% of these users reported consultations with more than one type of alternative practitioner, and many visited them more than once a year (Shmueli, et al. 2010). This growth has not reduced the use of conventional bio-medical services and in many ways has paralleled the increased use of alternative health care seen in other Western countries. It has progressed at a somewhat slower pace in Israel partly because of the authority and control of the bio-medical establishment. Growing consumer demand for alternative medicine has brought about the development of a variety of forms of health care in which biomedicine and alternative medicine are joined in a diversity of modes and structures. Many of these seek to preserve the traditional dominant role of bio-medicine while others express a more open spirit of integration between different epistemological models. Initiatives in this direction have come from the medical establishment but also from interested individuals and professional groups committed to these ideas. — 17 —

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The overall goal of the book is to explore the multiplicity of empirical types of coexistence between alternative and bio-medicine which have emerged in Israel. These are seen in a variety of forms which reflect cultural, political and social forces in the society. It is not our purpose to evaluate alternative health care or examine its effectiveness, but rather to understand the dilemmas and quandaries it poses in its relationship to conventional medicine. These are rooted in the different perspectives of the principal actors which in turn are anchored in deeply held beliefs and ideological commitments. The perspective of the authors is sociological: we hope to elucidate the social processes involved in this potentially uneasy relationship. Is such co-existence a form of restless cohabitation or is it a more or less stable marriage? How do the partners get along? Do they in fact actually work together? How do they manage to reconcile the different approaches and apparent epistemological contradictions that are inevitable when professionals from such different backgrounds and approaches to health care seek to work together? Can we accept Mary Douglas’s (1994) contention that people cannot belong to more than one culture at a time? We will explore these questions in the context of past and ongoing research carried out by a number of Israeli sociologists who have been intrigued by the many theoretical and practical issues involved. The volume presents an historical analysis of the development of complementary and alternative medicine in Israel as well as a theoretical framework by which we seek to conceptualize the current processes observed. We have studied the views of patients and of policy makers. A major focus of the book is on bio-medical practitioners who have acquired alternative skills and practice both forms of health care. The book includes analysis on both the macro and the micro levels. The macro level focuses on the overall cultural and political context. It concerns the principal actors and the major institutions involved in health care in the society. These include the sick funds, the Ministry of Health, the medical profession and its organizations, consumer groups, groups of alternative practitioners, and other groups involved in health care. A variety of interest groups play a critical role in the balance of power determining the relationships among the principal actors. Micro processes have been examined within this basic structure, focusing on individual practitioners in the context of their day-to-day work. In-depth analysis of the context of practice of bio-medical prac— 18 —

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titioners who have added alternative health care to their repertoire of professional skills and practice elucidates the quality of the dilemmas encountered. Such practitioners may be viewed as a “boundary group” which straddles two different worlds: the bio-medical world and the world of alternative medicine. While both are dedicated to helping patients suffering from disease or disability, each is a separate cultural entity with its own values, beliefs, norms of behavior, and modes of helping sick people. In-depth study of such persons and their strategies of coping with the dilemmas generated by this duality help us understand the social context in which alternative and bio-medicine co-exist. Some Definitions

1. Bio-medicine We will use the term “bio-medicine” to refer to the commonly established form of Western medicine taught in most medical schools, which exercises a dominant, often exclusive monopoly over legitimate medical care in many societies. Other names for this form of medicine include allopathic, conventional, Western, and mainstream medicine. Bio-medicine is based on the application of the principles of the natural sciences, especially biology and biochemistry, to diagnosis and therapy. The body is viewed as an integrated set of biological, physiological, and chemical systems such that disease is explained in terms of the functioning or mal-functioning of its internal systems (Dacher, 1995a). The bio-medical-paradigm is based on “the assumption that all disease is materially generated by specific etiological agents such as bacteria, viruses, parasites, genetic malformations, or internal chemical imbalances” (Berliner, 1984, p. 30). The epistemological axioms of bio-medicine lead to reductionism seen in a focus on irreducible cellular and molecular processes which results in dividing the body into its component parts in order to understand it. The concept of disease focuses on biological structure and is constructed as a visible entity which is associated with the Cartesian mind-body duality in medical theory and practice. In its thinking, bio-medicine is characterized by rationality, objectivity, positivism, determinism, universalism and linearity while its methods emphasize logic, controls, measurement and deduction. Its focus is on the biological structure and on disease rather than on the individual and illness (Davidoff, 1998; Foucault, 1994; Kleinman, 1995; Merriam-Webster Dictionary, 2002; Rosenberg, 1992). — 19 —

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Although the principles noted are predominant in the bio-medical community, there are on-going changes which relate to physicians’ attitudes toward CAM. There is increasing awareness among some physicians that, on the epistemological level, medical knowledge is essentially finite and that other approaches may be legitimate. Many accept the multiplicity of theories of causality in scientific thought and that modern science is no longer wedded exclusively to one inductive model (Pietroni, 1992; Scocozza, 2000). For example: chaos theory provides a challenge to the metaphysic of determinacy (Kekes, 1973). The objective stance of science has been questioned by an emphasis on the importance of social constructivism and subjectivity (Baudrillard, 1996; Latour and Woolgar, 1979). Critics both within and outside the bio-medical community believe that a part of medicine will always be beyond the reach of its scientific capabilities. Such beliefs are expressed in the distinction drawn between the “science” and the “art” of medicine; the latter is where the science of medicine shows its limitations (Gordon, 1988). There are growing doubts as to the capacity of science to solve human problems as well as a feeling that science may have itself contributed to many of the ills of contemporary society, (e.g. the spread of the HIVAIDS pandemic, environmental pollution, climate changes and global warming, evidence of misuse of atomic energy, implications of human genetics research, simultaneous abundance and shortages of food). These important changes in value orientations cannot fail to influence some members of the medical profession. 2. CAM: Complementary and Alternative Medicine Scholars are divided on the definition and categorization of complementary and alternative practices (Ernst, et al. 1995; Zollman and Vickers, 1999). Each of these terms carries a burden of political and evaluative connotations—which are in themselves of considerable interest. Physicians generally prefer to use the term “complementary” to refer to unconventional modes of health care. This stance reflects a medicocentric view which implies greater validity and centrality to bio-medical procedures and a lesser status to unconventional practices which “complement” them. The term “alternative” is viewed by many in the medical establishment as offensive and challenging to their exclusive hegemony. In order to avoid the pitfalls associated with both of these concepts, we decided to use the term “CAM” (complementary and alternative — 20 —

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medicine) to refer to the combined array of non- conventional health practices commonly in use in Western societies. These have also been referred to as holistic, natural, unorthodox, fringe and unconventional (Bombardieri and Easthope, 2000). Wolpe argues that CAM is “what sociologists refer to as a residual category” in that it is “defined not by its internal coherence but by its exclusion from other categories of medicine” (Wolpe, 2002). This is exemplified by the definition of CAM by the National Center of Complementary and Alternative Medicine (NCCAM) as “a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period” (Office of Alternative Medicine, 1997, p. 50). Thus the term “CAM” will be used throughout the book with the exception of chapters in which the meaning and implications of the terms “alternative” and “complementary” are under scrutiny as part of the substantive analysis (chapters 4 and 5). Insofar as possible in the context of a sociological analysis, the term “CAM,” as used in this book, seeks to be a value-free concept. While aware of the heterogeneity of CAM practices and the array of epistemological grounds on which they are based, we will follow Montgomery and Keshet’s precedent and, for purposes of the present book, consider them as a whole (Keshet, 2010; Montgomery, 1993). Undoubtedly, in-depth study of each of the forms of CAM practice is in itself important and useful; however, it was impractical in the context of the goals of the present book, to focus on each form of practice separately and in depth. We have therefore chosen—despite the limitations of this approach—to view them as a whole. Only homeopathy which has been studied in depth, will be discussed separately in chapter 7. Over and above the differences among its many modes, a number of common characteristics of CAM have been noted and may be viewed as paradigmatic. Most critical is a holistic perspective which recognizes that people are simultaneously biological and social creatures and that biology and culture interact as equal partners in defining “who and what we are” (Moerman, 2002, p. 154; Montgomery, 1993). Illness is viewed as an imbalance between opposing energy forces and a failure of the body’s restorative powers. Germs in themselves are not viewed as the cause of disease. Thus there is an emphasis on assisting patients to heal — 21 —

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themselves. In addition CAM emphasizes individuality, interpersonal interaction of practitioners with patients, subjectivity of experience, feeling, energy balance and prevention. The logic of treatment is seen in a focus on the patient whose body or mind (or both) will then initiate the healing process. (Baer and Coulter, 2008; Berliner, 1984; Clavarino and Yates, 1995; Coulter, 2004; Fulder, 1998; Keshet, 2010; Micozzi, 2001; Northcott, 1994). The principal forms of CAM practiced in Israel include homeopathy, Chinese medicine, acupuncture, herbal medicine, reflexology, shiatsu, chiropractic, biofeedback, Ayervedic medicine, naturotherapy, massage techniques, Bach flowers, Feldenkreis, anthroposophy, Dwina, osteopathy, Reiki, Paula and others. While this list is not comprehensive, it will be seen in the course of the book that these are the forms of CAM practice which have generally been incorporated into the clinics of the public medical care system in Israel and in many private clinics. Traditional forms of health care, which may also be viewed as a form of CAM, have generally not been incorporated into the medical care system as above and therefore are not a focus of the present book. They will be considered briefly only in chapter 10 which deals with consumers’ attitudes and behavior. 3. Integrative medicine The most complete merger of conventional, complementary and alternative health care practices has been termed integrative medicine (Boon, et al. 2004; Coulter, 2004; Jobst, 1998; Kailin, 2001; Kelner and Wellman, 2003); Launso, 1989). Such a merge refers to the personal as well as to the organizational context, and to the conceptualization of disease as well as to diagnostic approaches and treatment methods (Gamst, et al. 2006). Bell, for example, states that integrative medicine “emphasizes wellness and healing of the entire person (biopsycho-socio-spiritual dimensions) as primary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician-patient relationship” (Bell, et al. 2002, p.133). On the ideological level, integrative medicine is viewed by its proponents as providing optimal care to patients by drawing on a broader array of health care options. In this spirit Rees and Weil (2001) state that integrative medicine “views patients as whole people with minds and spirits as well as bodies and includes these dimensions in diagnosis and — 22 —

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treatment.” Integrative medicine inevitably involves some tensions because of the different knowledge paradigms involved, and these are not always taken into account by those interested in promoting integrative health care (Adams, et al. 2009, p. 793). No one model of integrated medicine has been institutionalized or legitimized. Mann, et al. (2004, p. 157-164) delineate a number of different models of integrative care: (1) the informed clinician who communicates his or her knowledge about CAM to patients; (2) the informed, networking clinician who adds “referral networks with CAM practitioners” to his or her knowledge of CAM therapies; (3) the informed, CAMtrained clinician who incorporates specific CAM therapies into his or her practice; (4) the multidisciplinary integrative group practice where “practitioners provide both conventional and complementary therapies in a partnership”; (5) the interdisciplinary integrative group practice “in which care providers in multiple disciplines see patients together as a team”; (6) hospital-based integration; and (7) integrative medicine in an academic medical centre. Other models have been proposed by Boon, et al. (2004), Kaptchuk and Miller (2005) and Leckridge (2004). Paradigms and their Implications A paradigm consists of the generalizations, values, axioms and technical apparatus which are shared by a community of scholars or scientists. These include a number of implicit a priori assumptions which are accepted without empirical examination. They are fundamental presuppositions which cannot be established through observation nor is the research they inspire geared to test these assumptions (Agassi, 1964; Kuhn, 1962, 1970). Coulter (2004, p. 188) has noted that bio-medicine and alternative medicine are based on paradigms “which hold fundamentally contradictory metaphysical beliefs and differing philosophies about health and health care” and that these involve different and sometimes opposing views about the nature of diagnosis, illness and treatment. A holistic approach clashes with several of the main cognitive principles of Western medicine and in particular with the view that controlled trials are a sine qua non for establishing therapeutic effectiveness. Although there are different theories of causality in the philosophy of scientific thought and considerable debate inside the medical profession regarding appropriate means of establishing efficacy, controlled trials remain one of its — 23 —

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axiomatic tenets (Hemminki, 1982; Pietroni, 1992; Saks, 1992, 1995; Scocozza, 2000). Cassidy (1995, p. 20) suggests that bio-medical and CAM practitioners speak different languages and are unable to understand each other. Willis (1989) believes that there is convergence with respect to day to day routine practice but not with regard to fundamental paradigms. It is precisely these potential conflicts which provide the background to a variety of forms of collaboration between CAM and bio-medicine which have emerged in Israel. Clearly not all types of mix appear in the Israeli context; other societies have developed additional or variant forms that are of interest and worthy of study. Indeed, it is our hope that the present research will serve to stimulate systematic comparative research. As a modest starter, it is our belief that the variety of forms of collaborative practice found in Israel permit a fruitful sociological analysis that can lead to a better understanding of the social processes underlying the meeting ground of CAM and bio-medicine. Bio-Medical Views of CAM The bio-medical community is far from consensual in its views regarding CAM. Some physicians continue to express strong opposition to CAM, claiming that there is only one kind of medicine and until CAM can provide appropriate empirical evidence of its efficacy it should be banned (Angell and Kassirer, 1998; Kelner et al. 2004). Such critics sometimes refer to CAM practitioners as quacks or charlatans and deplore the fact that the delay in getting suitable bio-medical care can be a serious risk for patients. Indeed, accusations of non-professional behavior have been directed against MDs who have incorporated CAM into their practices (Wright, 2003). The following quote is by a physician in response to an editorial in the BMJ which expressed support for integrated health care: I am appalled: if we get into bed with alternative medicine we are not only betraying our scientific heritage but we are also a short step away from betraying our patients. It has taken hundreds of years to pull medicine away from the quagmire of superstition, witchcraft, mumbojumbo and sheer quackery and turn it into something resembling a scientific pursuit. Now all of that progress appears to be in danger of being thrown away because — 24 —

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we are too gutless to stand up to the criticism of scientific rationalism which is being offered to anyone who will listen (Internet response to Rees and Weil, 2001). Although such views continue to be heard in the medical community, they are far from universal. In practice there is widespread referral by bio-medical physicians to CAM practitioners (Astin, et al. 1998; Hirschkorn and Bourgeault, 2005; Gamus and Pintov, 2007; Siahpush, 1999; Willis, 1989). In 2007, 17% of CAM users in Israel were referred to a CAM practitioner by a physician. This suggests considerable acknowledgement and acceptance of CAM by the medical establishment (Shmueli, et al. 2010). Indeed, the overall orientation of bio-medical practitioners to alternative practitioners ranges from total rejection to indifference and includes a variety of forms of acceptance (Boucher and Lenz, 1998; Grandinetti, 2000; Jobst, 1998). Among some, there is cautious approval of the potential usefulness of specific CAM practices on the assumption that the positive outcomes of such treatment may stem from psychological or placebo effects (Moerman, 2002; Rees, 1997; Sharma, 1992). Without relinquishing their commitment to basic bio-medical assumptions, some doctors view certain alternative methods as useful technical procedures that can be utilized on an instrumental basis even though observable, systematic evidence for their effectiveness is not always available (May and Sirur, 1998). There is also a growing awareness among some bio-medical practitioners of multi-causality, increased knowledge of the role of preventive behavior and of the importance of social-psychological factors in diagnosis and care. The most positive approach is seen among growing numbers of physicians, nurses, midwives, physiotherapists and other bio-medically trained health care providers who have themselves decided to study one or several CAM specialties. Full integration is expressed in CAM practice either in conjunction with their bio-medical work or in lieu of a biomedical specialty. As noted, these professionals are “boundary-crossers” in whom we have a special interest. Research Methodology Two chapters—those presenting an historical analysis and the theoretical approach—are based on archival materials and an extensive — 25 —

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analysis of the relevant historical and theoretical literature (chapters 3 and 4). Most of the remaining chapters are based on empirical case studies—consisting of narratives provided by a variety of CAM practitioners and policy makers all of whom who spoke freely of their views and experiences (chapters 5-11). These narratives were provided by 103 individuals who were interviewed individually. They included 87 physicians, nurses, midwives and family practitioners who combined CAM and bio-medicine in their regular practices as well as a variety of CAM practitioners without biomedical training. In addition, 16 policy makers were interviewed. In all of these case studies, we made use of qualitative methods, seeking to obtain in-depth information, opinions and perspectives from selected groups of persons who are involved in the delivery of CAM and bio-medical health care in Israel. Subjects were chosen by theoretical sampling which assures that participants are drawn from a wide spread of contexts (Glaser and Strauss, 1967). Although the bulk of our subjects are employed in the public sector of the health care system, some of them also practice privately. In Israel, it is difficult to draw a clear line separating the two sectors from each other. Our overall approach is phenomenological and seeks to understand the experiences and perceptions of individuals from their own perspectives by gaining insight into their motivations and behavior (Denzin and Lincoln, 2000; Gubrion and Holstein, 2002; Hycner, 1985; Moustakas, 1994). This strategy dictated the use of semi-structured interviews, focusing on the nature of providers’ professional background, the decisions which led them to practice CAM and their strategies of handling epistemological and other dilemmas that arise in the course of their practice. These interviews along with on-going observation yielded detailed narratives from a variety of individuals working in different types of integrative healthcare settings. These provided the empirical data through which we sought to understand the underlying social processes involved in these unique health-care situations. The only exception to the use of this qualitative methodology is seen in chapter 12, regarding patients’ views, which is based on a quantitative analysis of large population groups (Denzin and Lincoln, 2000; Silverman, 1997; Yin, 1994). Most of the field work took place between 2000 and 2008. However, — 26 —

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the development of CAM in Israel is a dynamic process and there are ongoing changes that need to be considered. In 2010, before the book was completed, we undertook a final round of interviews with a number of directors of CAM clinics in different parts of the country in an effort to update the empirical data when necessary. Further details regarding specific choice of subjects and other methodological issues are included in chapters 5-11. Structure of the Book The book includes a broadly based set of theoretical themes, historical analysis, and empirical research which provide an overview of CAM and bio-medical practice in Israel. Part I, Opening, consists of four chapters. The present chapter 1 states the goals, definitions of terms and research method of the book. Chapter 2 presents a brief glimpse of some of the more critical demographic and health status parameters of Israeli society. These are followed by data on CAM use and an overview of the basic structural features of CAM delivery in Israel. Chapter 3 formulates the underlying theoretical themes which serve as the foundation for the research design and analysis of the empirical findings presented in the book. Chapter 4 considers the historical context for the development of CAM in Israel. Taken together, the first four chapters may be viewed as the backdrop to the empirical case studies which follow. Part II, Case Studies, presents findings regarding the empirical scene in which CAM and bio-medicine are joined in the delivery of health care. It includes seven chapters: 5-11. While we cannot claim to offer an exhaustive picture of all forms of such care practiced in Israel, these case studies offer a broad perspective on most of the modes of such care currently in use. The empirical arenas for the case studies vary on two dimensions: occupational and organizational. The findings relate to the following types of health care practitioners who combine bio-medical and CAM practice: hospital doctors who work along with CAM practitioners (chapters 5 and 6); physicians who have chosen to study and practice homeopathy (chapter 7); nurses who work in hospitals but also practice different forms of CAM in the community (chapter 8); midwives who utilize both bio-medical procedures and CAM techniques in delivery rooms in conventional hospitals (chapter 9), and — 27 —

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family doctors who practice in community clinics of the public health care system utilizing both bio- medicine and CAM at their own discretion (chapter 10). As noted, the organizational settings of practice vary and include hospitals, outpatient clinics affiliated with hospitals, community clinics and private practice settings. The providers’ narratives speak mostly of their own professional lives but inevitably refer to two additional sets of relevant actors in the health care context: patients and policy makers. While this information reflects the providers’ view point, it contributes to our understanding of the overall social context. In order to enrich our understanding of these additional groups of actors, we have included two chapters which report on findings gained directly from decision makers and from patients. Chapter 11 is an indepth study of decision makers in health care institutions and focuses on their attitudes and evaluation of the problematics of integrating CAM and bio-medical care in Israel. It concludes with some applied conclusions with regard to these issues. Part III, Patients, is comprised of chapter 12, which differs from all the others in its focus on data from patient surveys in Israel. Here the point of view of CAM patients is considered as they explain why they chose integrative care and express their evaluation of its efficacy. This chapter highlights the cultural diversity of Israeli society by its inclusion of a wide variety of patient groups: men, women, Jews, Arabs, Bedouin and recent immigrants. Part IV, Summing Up, consists of two chapters. Chapter 13 focuses on the theoretical themes considered in the book by drawing together the findings from the case studies regarding the relationship of CAM to post modernism and to boundary theory. In the final chapter, 14, we discuss macro issues in the overall structure of CAM delivery as seen in processes of medicalization and CAMification. In this final chapter we also raise a number of policy issues.

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Chapter 2

Health, Health Care and CAM in Israel

Background Israel is a developed, industrialized country with a substantial hightech sector, a growing service sector and a small technologically advanced agricultural sector (Israel Central Bureau of Statistics, 2010; Israel Ministry of Health, 2010; Rosen and Samuel, 2009; Shuval and Anson, 2000). The State of Israel was established in 1948. In 2009 it had a population of 7.5 million, of which 76% were Jews, 17% were Muslim Arabs, 3% Christians, 2% Druze and 2% other groups. Immigration has played a central role in the society. In the decade 1990-2000 almost one million immigrants arrived, most from the former Soviet Union countries. The 2009 GDP per capita income with purchasing power parity (PPP) was US $29,404 (International Monetary Fund, 2010). Health care accounts for approximately 8% of the GDP. In 2009 life expectancy at birth was 79.7 years for males and 83.5 for females. The infant mortality rate was 3.8 per 1000 live births; it declined by 38% since 1996. The infant mortality rate for the Arab population has declined even more steeply than that of the Jewish population but remains double that of the Jewish population. This pattern reflects the influence of high rates of consanguineous marriage and lower socioeconomic status among the Arabs. In 2009 there were 3.4 physicians per 1,000 members of the population. Of all licensed physicians, 41% were trained in Israeli medical schools while the remainder were trained abroad—either because they were educated before immigrating to Israel or they went abroad from Israel for their training. Since 1995, when the National Health Insurance Law was formally enacted, all persons in Israel are covered by comprehensive health insurance which includes curative and preventive care as well as hospitalization. Health care is available and accessible to the entire population. The Law provides access to a broad benefits package which includes physician services, hospitalization, medication and other services. There is — 29 —

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cost sharing for pharmaceuticals, visits to specialists and certain diagnostic tests. The State, through the Ministry of Health, is responsible for supervising, licensing and overall planning of health services. Every citizen or permanent resident is free to choose among four competing, non-profit-making health plans: Clalit, Maccabi, Meuchedet, and Leumit. The respective market shares of the four sick funds in 2010 were: 53%, 25%, 14%, 9%.1 The health plans provide their members with access to a benefits package that is specified within the NHI Law. The system is financed primarily through progressive taxation linked to income. The government distributes the NHI funds among the health plans according to a capitation formula which takes into account the number of members within each plan and their age mix. The sick funds provide a broad network of easily accessible community-based clinics with salaried physicians and other health care personnel. In 2009, Israel had 45 general-acute hospitals (14,599 beds), 13 psychiatric hospitals (3,451 beds) and 311 chronic disease hospitals (23,325 beds). In the general-acute hospitals the bed-to-population ratio is 2 per 1,000 population (2009). The vast majority of the population lives within one hour’s drive from a hospital. The average length of stay in 2009 was 4.0 days (Israel Central Bureau of Statistics, 2010). Although CAM is not included in the universal set of entitlements provided by the National Health Law, all of the sick funds offer their members the possibility of purchasing extra insurance policies for partial coverage of additional services, including CAM. In 2000, about half of the population had purchased such supplementary insurance policies; by 2009 this figure rose to 74%, and among members of the Maccabi sick fund it reached 88%. Thirty percent of the population carry commercial voluntary health insurance (Gross and Brammly-Greenberg, 2003; Kaidar and Horev, 2010). CAM in Israel In this section we present data regarding CAM use and the basic structural features of CAM delivery in Israel. This information provides a background against which the dynamics of the social processes will be presented in some detail in later chapters. Use of CAM in Israel became more pronounced in the 1980s and has 1  in rounded percentages. — 30 —

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continued to increase since then. A large number of reasons have been suggested in the literature for the growth of CAM in Western countries and most of these apply to Israel as well. Increased use of CAM has been explained by objections of consumers to the excessive use of technology and the bureaucratic strictures of bio-medicine. There is increased questioning of its excessive invasiveness. Consumers are more aware of iatrogenic effects of modern medicine, prefer to ingest fewer drugs, and many object to the traditional dominance of doctors often seen in the physician–patient relationship. In a period of hyper-differentiation in bio-medicine, when it is practiced in large organizations where there is minimal attention to the individual and to her/his social and psychological needs, CAM provides a non-invasive, holistic alternative that is increasingly attractive to many, in particular to the better educated, more affluent segments of the population. There is more awareness among consumers of the relationship of lifestyle to morbidity, especially when bio-medicine is unable to provide relief or cure. It has also been noted that in the postmodern period, with on-going globalization, there has been an overall decline in faith in the ability of science and technology to solve health problems. This is seen in the lesser acceptance of traditional authorities such as physicians and a seeking of increased control over one’s life and health. Globalization has also been accompanied by increased migration of populations and the transmission of therapies and medical theories among different societies. A growth in consumerism has contributed by encouraging individuals to seek their own preferences in health care. These factors have combined in Israel, as in other nations, with demographic changes seen in an increased prevalence of chronic health problems that are less responsive to the methods of bio-medicine (Burford and Bodeker, 2007; Coulter and Willis, 2004; Rosenberg, et al. 2008; Sirois, 2008; Van den Brink-Muinen and Rijken, 2006; Wapf and Busato, 2007). 1. Use of CAM As noted, findings from a survey in Israel by BDI-COFACE in 2007 indicate 1.750,000 CAM visits a year or 146,000 a month (http//:Business Data Information COFACE). The most recent data concerning use of CAM in Israel are drawn from a study of patterns of CAM use in a representative sample of the Israeli — 31 —

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Jewish urban population aged 22-75 in 2007 (Igudin, 2010; Shmueli, et al. 2010).2 In 2007, 12% of the population reported using CAM at least once during the previous year. More than a third of CAM users reported consultations with more than one type of CAM practitioner. A study by the Brookdale Institute showed similar findings for 2007 (Gross, BrammlyGreenberg and Waitzberg, 2009). Although the use of CAM has increased in Israel in recent years, Israel ranks among relatively “light” users in comparison to other Western countries. Use of CAM was most prevalent among women, the educated, economically well-established and married persons. More than half of CAM users reported using it to treat a specific health problem. The most frequently mentioned were back pain, problems with joints and limbs and general health. General disappointment and dissatisfaction with conventional medicine, unwillingness to take many medicines or to use invasive care and the absence of alternative solutions are common reasons for use of CAM. At the same time, the number of people who reported using CAM following positive personal experience or recommendations by others was also high. The most frequently used therapy was acupuncture (37%), about a third were treated with reflexology, 29% used homeopathy and 26% reported using massage; less than a fifth used chiropractic therapy (16%). Most of the referrals to CAM practitioners were initiated by the individuals themselves, a fifth followed recommendations by friends and family members. A small, but increasing percentage of users as compared to previous studies were referred by a physician: the percentage of users referred by a physician increased significantly from 6% in 1993 to 10% in 2000 and to 17% in 2007. This increase suggests a growing acknowledgement and acceptance of CAM by the medical establishment (Shmueli, et al. 2010). Research shows that about 80% of those who used CAM reported that the therapy relieved their ailment. Two thirds of the users reported high general satisfaction with the CAM provider they used, and very high satisfaction was reported in all aspects of the practice: the provider’s attitude, the time dedicated by them, their availability, the information 2  Data on use of CAM by the total Arab population is not available, but findings of surveys carried out in specific areas are discussed in chapter 12. — 32 —

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provided by them and the quality of the therapy. More than half said they would recommend the use of CAM to others. Thirty percent of CAM users received conventional medical therapy for the same problem while 70% used CAM instead of conventional medicine. More than half of the CAM users did not disclose their use of CAM therapy to their family doctor. The reasons for nondisclosure varied. The common ones were, “It was none of the doctor’s business and I do not care what his/her opinion is,” and “The doctor has no knowledge about CAM, never asks about it or is against it.” When users were asked what they think their doctor’s attitude to CAM therapies is, most of them said that they think their doctor does not oppose the use of CAM. The findings from this study, carried out in Israel in 2007, do not differ substantially from the findings of similar studies concerning CAM use in other Western countries (Igudin, 2010). 2. CAM Providers In 2011, there were an estimated 20,000 CAM practitioners working full time and part time in Israel. Of these, only 2,800 are members of professional organizations representing a wide variety of CAM specialties (Association of Complementary Health Care Organizations, 2011). There were approximately 60 programs for teaching CAM in Israel in the framework of courses lasting between three months and four years. The courses vary widely in the quality of training they provide. In effect there is no regulatory mechanism for these training programs. A committee to consider this issue was established in 2005 by the Ministry of Health, but it has not yet produced a program of regulation largely because there is no agreement as to who will supervise the schools for CAM (Rosen and Samuel, 2009). 3. Delivery of CAM Services Israel has never established any formal jurisdictional regulation or control of CAM. There is no licensing procedure, little teaching of CAM in the medical schools and, as noted, no regulation of the many courses and schools which train CAM practitioners3. The only relevant jurisdictional control mechanism is the Doctors’ Ordinance (1976, 1987) which provides that only persons holding a 3  See Appendix B for details regarding the legal status of CAM in Israel. — 33 —

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physician’s degree and license may practice medicine. Despite the conclusions of the respected Eilon committee, set up by the Ministry of Health in 1988 to examine the status of CAM in Israel, none of its recommendations presented in 1991 were accepted (see chapter 4). Indeed, the Israel Medical Association issued a number of public declarations during the following decade seeking to assert the unquestioned hegemony of bio-medicine. In 1997 the Israel Medical Association stated in one of its widely circulated publications (Israel Medical Association, 1997) that “there is only one form of medicine which deals with care of human beings and only physicians are permitted to practice it…” In an apparent allusion to CAM, the same statement notes that “…within the context of professional practice, physicians may select a variety of methods” (Grinstein, et al. 2002; Yishai, 1999). The Ministry of Health, despite prolonged deliberations, has never been able to reach a formulation regarding regulation that was acceptable to the relevant parties, e.g. Israel Medical Association, CAM professional associations, the sick funds and others. The very absence of regulation may be viewed as an important strategy of control of the judicial-political boundary. In effect, it establishes the monopoly of biomedicine by denying access to medical practice by non-physicians. In 2003, an additional committee was set up by the Ministry of Health to formulate a licensing procedure. The committee considered the possibility that CAM be taught within the framework of the university system—but this proposal was strongly opposed by the CAM practitioners who run their own schools for training practitioners. During the committee’s deliberations, one of the elite colleges applied to the Council for Higher Education to gain approval for an undergraduate program in CAM studies. The Council rejected this proposal in 2009. To date the committee has not submitted a final report (Cohen, 2010). As in other societies, the growth in CAM was perceived as a challenge to bio-medicine’s exclusive hegemony in the field of health care (Horton, 1998; Larkin, 1978; Launso, 1989; Saks, 1992, 1995; Siahpush, 1999; Wardwell, 1976). The increasingly competitive medical market in Israel encouraged public bio-medical institutions to seek ways to incorporate alternative practitioners into the existing health care system. The primary motivation for this step was not a result of the acceptance of CAM theories and practice by bio-medical leaders. It was, rather, based on the hope that, given growing consumer demand, such a step would attract — 34 —

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paying patients to the public medical care system, thereby easing the increasing budgetary problems facing the bio-medical institutions. In considering the options to attain this goal, the interested parties had to consider the Doctors’ Ordinance which, as noted, limits medical practice to physicians but also provides that qualified persons working under the supervision of a licensed physician may also provide health care. Although the formal qualifications for such persons have not been established by law, the authority of a supervising physician is sufficient to legitimize their work under her/his auspices (Glauber, 2001). On this legal basis, a structural solution was found for the legitimation of CAM practice within a network of public clinics where it could be practiced by physicians who were also trained in a CAM specialty and by non-physician CAM practitioners working under the supervision of a qualified physician. This organizational procedure formally established the gate-keeping function of bio-medicine—in effect placing CAM under its authority. The clinics were entitled “complementary”—thus highlighting their secondary role relative to bio-medicine and its dominance over them. The Hebrew term “refua mashlima” makes clear that CAM adds to or completes the work of the biomedical component. In terms of the model suggested by Boon, et al. (2004), this structure is a form of parallel practice with little effort toward real integration. Thus, beginning in the 1990s, there was a growth in the establishment of CAM clinics under the auspices of major segments of the publicly supported bio-medical system in Israel. The first of these was at a government hospital in the Tel Aviv area (Assaf Ha’rofe) where an out-patient clinic for CAM was established in 1991 on the grounds of the hospital, within its formal organizational structure. It offered services by a wide variety of alternative practitioners in the fields of acupuncture, shiatsu, homeopathy, chiropractic, reflexology, Feldenkrais, Reiki, naturopathy, touch and movement modalities, herbal medicine, bio-feedback, Alexander, aromatherapy, alternative nutrition, Paula and others. Davies (2001, p. 120-121) points out that the acceptance of a wide variety of CAM practices in bio-medical clinics and hospitals, has endowed these modes of health care with a legitimacy and recognition which stem from being a normative part of the mainstream health care services—even though there is no formal licensing system for CAM (See Appendix B). — 35 —

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Within a short period, one third of the public hospitals had established outpatient clinics dedicated to CAM. In addition, three of the four sick funds established their own networks of CAM clinics in the urban centers. The number of clinics run by each of the sick funds in 2010 reflects their relative size: Clalit—50 clinics; Meuchedet—16 clinics; Maccabi—16 clinics. Kupat Holim Leumit does not run a separate network of CAM clinics but includes CAM practitioners in 86 of its regular community clinics.4 Some of the sick funds have negotiated contracts which permit their members to obtain CAM care at private clinics at reduced fees. As a whole, 65% of CAM in Israel is provided in publicly sponsored clinics. Some of the CAM practitioners employed in these settings also work part-time in private clinics (http://Business Data Information COFACE). As noted, CAM is not included in the package of health care entitlements under the National Health Law. Thus—unlike the regular network of sick fund clinics where there is no charge for primary care and only a small, symbolic charge for treatment by specialists—patients are required to pay for CAM treatment at these clinics. Fees are controlled and are lower than in the private sector where the fees are 2-3 times higher. Nevertheless, even those carrying supplementary health-care insurance—for whom the fee is reduced—are required to pay non-negligible sums for CAM treatment in the public sector. In the Israeli context of universal health care with no direct cost to the consumer, this is a source of inequality that makes CAM less accessible to lower income groups. In 2002, at the initiative of a small group of members of the Israel Medical Association (IMA), the Israel Society for Integrative Medicine was founded within the framework of the IMA. It includes members of the Association who practice both types of health care and seek to integrate them with each other. By 2009 it had 150 members, almost all of them with conventional medical qualifications as well as skills in one or more forms of CAM practice. As will be seen in chapter 4, the very existence of the Israel Society for Integrative Medicine is an important indication of the growing recognition by the medical establishment of the legitimacy of CAM practice by qualified physicians. 4  See http://www.clalitmashlima.co.il, http://www.maccabitivi.co.il/153-he/Maccabi_natural.aspx, https://www.meuhedet.co.il/meuhedet/downloads/extra.pdf, and http://www.leumit.co.il/natural. asp?pgId=69&catId=497 — 36 —

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Conclusion This chapter has introduced some basic structural information concerning health and conventional health care in Israel. With respect to CAM, we have presented data regarding overall utilization patterns and providers as well as a general picture of the structure of the delivery system. The varied case studies presented in chapters 5-11 will provide a detailed picture of the social processes characterizing CAM practice in Israel focusing on its relations with bio-medicine.

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Chapter 3

Theoretical Background

Introduction The concepts around which this book is structured are drawn from three sources — the theoretical literature concerning boundaries, post-modernist thought and the sociology of the professions. These three themes provided the conceptual framework for the design and analysis of the research on which the book is based. The Challenge to Authority in Post-Modern Society The well-documented growth of alternative medicine in the West in recent decades is only one example of an un-orthodox phenomenon presenting a challenge to an entrenched and powerful social institution (Eisenberg, et al. 1998; Fisher and Ward, 1994). This type of confrontation between competing narratives of knowledge and forms of practice is not rare in contemporary society. The growth of pluralism and the undermining of traditional authorities have been ubiquitous since the late twentieth century; indeed, they have become one of the period’s defining characteristics (Eastwood, 2000; Giddens, 2000). Scholars have separated the “modern” and the “post-modern” eras into two ideal-types of social reality (Best and Kellner, 1997). The meaning of “post-modern,” as it is used in this study, is not entirely consensual but it conforms to the widely accepted view that the post-modern period began taking shape in the 1970s and 1980s. We lay stress on the distinction between the two periods because the growth in CAM occurred at the juncture between them.1 Medicine as a profession and an institution is a distinctive product of the modern era which covered the end of the nineteenth century and 1  Bauman and Giddens emphasize the continuity between modernity and post-modernity viewing the later period as a continuous development of the earlier one rather than as a distinct period in itself. Nevertheless, regardless of the name attached to the later period or its relationship to its predecessor, “late modernity" and “liquid modernity” as described by Bauman and by Giddens are quite similar to what other scholars have called post modernism. We have chosen to use the term post-modern in the course of this book (Bauman, 1997; Giddens, 1991b). — 38 —

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most of the twentieth century (Foucault, 1975). This era is characterized by sharply-stratified hierarchies, clearly-defined centers of power and an almost unbounded faith in science and progress. It was a time of confidence in consensual values, “truth” was clearly defined and the domain of public discourse relatively homogeneous. Non-conformity was rejected, often with unequivocal sanctions (Giddens, 1991). It was a time of all-encompassing ideologies and meta-narratives (Lyotard, 1979) and of clear distinctions between holy and profane in the social and cultural worlds (Touraine, 1988). Bauman (1991) notes the sharp dichotomies and distinct boundaries between sociocultural categories. The nation-state played a key role in defining social structures, and capitalist markets controlled national frontiers (Smith, 2000). By way of contrast, the post-modern era is portrayed as a time when changes in the world economy weakened nation-state frontiers and globalization flourished. The power of the state declined and its institutions lost much of the stability and solidity they had once enjoyed (Smith, 2000). Faith in progress diminished, and with it other canonic beliefs that had been pillars of the great meta-narratives (Lyotard, 1979). “Truth” is thought to be socially constructed and therefore dependent on a local context and perspective (Rorty, 1989). Epistemological relativism gives legitimacy to new foci of authority, and what had once been peripheral gathers energy and moves towards the center. Knowledge and the scientific discourse are viewed as social constructs. Thus in its most extreme form, this approach denies that “scientific facts” are anchored in objective reality (Latour and Woolgar, 1986). The legitimacy of the scientific outlook itself is called into question by the claim that knowledge and power are but two sides of a coin (Foucault, 1972). In the cultural domain, post-modernism embraced ideals of difference and heterogeneity (Best and Kellner, 1997; Turner, 1995). Eclecticism is the order of the day (Jencks, 1986). Cultural products and artifacts are removed from their original context so that rootlessness and de-territorialization become a prominent phenomenon (Bauman, 1991; King, 1997). In these circumstances, disparate sorts of knowledge manage to coexist without conflict, which prompts Lyotard (1979) to argue that postmodern thinking allows us to preserve mutually incompatible concepts, — 39 —

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so that the combination of knowledge from a variety of sociocultural sources can be expected to become more and more acceptable. These sociocultural developments play a major role in the transformation of institutions and in the re-contouring of their boundaries. A classic instance is the dismantling of the canons of “high culture” and “mass culture” and their “fraternization” in the twentieth-century United States. DiMaggio (1992) demonstrates how changes in social structure and in products of the cultural market weaken established cultural authority. Compared to the first half of the twentieth century, it would appear that culture in the second half is distinctly less hierarchical, less universal and far more differentiated. Rapid and incessant change — social, cultural and economic — alters lifestyles and identities. Frequent changes of career and place of work, “lightning” marriage and divorce, migration to find employment or tourism experiences — all these have their effect on the style and pace of life and are signs of increasingly permeable boundaries. Lipovecki (1983) uses the term “personalization” to express the supreme importance of being “oneself.” The collective ideals of “a good education” and a “strong family life,” the very idea of the need for an ordered life, give way to hedonism and the desire for personal fulfillment. How do people manage to lead lives at the crossroads of “narrative units” which are all that remains of the former great overarching narratives (Lyotard, 1979)? And how does one live from day to day in an environment of multiple authorities where one is faced by competing truths, all claiming legitimacy? Owing allegiance to several social circles and moving among multiple identities, some mutually conflicting, is another sign of the times (Snow, 2001). In these circumstances, Simmel’s work on group affiliations (1955) gains a new relevance. While such conflicts may threaten some individuals, for others it can be a source of strength and character enrichment (Weinstein and Weinstein, 1993). For some non-orthodox groups, the objective of their struggle is recognition by the dominant movement; others prefer to stay in opposition, whether passive or militant; another strategy is cooperation and compromise which leads to some form of fusion of resources. In the modern period, conflicts between ruling orthodoxies and their challengers were, as a rule, confrontational as well as overt and public; in the post-modern era the “ruling powers” prefer subtler methods to — 40 —

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defend their power. They are less interested in involving themselves in the problems and inconvenience of direct conflicts (Bauman, 1995). For the individual, joining a group that is trying to unseat a ruling orthodoxy is a serious matter. His status vis-à-vis the parent group is at once marginalized; he becomes a “stranger.” This alienation and the peripheral mode of life that result create an inevitable tension because of the effort to simultaneously hold onto two allegiances while straddling the boundary between them (Simmel, 1971). The boundary-crossers are blamed by the “natives” for a lack of patriotism and for reneging on a commitment. Yet the very fact that these erstwhile “strangers” could cross the boundary demonstrates that what was once thought to be a solid and hermetic divider has become malleable and porous (Bauman, 1989). Bauman reports a variety of tactics used by social institutions to defend themselves against “strangers.” Among these are territorial and functional strategies. For example, they may try to force aliens to leave and, should this prove impossible, turn them into “untouchables” by cutting all contact with them to a minimum. Boundary crossing demands courage, and group support is a major source of help. Patrolling the Boundaries of Medicine: A Historic Perspective Like other social institutions, medicine maintains mechanisms for managing its boundaries. Its paramount functions have been to impose and defend a body of knowledge and practice, and to protect the profession’s social status. The critical period in attaining these goals occurred in the late nineteenth and early twentieth century. Research on boundaries has grown in recent years and has focused on a number of arenas: scientific boundaries (Gieryn, 1983); boundaries used to maintain the distinctions between groups of different status (Lamont, 2000); organizational boundaries (Scott, 1992); social-role boundaries and mobility between them (Nippert-Eng, 2005); cognitive boundaries (Zerubavel, 1991) and numerous others. Research on the professions, including health-care professions, has also made use of this concept. Halpern (1992) investigated crossing professional boundaries in health-care and the imposition of boundary controls; Theberge (2009) analyzes the structuring of boundaries among professions struggling for an area of jurisdiction within sports medicine; a historical perspective is taken by Kronus’s 1976 study on the drawing of boundaries — 41 —

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between medicine and pharmacology in the nineteenth century. Most recently a group of researchers have been investigating the boundaries of conventional and non-conventional medicine in Israel (Averbuch-Smetannikov, 2010; Mizrachi and Shuval, 2005; Shuval, et al. 2002; Shuval and Gross, 2008a). Study of the development of the medical profession throughout the modern period shows that its success in building a power base in the health-care market and in the broader social context stemmed not only from its achievements in the battle against illness, but also from success in its boundary demarcation strategy which enabled it to establish itself as a homogeneous, united and dominant social institution (Freidson, 1986). Toward the close of the nineteenth century the health-care market in the Western world exhibited a wide array of treatment options and an equally wide variety of types of practitioners. In the United States the period was one of “free trade in medicine” (Blevins, 1995). Since the beginning of the century botanists, hygienists, osteopaths, and other schools of practice offered their services alongside physicians. The latter were also divided between those who followed allopathic methods (from which contemporary bio-medicine developed) and the homeopaths (Baer, 1989). At this stage, “official physicians” could be distinguished from the others by having received their training in special medical schools and by their membership in a professional association. The state of affairs in Europe was no less open and competitive. It was from this condition that the doctors moved steadily forward to establish the boundaries of what became an almost unchallenged monopoly for the bio-medical model. The numerous forms of healing were not viewed with tolerance or mutual recognition. Trials of strength between representatives of various persuasions were common and numerous groups claimed authority in health-care (Parssinen, 1992). Economics and politics drove the groups to compete vigorously for clients (Baer, 1989; Blevins, 1995). Physicians had to compete not only with “outside” competitors, such as the pharmacists, surgeons and other non-medical contenders, but also against fellow doctors seeking to introduce theoretical and practical innovations, which the profession as a whole refused to accept. The battle against homeopathy provides an example of boundary demarcation. At this time, homeopathy had numerous champions in Eu— 42 —

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rope and the U.S. and had gained widespread public recognition (Kotok, 1999). Economic and social sanctions were used by the organized medical associations against the homeopaths in their effort to establish an impermeable boundary around the “official” practice of medicine. Their means of boundary control included prohibiting professional relations with homeopaths, monitoring the content of medical school syllabuses, and regulating public discourse by screening the content of medical journals (Gezer, 1890; Nicholls, 1992). Public respect and trust for medicine was at this time at a low ebb. Inadequate training, the mushrooming of for-profit medical schools and, more than anything, the licensed physicians’ predilection for “heroic” therapies scared off potential clients and drove them to other practitioners who were in turn labeled as “quacks and charlatans” by the licensed doctors. Wright (1992) observes that the methods used by these contenders were not necessarily wrong or harmful: their main offense was that they were serious competitors. The medical associations played a key role in establishing the boundaries of physicians’ professional status. The American Medical Association, founded in 1847, set itself the goals of building a solid economic base for licensed physicians by restricting entry into the profession, upgrading the training network and expelling the “sects”, that is the homeopaths, chiropractors and their like (Hamowy, 1979). The licensed physicians managed to gain entry into many of the power centers of society to which unqualified practitioners had no entry. Thus, the hospitals were manned almost exclusively by physicians. It was the physicians who staffed the programs for the development of public health (Shryok, 1948). Licensed doctors enjoyed close relations with society’s elite, who could pay well for their services and exercised influence in many social arenas. Indeed, most of the physicians came from the same affluent social background (Saks, 1992). The licensed doctors also made use of “scientific” rhetoric claiming that their professional authority was based on empirical research studies (Warner, 1985). The non-licensed practitioners did not seek professionalization. Usually they worked alone, utilizing knowledge procured by their own initiatives. They ran no medical schools and did not publish professional journals. Convinced of the rightness of their own methods, they constituted a passive opposition (Whorton, 2004). It was the expansion of public medicine and the rise of the state to — 43 —

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the position of the largest employer of medical professionals that finally made the licensed physicians the chief providers of health-care and drove other providers to the margins so that their livelihood relied exclusively on individual paying clients (Blevins, 1995; Johnston, 2003; Sharma, 1992). The spread of licensing, and the restrictions imposed on alternative practitioners and “rebel” physicians who persisted in using non-conventional methods, allowed those officially licensed to label them as “sectarian.” By the middle of the nineteenth century, a new era in the history of “modern medicine” had begun. From this point on, the methods of non-bio-medical medicine had no foothold within the medical profession (Shryok, 1948). Over time, this divide was used to establish a range of dichotomies defined by rhetorical boundaries: scientific/unscientific, rational/irrational/, professional/charlatan — and others. This long history of rivalry, delegitimization and repudiation turned the divide into a watershed that that was difficult to traverse. Despite this, over time, some alternative health professions did achieve full or partial rights to practice. Recent historical research has qualified the picture of the total repression of alternative therapies by the bio-medical establishment (Johnston, 2003). Un-recognized, they remained active. One of the key vehicles for this was the ties formed with political movements and oppositional forces. Homeopathy, for example, was strongly connected with the feminist movement, while folk therapies were preserved in no small measure by ethnic and nationalist movements. Individual patrons of power and influence also played a part; Baer (1989), for instance, points to the British royal family’s longterm support for homeopathy. Study of its boundary management shows how the medical profession has deployed its defenses across several arenas of which the central one is judicial-political. Here the key mechanisms are licensing and accreditation. These provide clear cut definitions of who is in and who is out. With regard to the organizational boundary, the mechanism is control over who can be employed in the profession’s institutions and who is eligible for membership in its organizations. Control is maintained on the boundary of public discourse by the screening of conference agendas and professional journal content, restrictions on language and rhetoric, and the dissemination of official interpretations of news events (Foucault, 1972). — 44 —

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Other evidence of symbolic boundary demarcation can be seen in the markers which indicate membership in professional groups, for example, dress codes. The geographical boundary is another where the profession is vigilant, requiring, for example, degrees of physical distance between clinical facilities and staff space for professional offices and research. Are the Boundaries of Bio-Medicine Changing? Although the medical profession has historically enjoyed considerable autonomy, this privilege is not absolute, and in recent years there have been more intrusions on its internal agenda and decision-making processes. Patients, outside experts, government officials and politicians all intervene to complicate the profession’s boundary-management and often succeed in bringing about change. The profession demands the loyalty of its individual members and utilizes a wide array of measures to keep them within bounds. But social boundaries are often permeable. Despite sanctions on boundary transgressors, the option remains of escaping the pressures of conformity by seeking freedom from group membership (Simmel, 1971). Indeed, CAM has infiltrated many areas of the professional medical scene as will be seen in the chapters of this book. In a study carried out in the 1990s in Israel, Cohen (2009) suggests that integrative medicine is poised on the profession’s boundary, seeking to build bridges between hitherto estranged bodies of knowledge and practice. As noted, the “outsider” status of CAM in its relation to mainstream bio-medicine dates to the second half of the nineteenth century. Up to approximately the 1970s bio-medicine steadily progressed to monopoly status in the health-care market in much of the Western world. From that point on its absolute hegemony began to decline. The profession, “challenged from outside and fragmented from within” (Coburn, 2001), has been forced to confront a series of political, economic and social confrontations which have limited its autonomy and social status (Turner, 2004). New categories of knowledge have questioned the pillars on which bio-medical science stands. Non-clinical specialists, such as epidemiologists, challenge the rationale and efficacy of medical procedures; economists, planners and management experts lay claim to superior judgment over health-care administration (Coburn, 2001). Further pressure has come from patients, members of the paramedical professions as well as from CAM practitioners. Physicians and other — 45 —

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bio-medical health professionals who have themselves accepted CAM represent a small but active opposition from within. Today broad segments of the public actively seek CAM treatment and seem unconcerned that much of it is provided by unlicensed practitioners. In many ways this situation recalls the state of affairs in the early nineteenth century when the flocking of potential clients to “charlatans” threatened the licensed physicians’ livelihoods. In the 1980s, professional resistance to CAM softened somewhat and certain types of treatments were accorded a measure of recognition. Medical school syllabuses around the world began to offer elective courses on alternative medicine (Ben-Arye and Frenkel, 2001; Sampson, 2001). Many Western countries embarked on the complicated process of regulating the CAM market, in some cases according recognition to its professional associations (CAMDOC Alliance, 2010). Health-care insurance bodies began to provide full or partial coverage for CAM treatment, and a number of government bodies allocated funds for evaluating the effectiveness of non-conventional treatments, e.g. the NIH in the U.S. (Aldridge, 1994; Furnham, 2004). In some cases CAM practitioners were allowed to practice inside bio-medical facilities (Saks, 1991). Attitude surveys among doctors regularly report a growing readiness to accept the usefulness of selected CAM therapies. More and more patients in increasing numbers of countries are referred by physicians to CAM practitioners (Easthope, et al. 2000; van Haselen, 2004). Another facet of this development is the growing number of mainstream doctors and other bio-medical professionals — nurses, midwives, physiotherapists and others — who study CAM and undertake to practice it. Some of these advocate “integrated medicine,” a movement which believes in combining divergent therapeutic approaches. Its declared ambition is to redefine medical care by introducing CAM into bio-medical practice, “combining the best from the alternative and conventional approaches” in order to reinvigorate bio- medicine’s overall orientation to care and cure (Remen, 1999). It seeks cooperation and collaboration between physicians and “practitioners,” and integrated medical centers tend to employ both side by side. Some researchers see the strides made by this movement as a paradigm shift (Coulter, 2002). Various explanations for the shift have been put forward. One is the multiplication of sources of authority, characteristic of the post-modern era, and the internalization of the new values — 46 —

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by doctors (Eastwood, 2000). Another is the profit motive (Johnston, 2003). A third is the pragmatism of doctors who value “clinical legitimacy” over “scientific legitimacy”; if a method “works” it should be allowed even if it does not carry an “evidence-based” stamp of approval (Willis, 1994). Other researchers view the trend as an effort by the medical profession to control competitors (Saks, 1992; Shuval, 1999). There is also the issue of the nature of this integration. Some scholars, pointing to the essential contradictions between the therapeutic paradigms, see no good in trying to harness them together. CAM embodies independent philosophical paradigms which translate into divergent explanatory models of health and ill-health (Furnham, 2004). Some of these models explicitly criticize the bio-medical paradigm. Willis (1994) has noted the “theoretical paradox of orthodox doctors who themselves offer complementary treatment modalities.” Morton and Morton (1997) refer to physicians who had taken a brief “technical” course on a new CAM method and at once started applying it to their clients. They note that these doctors use CAM therapies in a manner which “lacked both holism’s spirit and its ethos.” Coulter (2002) anticipates that integration faces many pitfalls. His prediction is that bio-medicine will accept some alternative therapies but will ignore philosophies. Indeed, Wolpe (1985) claims, mainstream doctors who started giving acupuncture treatment may be perceived as threatening established authority until they redefined its concepts in bio-medical terms. This prompts the question whether this uprooting of therapies from their original theoretical paradigms might not end up disabling them (Coulter, 2002). Bodeker (2001), who studied integration in the Third World, agrees: When conventional medicine dominates complementary medicine, loss of essential features of complementary medicine can occur and professional conflicts can arise. What we may be witnessing is what Conrad (2007) has termed the “medicalization” of alternative medicine, that is, converting it into another “conventional” therapy by expunging most of its independent theoretical components and incorporating it as a sort of paramedical field into the overall bio-medical family. Needless to say this approach implies jurisdictional control under the hegemony of bio-medicine and — 47 —

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the reduction of CAM to a collection of techniques legitimized by their clinical pragmatism. No less important are the deliberate and simultaneous efforts to CAMify bio-medicine: this process refers less to techniques and more to changes in the overall professional orientation and treatment of patients: increased emphasis on holism, integration and the unity of mind and body. One of the goals of this book is to learn more about these processes and to understand their long-term implications. Conclusion The book examines the relationship of CAM and bio-medicine in Israel from an historical and sociological perspective. The boundaries separating bio-medicine and CAM define an organized body of knowledge and practice as well as an institutionalized profession. The relationship between bio-medicine and CAM is viewed as a process of boundary crossings negotiated by practitioners in the course of their daily clinical work. In order to highlight these processes, we have focused on the “boundary work” of bio-medical practitioners who have developed strategies to move between different bases of authority and legitimacy, competing bodies of knowledge and practice—between a bio-medical alma mater and a non-bio-medical “alternative.” The history of the medical profession shows an on-going process of guarding its strongly established boundaries. Therefore, this boundaryspanning work, both conceptual and instrumental, carries a potential for conflict because the processes take place in the context of different epistemological paradigms as well as dissimilar clinical forms and content. At the same time, in the context of the post-modern social climate prevailing in Western societies and in Israel, there is widespread acceptance of the amalgamation of different types of knowledge such as to reinforce experiments in boundary-crossing. Furthermore, sanctions against non-conformity have lost much of their deterrent influence. The processes observed in Israeli health-care have both local and global implications, and can therefore shed useful light on similar developments in other countries.

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Chapter 4

Historical Perspective: Unconventional Medicine in Israel Moshe Cohen

Over the past decade, unconventional medical therapies have played an increasingly prominent role in Israeli health care. At first glance, it would appear that the burgeoning interest in unconventional medicine has appeared almost phoenix-like at the tail end of the twentieth century. However, its cautious acceptance during the last decade in Israel has a long history of negotiations and struggles between unconventional practitioners and the medical establishment. This chapter describes the transformative process that unconventional medicine underwent: from a marginal discipline in Israeli society up to the 1980s, to a widespread, institutionalized and legitimate field of practice after 30 years. The description begins with the first steps of naturopaths and Feldenkrais in the 1950s, proceeds with the unique circumstances under which “alternative medicine” was formed in the 1980s and ends with the transformation processes during the past two decades of a small number of physicians, who also practice unconventional medicine, from “dissidents” to qualified members of the medical community. The terminology to be used when referring to the subject of unconventional medicine is problematic with regard to current practice and particularly when dealing with the history of unconventional medicine (Davidovitch, 2004; Jutte, Eklof and Nelson, 2001). The term CAM (Complementary and Alternative Medicine) is used throughout most of this book. However this term only appeared in Israel during the 1990s and has no meaning in the context of the society before that period. Therefore, I have chosen to use the term “unconventional medicine” since it is in fact the antithesis of those methods of treatment that enjoy the cooperation, approval and legal protection of the establishment. When describing the events that occurred from the 1990s and onward, I use the term CAM. By doing so, this chapter — 49 —

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explores ways in which the rhetoric used by unconventional practitioners, physicians and health authorities sought to control the boundaries of their professions. Health Care Systems in Palestine until the 1950s Before I describe the transformative process that unconventional medicine underwent beginning in the 1950s, I will briefly set the scene by describing two types of medical practitioners operating in the country at that time: traditional healers and trained physicians. Until the mid nineteenth century, a period when Palestine was part of the Ottoman empire (sixteenth century to 1917), traditional medicine was almost the only health care service available for the Arab and Jewish population of the region (Amar, 2002; Hes, 1964; Levi, 1998; Reiss, 1991; Shuval, 1992). Traditional healers were widely spread and accepted by their communities. They used techniques such as bloodletting, amulets and herbal medicine. The authority of such healers was generally transmitted generationally from a father or other predecessors with acknowledged expertise (Shuval, 1992). There were a considerable variety of healers of this type drawing on different ideologies and traditions. They had in common a rationale of healing based on explanation of events and problems in terms of ancient texts or traditions and claims of access to higher spirits or deceased figures in their diagnostic and therapeutic procedures. A violation of moral taboos or behavior that ignores the spirits was viewed by many of these healers as a source of a patient’s suffering. Depending on the tradition which served as their rationale, healing involved astrological formulas, reference to oracles, interpretation of dreams in which sacred figures appear or manipulation of sacred names and verses. Jewish healers often specialized in writing texts on amulets or parchments which were then worn or burned in order to inhale the smoke, drunk in solution or placed in safekeeping near the patient. Exorcism, namely removal of demons or the evil eye, was in some cases a central element of therapy (Shuval, 1992). Modern medical knowledge and technology that were developed in Europe during the eighteenth century were hardly available in the region until the mid nineteenth century. Qualified physicians were few and far between at that time (Amar, 2002; Levi, 1998; Michlin, 1999; Shuval and Anson, 2001). The European empires tried to promote their imperialist aspirations through cultural and religious activities and by establishing — 50 —

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modern health-care services. Christian missions established hospitals and offered medical services for the Arab and Jewish communities. As a response, Jewish philanthropists and some European Jewish communities sent physicians and medications to Palestine in order to offer the Jewish colonists an alternative to these Christian hospitals. By 1902, six Jewish hospitals and a few modern clinics were established (Shuval and Anson, 2001). As part of the Second Aliyah (1904-1914), 40,000 Jews immigrated to Palestine mainly from Russia following pogroms and outbreaks of anti-Semitism in that country (Reiss, 1991). This group, influenced by socialist ideals, established the kibbutzim and formed self-defense organizations. The years 1911-1913 marked several beginnings in health care: the creation of the first sick fund (HMO); the organization of the Hebrew Medical Association (predecessor of the Israel Medical Association); and the first public health nurse service in Jerusalem by the predecessor of the Hadassah women’s organization (Reiss, 1991). Following World War I, Palestine was ruled by the British Mandate government (1918-1948), which in 1920 set up a Government Health Service. A Sanitation Department was responsible for the quality of drinking water, modern urban sanitation was introduced, inoculations against typhoid, cholera and smallpox were made compulsory and clinics for the treatment of eye diseases were established (Reiss, 1991). The services run by the British Mandatory authorities were concentrated primarily in Arab towns, as the Jewish community had already developed institutions of its own. The Histadrut (General Federation of Hebrew Workers) was established in 1920, and it created the Histadrut Sick Fund (Kupat Holim Clalit) which established two hospitals, 274 clinics and additional health stations by 1946. The Hadassah Medical Organization established hospitals in urban centers and engaged in a broad range of public health activities (Shuval and Anson, 2001). During the British Mandate period, the seeds were sown for the health care delivery system of the future state of Israel. It was characterized by a combination of public and private provision of services, and included: activities by the Mandatory government, the Christian missions, Jewish and Arab institutions of self-government, the Hadassah Medical Organization, the Histadrut Sick Fund and other voluntary sick funds, some Jewish, Christian and Arab charitable societies, private physicians and hospitals. — 51 —

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When the State of Israel was founded in 1948, the newly established Ministry of Health inherited the fragmented health care system that existed during the British Mandate. During the early years of independent statehood, the major challenges to the health care delivery system were to provide medical services for the masses of Jewish immigrants and Holocaust survivors who came to the country during the 1950s and 1960s from Europe, North African and Middle-East countries, and to extend medical services to rural areas (Swirski, 1999). Although the health care system was based primarily on modern biomedical facilities, traditional healers were still widely dispersed during the 1950s (Bilu, 1978; Hes, 1964; Lev, 2006). These traditional healers were not viewed as legitimate health care providers by the public authorities (Matzalcha and Baron, 1994; Shuval and Anson, 2001). Practicing physicians were not unduly concerned with the phenomenon since they were convinced that once the patrons of unconventional medicine became familiar with bio-medicine, they would quickly be convinced of its effectiveness and abandon their earlier practices. Dr. Gretz Bi-Gil exemplified this view in an article on Yemenite immigrants in 1959: “When someone who used traditional medicine becomes a civilized, mature Kibbutz member and is offered the opportunity to get medical assistance from physicians, he slowly grows accustomed to the new situation […] and drops these magic practices and other so called spirits and ‘medical’ experts.” Thus, the common narrative regarding the growth of conventional medicine in Israel did not include references to significant challenges from competitive or alternative health care providers. However, this view overlooks the fact that during the 1950s, a time when the new Jewish state was taking form, homeopaths, naturopaths, acupuncturists, chiropractors, Feldenkrais and other unconventional healers were practicing actively and seeking recognition. In that breeding ground of entrepreneurship, a small number of unconventional practitioners laid the groundwork for the thriving, active complementary medicine that exists today. These practitioners were different from the traditional healers: they were middle class, educated European immigrants who developed their own style of healing, drawing on existing Eastern and Western knowledge and traditions. They claimed a scientific basis, established associations and acted in the national political sphere to gain legitimacy. Although these unconventional healers did not have formal medical training and were few in numbers during the — 52 —

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1950s, they used their charisma, knowledge and skills to challenge the hegemony of conventional medicine during the formative stage of the medical discourse in Israel. Challenging the Bio-Medical Hegemony Before the 1980s Naturopathy was one of the most significant and influential movements that operated in Israel between 1930 and the 1980s. It started in the context of the early waves of immigration of Jews, a phenomenon that intensified throughout the 1930s with the rise of the Nazi party in Germany. As a consequence, the number of immigrant physicians greatly increased (Niderland, 1983), but other kinds of unconventional practitioners also arrived. Mordechai Netzach, for example, was a 30 year old accountant who turned to naturopathy after he almost became blind in 1931, published 45 articles about “the natural way of life” during the 1940s and opened a clinic in Tel-Aviv. He defined naturopathy as a scientific technique in the following manner: The science of naturopathic therapy includes the following rules, which are the major ways of gaining absolute health: improving body structure and operation, proper nutrition, exercise, rest, proper water intake, hot and cold baths, correct posture, controlling emotions and impulses, strengthening and shaping the nerves, healthy atmosphere, proper clothing (Netzach, 1944). This definition of naturopathy was similar to definitions of naturopathy used in the United States and Europe (Jutte, et al. 2001; Whorton, 2002). However, at the same time the Israeli version of naturopathy was localized by including additional forms of healing such as chiropractic, acupuncture, homeopathy and osteopathy. Yom Tov Al-Or, an official in the Ministry of Health and a firm naturopath, described how he learned acupuncture in a letter to Mordechai Netzach: I just came back a few weeks ago from abroad (Germany, Switzerland). I participated in a number of scientific conferences dealing with naturopathic and homeopathic medicine as well as in an international conference of Electro-Acupuncture. I can tell you some interesting — 53 —

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things (Al-Or, 9/2/1964). Naturopathy was practiced as an amalgam of several of the naturalistic techniques that were usually practiced separately in other Western countries at that time. These naturopathic healers used scientific language, published articles and books, and appeared as respected experts. Their claim for legitimacy, like home farming and conserving money for the country’s treasury, conformed to the Zionist ideology that prevailed during this influential early stage of the young state of Israel (Almog, 1997). Until the late 1950s, these naturopaths worked independently and were not organized in any form. In 1957, the Jerusalem naturopath, Yom Tov Al-Or, convened a meeting of ten naturopaths that practiced in Israel at that time and decided to establish the “Israeli Naturopathic Association” (INA). He convinced INA’s members to approach the government and demand rights equal to those of physicians. Due to Al-Or’s close connections with officials at the Ministry of Health, he succeeded in setting up a meeting with the Minister of Health, who expressed his view toward the subject: The Health Minister expresses his personal support for naturopathic medicine, however he thinks that naturopathic medicine should be practiced exclusively by licensed physicians who completed full medical training (10/12/1958). Furthermore, the Director General explained during the meeting that it would be a “danger to the public health” if the diagnosis of disease were to be placed in the hands of naturopaths. At that time, physicians were the backbone of the Ministry of Health and controlled most of its key positions. They were about to dismiss the request for legalization of the naturopaths, but Al-Or was unwilling to give up. He wrote in his diary, “Under these unfortunate conditions, the writer, as a veteran member of the staff of the Ministry of Health and as an experienced naturopath, undertook the responsibility to do his best to bring both sides to direct negotiations” (Al-Or, 1959). Al-Or found some support for his proposal to table a bill in the Knesset (parliament) that would legalize naturopathy and provide na— 54 —

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turopaths with rights equal to those of physicians. In particular, he was encouraged by a vegetarian Knesset member, Israel Guri. At the same time, Al-Or persuaded most of his fellow naturopaths to relinquish their work on patient diagnosis and allow it to remain exclusively in the physicians’ domain “because of the strenuous objection regarding the diagnosis question” by the Director General of the Ministry of Health (Al-Or, 1959). His reasons for giving up on the right for diagnosis were based on two considerations: first, most of the patients visited physicians before they turned to unconventional healers and, second, his fears of failing formal physiological and anatomical examinations that the government would force the naturopaths to pass (Al-Or, 1959). Al-Or sent an official letter indicating INA’s decision on December 16, 1958. Ironically, the naturopaths thought that the decision of the Minister of Health, Israel Barzilay, to set up a committee made up of physicians to judge the naturopaths’ claims, was a goodwill gesture regarding diagnosis. But in fact, it was a response to the proposed bill that was placed on the public agenda. When the naïve naturopaths were invited to testify before the Ministry of Health committee on January 11th, 1959, they were taken aback to discover that most of the committee’s members claimed that waiving the right to diagnose patients would not be sufficient, as indicated by the chairman of the committee. Said Dr. Theodor Grushka, a prominent public health specialist, “If such legislation were to be passed there would be no control in the matter of diagnosis, and every healer could accept patients in any manner he sees fit” (11/1/1959). As the negotiations progressed, Al-Or felt that the committee would reject their claims for legal status. He wanted desperately to prevent that and as a last resort decided to send a warning letter to the Minister of Health, stating that “the minimalists of our association have invested enormous efforts in persuading other members that a moderate and compromising method is best” (Al-Or and Heyman, 6/4/1959). Although Al-Or used the word “persuade,” in reality, he did not succeed in convincing those naturopaths who did not agree with the “minimalists” of the association. Yossef Hasidoff, one of the members of the — 55 —

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naturopathic association, was expelled from the negotiations with the Ministry of Health because he “did not accept the authority of our decisions” (Al-Or, 1959). On April 7, 1959, the committee rejected the claims of the naturopaths for legal status stating that: “we are sorry that we cannot use these people in programs of education for hygienic behavior and a healthy life style, as they are idealistic and very persuasive, however the problem is that they are prejudiced extremists” (7/4/1959). The committee went on to state that: “the health committee believes that the proposed changes to the Doctors’ Ordinance pose dangers to the public’s health.” The naturopaths were disappointed with the committee’s decision and promised to fight back: “our legal battle is now entering its final and most difficult stage […] we have no choice but to start a public campaign to gain our full rights” (Al-Or, 1959). Although Al-Or promised a public contest, he knew it could not be activated by a scattered number of vegetarians and naturalists who opposed any form of violence. As a result, the organized fight for legalization was delayed for more than 20 years. Another unconventional practitioner who operated in Israel during the 1950s was Dr. Moshe Feldenkrais. His technique is widely practiced today in many parts of the world, but when the 47 year old physicist immigrated to Israel from Britain in 1951 he was completely unknown. The turning point in Feldenkrais’s career occurred after he became the personal healer of the first prime minister of Israel, David Ben-Gurion. In a well publicized incident, in 1957, the 71 year old prime minister was seen while on vacation performing his daily beach ritual of standing on his head. This unique event triggered a huge public interest in what became known as the “Feldenkrais technique.” Moshe Feldenkrais was born in a small village in Ukraine in 1904. His father was a rabbi who also ran a business selling wood. In 1918, at the age of 14, Moshe decided to immigrate to Palestine with his friends from the town of Baranovichi. He was employed as a construction worker in Tel-Aviv and enjoyed playing soccer. During one of the matches, he was injured badly in his left knee. He could barely walk for several months. This was the trigger that aroused his “body consciousness” (Feldenkrais, 1981). At the age of 23, he finished his matriculation examinations at the Gymnasia Herzelia secondary school and started working in the survey department of the British Mandatory government in an effort to earn — 56 —

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enough money to study in Paris. In addition to his work, he studied JiuJitsu and wrote a small book that was circulated among members of the “Hagana” (the Jewish underground). He stayed in Paris from 1930 to 1940, and completed his PhD in physics at the Sorbonne. When the German army invaded France in 1940, he escaped to Britain and joined the navy as part of a unit that developed anti-submarine weapons. His work on the slippery decks exacerbated his old knee problem, and he was forced to spend more time lying down than walking. His physicians proposed surgery, but he refused and decided once again to cure himself on his own. He investigated his knee movement, searched for alternatives, and changed his posture and his gait until he could walk freely. Feldenkrais incorporated Eastern and Western techniques in his doctrine, and in 1949, after gathering enough knowledge and confidence, he published his first book, “Body and Mature Behavior,” that came to be the basis of the Feldenkrais technique. The young state of Israel, established in 1948, was in urgent need of scientists who could develop sophisticated weapons. Efraim Katzir, commander of the Science Corps of the Israeli Defense Force, persuaded Feldenkrais to join the army’s rocket development team. Katzir quickly realized that Feldenkrais “didn’t know anything about rockets” (Lori, 2004), but he was deeply impressed by his healing techniques. Feldenkrais left the army shortly after to live with his mother in Tel-Aviv and conduct classes teaching his methods in Haifa and Tel-Aviv. He traveled abroad often and introduced short courses of his technique in Europe and the United States. The demand for his courses grew rapidly, but he did not view this as a particular sign of success. He sought official recognition by the Israeli government authorities for his teaching in the form of a state funded “Institute for the Coordination of Spirit and Body.” Feldenkrais did not envision a simple clinic, but a large institution that would be a college and a clinic under state regulation: The interest that I have in my technique and doctrine is public and national. It is my hope to infuse my doctrine into the consciousness of the people of Israel in order to improve their body awareness. And this will not be done without a real institution that will have effective governmental authority (Eligon, 20/10/1950).

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An opportunity to realize his dream came when he became the personal healer of Prime Minister David Ben-Gurion, who suffered from chronic back pain. He sent Ben-Gurion a letter indicating that he could help him stand on his feet again. Ben-Gurion showed this letter to his physicians and they advised him not to meet Feldenkrais (Perlman, 1987). But when the chronic back pain continued Ben-Gurion decided to give Feldenkrais a chance. Feldenkrais taught Ben-Gurion to stand on his head and proposed a daily walk of 5 kilometers. In September 1957, Ben-Gurion went down to the Herzelia beach and stood on his head regularly every morning. The journalists were all after him, taking photos of the phenomenon and looking for information on the identity of the person who turned their prime minister on his head. Ben-Gurion and Feldenkrais met on a weekly basis and became close friends. Ben-Gurion indicated in his diary several times that he tried to get funding for Feldenkrais’s institute, but with no success. Ben-Gurion trusted Feldenkrais and introduced him to his friends and colleagues. One example of such a referral occurred in 1958 when Ben-Gurion asked Feldenkrais to treat Amos Hacham, the first winner of the competitive Bible quiz held in Jerusalem, who suffered from paralysis in his hand and a speech defect. Feldenkrais refused at first, but finally agreed when the Prime Minister insisted. Despite his busy schedule of government duties, BenGurion invited Feldenkrais to his own home to examine Hacham. He described this meeting later in his diary: Feldenkrais checked Amos. He is not of the opinion that his paralysis is due to a fall from his cradle as Hashin described in the Bible quiz final inJerusalem. There is no remedy for the hand and in his opinion it would be better to amputate the broken palm and match a prosthesis. He believes that his speech can be improved, though he is not sure it can be fully corrected (Ben-Gurion, 20/8/1958). Although Feldenkrais proposed a specific medical diagnosis, a process that was permitted to physicians only, his treatment was very different from that of physicians. This is exemplified in the case of Nora as described below:

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When I am presented with a trouble in function, I make a special effort not to think in words. I try not to think logically and in correctly formed sentences […] sometimes I’m stuck at a point where I cannot imagine the pattern of the flow, or the possible obstacles in its way. Then I ask, is the obstacle a diffusion, damping, deviation, loss of impetus, break of continuity, or impossibility of one of the transformations? (Feldenkrais, 1977, p. 16) In a period when the Israel national ethic emphasized active exercise, Feldenkrais advocated lying on a soft mattress and repeatedly performing small bodily movements. He claimed that achieving physical fitness can be reached only by finding harmony of the bodily, emotional, spiritual and mental aspects of life. Feldenkrais desperately wanted to be officially recognized by the Israeli medical authorities, but his dream was not realized. His students proposed him for the prestigious “Israel Prize,” but he was not selected. His failures in Israel encouraged Feldenkrais to train followers around the world. He died at the age of 80 after several strokes. Ironically, when he was dying he refused to be treated by his students and accepted assistance from a qualified nurse. The cases of the naturopaths and Feldenkrais illustrate two examples (out of many) of unconventional practitioners who approached governmental authorities and sought recognition of their vocation during the 1950s. In both cases, the boundaries of the treatment and the qualification process of new practitioners were not defined clearly. Both techniques were defined as “scientific” by their practitioners and patients, even though they were not subjected to any scientific examination. Their scientific rhetoric, their presence in central cities and their European origin distinguished them from the traditional practitioners who relied on spells, amulets and religious authority. Notwithstanding some similarities, the difference between the two cases is significant. The naturopaths were idealists and their claims for legitimization corresponded closely to the Zionist rhetoric that prevailed at that time. They were considered marginal and radical due to their ascetics, lack of medical credentials and their revolutionary ideas to replace conventional medicine with naturopathic medicine. They had — 59 —

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to create a crisis and escalate their case into the political sphere in order to gain the attention of the medical establishment. Feldenkrais, on the other hand, adopted a different strategy. He was selective in choosing his patients and students and did not seek to transform his patients’ lifestyles. He used his close connections with the highest political figures and avoided referring directly to the medical authorities to gain recognition for his technique. Despite these differences, both the naturopaths and Feldenkrais posed new challenges for the medical establishment which could not avoid confronting them. The Struggle for Freedom of Choice and the Social Construction of “Alternative Medicine” The term “alternative medicine” was first used in Israel in the 1980s as a result of a number of decisions taken by government officials in the Ministry of Health. The change started when state officials from the pharmaceutical department of the Ministry of Health noted a growing number of requests to approve the import of homeopathic products: Lately we have approved the import of homeopathic raw materials (that were not yet defined) to pharmacies which prepare homeopathic medicines. Loopholes in the regulations do not justify our action which is to avoid confronting, discussing and expressing our professional opinion on this type of medicine (Panton, 7/8/1978). Dr. Zvi Panton, an official of the pharmaceutical department of the Ministry of Health, noted the importance of setting a policy for these unregulated medicines. In 1980, the Director General decided to set up a committee that would formulate a policy regarding homeopathy. The committee members included three physicians, one pharmacist that worked in the Ministry of Health and one pharmacist who was the owner of a homeopathic pharmacy in Jerusalem. Homeopathic practitioners (MDs and non-MDs) were not nominated as members since none of them belonged to any recognized medical institution, as Dr. Panton stated: As long as there is no recognized organization of homeopathic physicians that can ascertain that a specific — 60 —

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physician is authorized to prescribe homeopathic products, we are unable to recognize homeopathic physicians (15/5/1980). According to officials of the Ministry of Health, facts could be accepted only if they met scientific criteria, as expressed in the conclusions of the committee: The definitions and targets of homeopathic medicine do not meet any acceptable physiological criteria. General principles, such as “treating the patient and not the disease”—“rest”—“diets” etc, are nothing new for modern medicine. Many homeopathic notions, such as “natural healing by simulations of natural vital forces” have no scientific medical meaning (Gitar, 12/2/1980). In 1982, the Ministry of Health published a regulation that prohibited importing homeopathic drugs to Israel. Thus, the raw materials on which the local homeopaths were dependant, were suddenly unavailable. In addition, health officials began conducting raids in homeopathic pharmacies, confiscating homeopathic drugs, investigating the practitioners and seeking suspicious evidence. These punitive procedures were reported to Prof. Baruch Modan, the Director General of the Ministry of Health, who stated laconically after one of these raids: “congratulations for bringing the fish into the net” (14/4/1983). Homeopathic practitioners felt that they had to go underground. Along with these measures against homeopaths, officials from the Department of Medical Professions at the Ministry of Health decided to set up another committee to evaluate other unconventional medical therapies. This was a result of the growing number of requests by naturopaths, chiropractors and acupuncturists to legalize their professional practices. The committee to examine the issues regarding the “Recognition of Medical Professions in Israel” was formed in 1982 to determine “to what extent various health care occupations currently working in Israel should be defined as para-medical, i.e. supportive of the medical profession.” The appointed members of this committee were physicians and physiotherapists. The committee decided to outlaw the following unconventional — 61 —

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practitioners: “electro-therapists, hydro-therapists, medical masseurs, chiropractors, certified acupuncturists (non physicians), Shiatsu practitioners, and reflexologists” (Israel Ministry of Health, 1982). An interesting point in these conclusions was the fact that acupuncture was forbidden to practitioners who did not have a medical degree, but approved for physicians. The criteria to accept or reject a therapy had nothing to do with its effectiveness, but only with the formal, legitimate status of the practitioner. The Ministry of Health embraced these conclusions and proposed a Knesset bill that would legalize acupuncture for physicians only. These acts of the Ministry of Health encouraged unconventional practitioners to initiate other strategies to attain their goals: recruiting well-known figures who would represent their case publicly, initiating public relations campaigns and forming professional associations to claim their rights. David Greenblatt, one of the first chiropractors who worked in Israel during the 1980s, claimed that Ministry of Health officials initiated a “program of harassment” against the 6 chiropractors already in practice in Israel at that time: The effect of this campaign was that chiropractors finally united to form a Chiropractic Society. We engaged the services of an attorney and began to fight back (Greenblatt, 1983). Mordechai Ben-Porat, a member of the Israel Knesset and a recently converted vegetarian, was sympathetic to the unconventional practitioners’ cause. He rose in the Knesset plenum in 1983 and declared for the first time in Israel that “alternative medicine—as I labeled it in the motion for the agenda—should be legally recognized” (4/3/1983). He fought public officials in the Knesset committees who sought to outlaw unconventional practitioners, and expressed his reservations to the decision to limit the practice of acupuncture to physicians, stating, “Who are the physicians? Do they have any training in acupuncture?” (22/11/1983). Ben-Porat was outraged at the idea that physicians controlled the hegemony over medical practice. He spoke personally with the Minister of Health in an effort to persuade him to appoint an objective committee to evaluate unconventional medicine. — 62 —

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Another central figure who joined this effort was Professor Avshalom Mizrachi, a biologist who was convinced in 1977 that CAM can add to the repertoire of conventional medicine (Mizrachi, 2003). In 1983 he decided to form a public “Council for Nutrition and a Healthy Lifestyle” that would promote “legislation in the field of health care to allow individuals freedom of choice for any type of medical therapy they find appropriate” (19/1/1984). Mizrachi tried to redirect the efforts of unconventional practitioners to gain recognition of their professions toward a wider struggle for medical freedom. The media embraced this campaign and started to question the exclusive authority of conventional medicine. “Health as a free choice” proclaimed the headlines in 1985 in a series of six articles in the respected newspaper Ha’Aretz. These public statements reached top officials of the Ministry of Health, but at the time they did not appreciate the implications or the effects of this campaign. One of the turning points that alerted officials in the Ministry of Health to the implications of their decision, occurred in October 1985, when the official television channel in Israel was about to go on the air with a report on homeopathy. The reporter asked Professor Efraim Menczel, head of the pharmaceutical department in the Ministry of Health, for his response to the TV program. Menczel chose to respond to the Director General of the Israeli TV in the following manner: Every practitioner of homeopathy, who prescribes homeopathic products, is violating the law and as far as we are concerned is a criminal. Just as television cannot defend financial smugglers and pimps—it is unacceptable for it to present such a program—nor can the Ministry of Health be expected to respond to it (15/10/1985). Menczel understood the impact of broadcasting such a report on TV and wanted to do whatever he could to change its content. He tapped into a vocabulary that compared unconventional medical practitioners with criminals, prostitutes and pimps. The program was eventually broadcast and Menczel was called immediately to the office of the Director General of the Ministry of Health. He was asked to find alternatives to the current policy towards homeopathy. This time, however, the General Director, Professor Dan Michaeli, decided to summon other experts — 63 —

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who might have different opinions on this matter. He invited Professor Hillel Elkin, director of the pharmaceutical department of Sheba hospital, who had a more tolerant view toward homeopathic drug regulation. Menczel eventually was forced to propose an alternative official position of the Ministry: Treatment by homeopathic products may be viewed as analogous to treatment by a placebo product, i.e. not as a medical drug but a placebo which physicians may use in psychosomatic situations. This proposal is intended to meet public pressure of many persons including patients who claim to be treated successfully with homeopathic products (Position paper in the matter of Homeopathy, 28/10/1985). Until the time of this broadcast, the Ministry of Health had always held to an unambiguous and uncompromising stance regarding the medical profession: bio-medicine was viewed as the unquestioned foundation of health care in the society, the effectiveness of which was never doubted or mistrusted. No reservations were ever expressed with respect to its absolute hegemony in the field of health and health care, and there was no awareness that the public might not always accept this stance. This overall confidence was shaken after the program was broadcast and the public’s views concerning unconventional practitioners became a more important element in the considerations of the decision makers of the Ministry of Health. Due to growing tensions between unconventional practitioners and state officials, a formal policy towards homeopathy could not be formulated at that time. But in 1987, Shoshana Arbeli-Almozlino, the Minister of Health, decided to form a committee headed by a neutral judge “who will have an objective approach” (4/8/1987) to the subject. Supreme Court Deputy Judge, Menachem Eilon, who was a well known champion of individual rights, was appointed as the committee chairman. The remaining committee members included nine physicians and two persons from the legal profession. It was popularly known and the “Eilon Committee.” Nineteen witnesses appeared during a course of 22 meetings. Almost all of the witnesses were practitioners or specialists in one of the alternative professions. — 64 —

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The goal of the public committee was to examine all aspects of “natural medicine” including “homeopathy, acupuncture, reflexology, chiropractic, etc.” Its mandate was to provide recommendations regarding “the possibility of legitimizing these methods and licensing practitioners by examining information and experience in other countries” (Israel Ministry of Health, 1991, p. 1). The report of this committee was submitted in 1991. The meetings of the committee were held at the Van-Leer Institute in Jerusalem, and Eilon decided to open most of them to the public. This time, members of the committee included non-physicians as well as physicians: public figures, such as Mordechai Ben Porat and Professor Avshalom Mizrachi, leaders in the struggle for freedom of health care, were appointed as committee members. Eilon and Mizrachi were the life and soul behind the committee’s deliberations. Mizrachi described the preparations for the committee meetings as “hectic” and his home as a “battlefield” for 3 years. He managed the list of witnesses and prepared background materials for the committee (Mizrachi, 23/1/2005). The result was the publication in September 1991 of a twenty six page report entitled “Report of the Committee on Complementary Medicine in Israel.” The change in rhetoric from “alternative medicine” to “complementary medicine” was not a chance phenomenon. Professor Moti Ravid, a member of this committee, explained that “we preferred this term, since it is not alternative and doesn’t replace anything” (22/8/1991). The report opened with a description of the current legal status which was “far from satisfying” and claimed that “there is no control, of any kind, over what these practitioners offer or over what they do, or over their professional training” (Israel Ministry of Health, 1991. Eilon Committee). The recommendations of the committee were revolutionary in the sense that they suggested a radical transformation in medical legislation in Israel. They proposed to abolish the special status of physicians in Israeli law and allow non-MD practitioners to practice unconventional medicine with no restriction. In addition, the committee suggested that the Ministry of Health should not be responsible for the regulation and inspection of unconventional licensing, but should “focus on protecting the public from the danger of harm and deception when using complementary medicine” (Israel Ministry of Health, 1991). They recommended that the use of homeopathic medicines be permit— 65 —

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ted with few restrictions. Most of the committee members, including many physicians, signed these recommendations, and only 3 members representing the Ministry of Health refused to accept them and published a minority position paper. After a decade of bitter struggle over “medical freedom,” unconventional practitioners celebrated these results. They intensified their professionalization process by establishing several new professional societies: the number of societies grew from 2 in 1990 to 16 in 2007 (Cohen, 2009). These societies sought to set standards for practitioners’ training and to define the boundaries of their professions. However, for the Ministry of Health and for the Israel Medical Association (IMA), the Eilon Committee report was an urgent call to respond to this threat on the hegemony of bio-medicine. A Revolution Within the Medical Profession Just a few months before the publication of Eilon’s report in September 1991, two young physicians who also practiced homeopathy, Dr. Shai Pintov and Dr. Micha Altman, established CAM clinics in two central public hospitals: Sheba and Asaf Harofeh. Many physicians were worried about this development and sent letters of protest to the chairman of the Scientific Board of the Israel Medical Association(IMA), Professor Shmuel Edelman, asking him to respond. IMA’s Scientific Board immediately took two actions, the first of which was sending letters to the management of these hospitals warning them that unless they close these clinics, IMA would no longer support the regular departments of the hospitals. Despite this threat, the hospitals were not willing to close the CAM clinics because they offered an opportunity to help the hospitals reduce their growing deficits by means of direct payments for service by patients and indirect payments by insurance bodies. In addition, the IMA’s scientific board established an ad hoc committee which—within only a month—prepared a two page position paper as a response to the recommendations of the Eilon Committee. In December 1991, this first position paper (out of 4 that were published by IMA between 1991 and 2006) was handed personally to the Minister of Health, Mr. Ehud Olmert, by the chairman of IMA: The scientific board is of the opinion that there is only one medicine, and that other methods of treatment — 66 —

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should not be called “medicine” […] there is a risk that because of economic considerations, less expensive, non-medical methods could gain widespread recognition (Edelman, 18/12/1991). The first position paper denied the existence of unconventional medicine and did not suggest any means or method for its future recognition. By doing so, its authors ignored the growing number of physicians who had undertaken to study various forms of CAM and those already practicing unconventional medicine in Israel. Despite IMA’s opposition, the popularity of CAM grew, and by 1997 10 clinics were established in public hospitals and headed by physicians (Grinshtein, 1997). The pressure to change IMA’s negative official position was intensified by doctors who practiced CAM and by members of the Knesset. In a meeting of the Control Committee of the Knesset in 1996, which dealt with the regulation of CAM, the chairman of the Committee, Ran Cohen, asked: I believe that there is an inherent problem, and I ask the MDs to explain it to me: what is really going on here? I understand completely that physicians—who are committed to their doctrines, their beliefs, their ethics and values and their conventional medical profession— may object to other forms of healing (Protocol no. 40 of Control Board Committee, 3/12/1996). Cohen declared that physicians had an in-built opposition to CAM, and thus he questioned their professional qualifications to judge and evaluate it. When the bio-medical professionals tried to respond to these accusations, their perception of their CAM colleagues suddenly changed. The Director General of the Ministry of Health, Professor Gabi Barabash, responded in that meeting stating: “providing alternative medicine in hospitals is not the problem, because there the physician is in charge” (Protocol no. 40 of Control Board Committee, 3/12/1996 p.21-23). Although the official standing of IMA towards CAM was altered in 1997, the anonymous writers of IMA’s second position paper were struggling to find an appropriate formulation for its position. The fol— 67 —

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lowing was one of the ambiguous results of this effort: There is no such thing as alternative medicine, only an alternative to medicine […] despite that, and in order to make this position paper clear, we will make use of the term “alternative medicine” (IMA, 1997). Despite this ambiguity, the writers were referring to physicians who also practice CAM as experts who defend public health: “we must repeatedly declare that only a physician may perform these treatments” (IMA, 1997). The writers of the second position paper sought to convey a message of partial recognition of some CAM therapies. They viewed CAM physicians as gatekeepers who are able to judge and determine which therapies are scientifically proven. Public demand and the growing professional authority of these physicians positioned them to influence IMA’s official standings over time. Dr. Shai Pintov, the founder of the first CAM clinic in Assaf Harofeh hospital, indicated that “In 2003, IMA changed its position paper; it is more tolerant towards complementary medicine [….] the official bodies are starting to collaborate” (Pintov, 2006). Indeed, the content of the third position paper in 2003 showed a significant influence of CAM physicians in advancing their agenda. It called for academic research, recognition of non MD practitioners as para-medical workers, establishment of a committee comprised of physicians to differentiate the types of CAM according to scientific criteria and incorporation of CAM courses in medical training. The establishment of the “Israel Society for Complementary Medicine” within IMA in 2002 was another indication of the growing recognition of CAM physicians (the number of members grew from 30 in 2002 to 150 in 2009) (Ben-Arie, 2009). These physicians were able to use IMA’s authority to promote their expertise and occasionally to act contrary to the IMA’s official position. For example, in 2006, the society’s leaders organized a conference in collaboration with the “Medical Herbal Society” (most of them non-physicians), while at the same time IMA’s web-site indicated specifically that herbal medicine is prohibited for non-physicians. The fourth position paper was written in 2006 by two physicians, Dr. Eran Ben-Arie and Dr. Elad Schiff, members of IMA’s “Israel Society — 68 —

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for Complementary Medicine.” This paper dealt with the need to establish open channels of communication between physicians and CAM practitioners. In March 2006, they introduced a draft of this paper, entitled “Complementary Medicine, Ethics and Law,” at a conference co-organized by physicians, practitioners and jurists. The writers sought to regularize the communication between practitioners and physicians by using conventional medical terminology. They were willing to change the content of the proposed position paper in response to comments offered by the audience during the conference. They also introduced the term “Integrative Medicine” and proposed the idea of merging bio- and non-conventional medicine. This position paper was not written anonymously; to reinforce their professional authority, Ben-Arie and Schiff unambiguously stated their affiliation as members of IMA in expressing their views. Despite this success in representing themselves within the IMA, bitter controversies arose among CAM physicians with regard to the level of training and “holism” of many of their colleagues. For example, Dr. Dani Keret, a physician and a naturopath, claimed: Among Western physicians it has become common to take a brief course, acquire a few basic principles and techniques, and begin treating patients. These physicians are essentially not holistic (Katzman, 2003). When physicians who also practice CAM began to deal with their own professional standards within IMA, they actually created a new group of “dissidents” who did not meet these standards within their ranks. Conclusion The cautious acceptance of CAM during the last decade in Israel was preceded by a long history of negotiation and struggle between CAM practitioners, physicians and the medical establishment. Until the 1980s, CAM practitioners tried different strategies and tactics to attain official recognition of their fields of practice. All of these efforts were thwarted by a powerful medical establishment represented by the Ministry of Health and the Israel Medical Association. With the expansion of consumer use of CAM during the 1980s, professional elements in the Ministry of Health attempted to prevent — 69 —

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this development by various means: conducting raids in homeopathic pharmacies, confiscating homeopathic drugs and conducting personal investigations. But the leaders of CAM practitioners groups redirected their struggle to a wider arena by linking it to issues concerning the freedom of individuals to choose their preferred form of health care and to questions focusing on the freedom of occupational choice. The media embraced these causes, giving the practitioners a platform to convey their opinions, and thus played an important role in establishing their legitimacy. As a result of these processes, CAM became a mechanism by which individuals could maximize their lifestyle preferences and quality-of-life as part of a changing cultural climate based on expanding neo-liberal principles. CAM’s expansion is also related to post-modernism, which supports a climate in which individuals seek to diffuse boundaries and enlarge their personal freedom and self-fulfillment. The economic pressure on hospitals and clinics, which grew during the 1990s, provided a welcoming arena for physicians to open CAM clinics within hospitals. These clinics constituted a model by which the private and public sectors joined forces, enabling new work-structure models (personal contracts and part-time work), while charging patients directly for service and organizing indirect payments by the sick funds and insurance companies. The small but determined group of physicians inside the IMA who established these clinics created a new interest group which challenged the modes of treatment, training and research in bio-medicine. This challenge did not seek to undermine the bio-medical model of conventional medicine; rather, it sought to expand it so as to include psychosocial and spiritual elements in conventional treatment. In effect, the CAM physicians in the IMA have CAMified the integrative process by introducing important elements of CAM—especially its psycho-social components—into conventional medicine. Physicians who practice CAM and act to further its institutionalization are increasingly accepted as spokespersons of the IMA, participating on behalf of the IMA in Ministry of Health committees, giving IMA endorsement to conferences organized along with the heads of CAM practitioners groups, and writing papers on issues of regularizing communication between physicians and CAM practitioners. At the same time, this group remains relatively small (150 members) and—despite its importance—is still marginal and far from mainstream medicine. — 70 —

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In accordance with this, it would seem that “conventional medicine” does not control “unconventional medicine” in the simple sense; rather, a small group of physicians who themselves practice CAM—and who act through the IMA—needed the support and cooperation of CAM practitioners and encouraged them to institutionalize their specialties in order to increase their own professional legitimacy in the medical community. Therefore, the legitimacy and credibility that CAM receives today developed from the establishment of a new elite consisting of practitioners and physicians practicing CAM. Although not all practitioners and physicians consented to the approach of this group, it in effect mediated between new perceptions of health and illness and traditional concepts of conventional medicine by conducting collaborative research programs, making joint appearances in conferences and building a cooperative work model in clinics. In this respect, the recent legitimation of CAM broadened the medicalization processes in Israeli society, turned CAM into a more rational and bureaucratic field, while at the same time perpetuating the on-going hegemony of bio-medicine. Primary Sources

(10/12/1958). Protocol of the Discussions Between the Ministry of Health and the Israeli Naturopaths’ Delegation. Jerusalem: Shlomit Netzach Files. (Hebrew). (7/4/1959). Protocol of Health Committee Meeting—Held on Tuesday 7.4.59 Before Noon at the Doctors House in Jerusalem. Jerusalem: Ginzach. (Hebrew). (11/1/1959). Protocol of the Health Care Subcommittee. Jerusalem: Shlomit Netzach Files. (Hebrew). (1982). Committee for Analyzing Medical Professions in Israel. Jerusalem: Ginzach. (Hebrew). (4/3/1983). The Danger to the Public Health from Harmful Lifestyle—of Knesset Member M. Ben-Porat. Jerusalem: Knesset Protocols. (Hebrew). (19/1/1984). Seminar on Organic Agriculture. Tel-Aviv: Nutrition and a Healthy Life Style Board. (Hebrew). (28/10/1985). Position Paper in the Matter of Homeopathy. Jerusalem: Ginzach. (Hebrew). (1991). Eilon Committee. Jerusalem: Ministry of Health. (Hebrew). (3/12/1996). Protocol no. 40 of the Control Committee. Jerusalem: Knesset. (Hebrew). (1997). IMA’s Position to Alternative Medicine. Michtav Lachaver 59 (11), 9-12. (Hebrew). (2006). Pintov: Complementary Medicine, Ethics and Law. Retrieved on May 6, 2010, from http://law.haifa.ac.il/events/event_sites/medlaw/ALTERNATIVE/ protocol%20communication.doc. (Hebrew). — 71 —

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Al-Or, Y.T. (9/2/1964). Hello. Letter to M. Netzach. Jerusalem: Shlomit Netzach Files. (Hebrew). Al-Or, Y.T. (1959). The Negotiations Between Health Care Authorities and the Israeli Naturopaths Association. Jerusalem: Shlomit Netzach Files. (Hebrew). Al-Or, Y.T. and Heyman, A. (6/4/1959). The Hearing of the Health Council on the License of our Vocation. Letter to the Director General of the Israeli Television. Jerusalem: Shlomit Netzach Files. (Hebrew). Arbeli-Almozlino, S. (4/8/1987). Setting up a Committee to Evaluate Natural Healing. Letter to D. Golan. Jerusalem: Ginzach. (Hebrew). Ben-Arie, E. (2009). Editorial. Integrative Medicine 1, 2. (Hebrew). Ben-Gurion, D. (20/8/1958). Diary. Tel-Aviv: Ben-Gurion Archives. (Hebrew). Ben-Porat, M. (22/11/1983). Reservations on Enhancements to the Doctors’ Ordinance (New Version) - Hatashmad - 1983. Jerusalem: Mordechai Ben Porat Archives. (Hebrew). Edelman, S. (18/12/1991). Honor Minister. Letter to E. Olmert. Jerusalem: Ginzach. (Hebrew). Gitar, S. (12/2/1980). Homeopathic Medicine Committee. Letter to B. Modan. Jerusalem: Ginzach. (Hebrew). Greenblatt, D. (1983). Chiropractic in Israel. Jerusalem: Center of Chiropractic. Menczel, E. (15/10/1985). Homeopathy. Letter to the Director General of the Television. Jerusalem: Ginzach. (Hebrew). Mizrachi, A. (2005). Personal Communication. Modan, B. (14/4/1983). Dr. Finger Homeopathic Institute. Letter to G. Egoz. Jerusalem: Ginzach. (Hebrew). Netzach, M. (1944). The Science of Natural Healing. Bulletin for Health Care and Physical, Spiritual and Mental Beauty 44. (Hebrew). Panton, Z. (7/8/1978). Unconventional Medicine. Letter to the Director General of the Ministry of Health. Jerusalem: Ginzach. (Hebrew). Panton, Z. (15/5/1980). Notes on Homeopathic Report from 12.2.1980. Letter to E. Menczel. Jerusalem: Ginzach. (Hebrew). Ravid, M. (22/8/1991). Alternative Medicine. Letter to S. Edelman. Tel Aviv: Ginzach. (Hebrew).

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CHAPTER 5

A DECADE OF CO-EXISTENCE OF CAM AND BIO-MEDICINE

Introduction This chapter presents the first of the case studies in which we address questions of the co-existence of CAM and bio-medicine in Israel (chapters 5-11). Our principal strategy is to examine work patterns, attitudes and modes of dealing with different approaches to health care among a variety of bio-medical practitioners who also use CAM in their daily clinical work, or who work regularly along with CAM practitioners. The last chapter in Part II deals with policy makers and their views on these subjects. In the present chapter, we address a number of issues: given their different views and assumptions regarding health care, how do CAM and bio-medical practitioners work together? How do CAM practitioners “fit” into the social and geographical space of clinic and hospital structures? How do organizational and cognitive boundaries relate to each other? In order to explore these questions, we examined CAM practice in a number of publicly sponsored clinics and hospitals in Israel in 20002001—at the start of the period when the present modes of co-existence were established. In 2010 we returned to the field for another brief look at the modes of co-existence in order to consider the dynamics of change during the decade. As we shall see, many of these early patterns were deeply imprinted and have persisted over time; others have developed and changed during the past ten years. In all of these settings, CAM was practiced under the formal auspices of publicly sponsored bio-medical organizations. As noted in chapter 2, 65% of CAM is practiced in Israel in these settings. Some of these CAM practitioners also work part-time in private clinics. Networks of CAM clinics are run by three of the sick funds, and one third of the public hospitals run CAM clinics for ambulatory patients in the community. A clear policy stance defining the relationship of CAM and bio-medicine was adopted by these institutions: CAM is practiced solely under bio-medical supervision. In effect, the policy defines a pro— 75 —

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cess of co-optation in which the boundary is re-contoured to include selected CAM practitioners who were previously denied admission to practice inside bio-medical institutions. This policy conforms to the Doctors’ Ordinance of 1976 by appointing a physician with CAM training to senior, supervisory posts in each of the clinics. Given this formal supervision, CAM practitioners with and without medical training can practice legally. In the absence of a licensing system, quality control of CAM is exercised by this senior physician who examines the credentials and experience of candidates for employment at the CAM clinic and selects the ones deemed qualified. By this process, he/she also determines which fields of CAM practice will be offered at the clinic. Bio-medical control is further expressed by a one-time screening process of all new patients: a bio-medical physician, whose role is that of a gate-keeper, examines the individual’s bio-medical records before admission to CAM treatment. If these are deemed insufficient, the patient may be required to undergo additional bio-medical tests before acceptance at the CAM clinic. Once these are approved, the patient is assigned to a CAM practitioner for a series of treatment sessions. The screening is geared to prevent the admission of patients for whom CAM treatment could be problematic or inappropriate from a bio-medical viewpoint. After the screening is completed, on-going encounters are scheduled for the patient with a CAM practitioner; there is no further bio-medical interference or supervision. At the end of a series of CAM treatments, the patient is re-evaluated by the bio-medical physician and the CAM practitioner to decide on the next stage of treatment. The evaluation focuses primarily on the outcome rather than on the process of treatment. The physician who performs the screening is in most cases not a specialist in the field of the patient’s health problem. The final decision is made by a bio-medical doctor—along with the considered judgment of the CAM provider. This structural arrangement creates two separate arenas of health care with minimal contact between them: a short bio-medical screening process and a much longer, on-going series of CAM treatments in which the CAM practitioner is in effect entirely in control of the process. The two arenas are dependent on each other in a structural sense, but are functionally separate. Far from integrating the two systems of health care, this structure highlights their separateness and hierarchical rela— 76 —

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tionship. The bio-medical screening carries a symbolic signal of control, but in practice is largely ritual. Once accepted into the CAM clinic system, neither the patient nor the CAM practitioners are much affected by bio-medical controls. Davies (2001) notes the symbolic legitimation of CAM by its very inclusion within the organizational boundary of bio-medicine. The high status and impressive achievements of bio-medicine impart confidence to patients who are uncertain about the acceptability of CAM. At the same time, the data to be presented will show that this inclusion does not endow the CAM practitioners with the symbolic and social status of bio-medical personnel who work in the organization. A different type of setting is seen in some hospitals where CAM practitioners provide care to hospitalized patients. There is no formal policy structuring this phenomenon. Most of it takes place on an informal basis: entry and clinical work are negotiated individually by interested CAM or bio-medical practitioners who establish ad hoc arrangements regarding their work. These will be discussed below. Data Collection As noted, most of the findings refer to an early period when CAM was first incorporated into the public system of health care. Data for this chapter were collected between 2000 and 2001 in two types of settings in which CAM is practiced under the formal auspices of publicly sponsored, bio-medical organizations in Israel: a) in ambulatory clinics run by hospitals and sick funds and b) in hospitals where hospitalized patients were offered bedside care by CAM practitioners. A second, more limited, round of data collection took place in 2010 when a further set of interviews and on-site observations were carried out. This makes it possible for us to consider changes in the patterns of co-existence of CAM and bio-medicine over a period of a decade. The two settings differ in the extent of bio-medical dominance. In the ambulatory clinics under study, only CAM is offered by a wide variety of practitioners. The bio-medical practitioners working there are also trained in and practice one of the CAM specialties. On the other hand, when working with hospitalized patients, the CAM practitioners work in a predominantly bio-medical setting where their principal collegial contacts are conventional bio-medical personnel. Of the eleven CAM ambulatory clinics run by the hospitals, two were — 77 —

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chosen: one associated with an elite university-affiliated hospital in Jerusalem and the other affiliated to a municipal-government hospital in Tel Aviv. Two additional CAM community clinics associated with the sick funds were chosen in Jerusalem. One was formally associated with one of the sick funds while the other was a private clinic which provided services at reduced prices to members of the largest of the sick funds. Seventeen practitioners were approached by telephone in the above four ambulatory clinics and 14 agreed to participate. Of the 14, 9 were physicians practicing an alternative specialty: acupuncture (5), homeopathy (3), osteopathy (1). Five were trained only in CAM: homeopathy (1), biofeedback (1), reflexology (1), Shiatsu (1), Chinese medicine (1). In addition to the four settings described above, data were collected in 4 Jerusalem hospitals in three of which alternative practitioners were found to be providing bedside care to hospitalized patients. In these hospitals, two types of practitioners were included: CAM practitioners and their principal bio-medical colleague or host (who was not trained in an alternative field). In selecting the individuals to be interviewed, we first sought out the CAM practitioners. A survey of the four hospitals showed that departments in which CAM practitioners worked included one or at most two such practitioners. Thus, it was decided to interview one CAM practitioner in each of the hospital departments in which they were found to be working. In addition, each of the CAM practitioners interviewed was asked to indicate the name and location of the principal bio-medical practitioner with whom she/he was associated in the hospital. In the hospitals, a total of 15 persons were interviewed: five non-biomedically trained CAM practitioners: 2 homeopaths, 1 reflexologist, 1 chiropractor, 1 naturopath; three bio-medical practitioners (not practicing CAM)—the head of the orthopedic department, the head of the department of psychiatry, and an oncologist; seven CAM practitioners who were also bio-medically trained—3 nurses practicing healing, 2 physician-acupuncturists, 1 physician- acupuncturist-homeopath, and 1 physician-homeopath. Informed consent was provided by all interviewees and anonymity was assured by a coding process. All interviews were carried out by a sociologist (Dr. Emma Averbuch). In all of the research settings, a set of open-ended questions provided a framework for the semi-structured interviews. These served to guide the narrative to cover the interviewee’s work experience, formal — 78 —

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and informal status in the workplace, remuneration patterns, modes of interaction with colleagues and views on the place of CAM in a biomedical setting. The interviews were recorded during the course of the encounter and additional details were filled in immediately after the meeting in order to maximize recall. The full text of all the narratives was subsequently entered in systematic computerized records. In addition to the interview protocols, characteristics of the workplace were closely observed and written material about the practice setting was collected. This information was recorded as an addendum to the interview protocols. The data provided the raw material for the substantive analysis. Intensive reading and re-reading of the narratives led to the identification of the principal themes which related to the theoretical issues under consideration. Data Analysis: The Early Period: 2000-2001 a. Changed contours of the organizational boundary The admission of CAM practitioners to practice in bio-medical organizations provides evidence for on-going changes in the contours of the organizational boundaries of these institutions which—in the past—limited their health care providers exclusively to persons with bio-medical credentials. The Doctors Ordinance (1976) makes clear the critical role of formal bio-medical licensure in legitimizing entry to practice in bio-medical institutions, but also indicates that a physician may chose whatever clinical methods she/he deems appropriate. Confidence in the physician’s choice is bolstered by her/his personal and legal responsibility in case of negligence claims. In this context, use of CAM is viewed as acceptable by the Israel Medical Association on condition that it is carried out by a licensed physician (Israel Medical Association, 1997). This condition seeks to preserve the cognitive boundaries of bio-medicine by tacitly assuming that such practitioners will be guided primarily by the bio-medical component of their professional role while acting out its CAM component in a minor mode. The interview data indicate that among bio-medical health care providers who have chosen to practice CAM in the settings under study, this does not always prove to be the case. In many cases they — 79 —

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gave priority to their CAM skills (see chapters 7, 9 and 10). However, seeking to conform to the above norm, several of the directors of the CAM clinics stated that it was a matter of policy for them to try to employ only licensed bio-medical practitioners who are also trained in a CAM field. Thus, we observed physiotherapists practicing osteopathy, a nurse practicing healing and physicians practicing acupuncture or homeopathy. But in practice this policy proved difficult to implement fully because there is a limited supply of bio-medically trained practitioners in many CAM specialties. Thus, physicians with an interest in CAM most frequently train in acupuncture or homeopathy and less frequently in other fields of CAM such as reflexology, Feldenkrais, Alexander, Paula, biofeedback, Reiki or aromatherapy. Since the underlying market orientation of the clinics motivates them to offer patients a broad spectrum of services—they have no choice but to include non-bio-medical practitioners among their CAM providers. Indeed, some of the CAM clinics included in the study even had non-physicians as directors; at the time of the study two were specialists in Chinese medicine and one a reflexologist. As a result of these constraints, only a minority of the CAM practitioners working in the clinics included in the study hold bio-medical credentials. The interviews and on-site observations showed that the outpatient clinics included a wide variety of CAM practitioners. The most frequent areas of practice included Chinese medicine of various sorts, Shiatsu, aural acupuncture, homeopathy, chiropractic, osteopathy, healing, reflexology, and herbal medicine, as well as a number of massage techniques, Reiki and several other specialties. When practicing with hospitalized patients, CAM practitioners were located in a variety of departments: orthopedics, oncology, pediatrics, internal medicine, obstetrics, neonatal intensive care, gastroenterology, neurology and pain clinics. They were not located in surgical facilities, radiology, imaging units or emergency rooms. We will see that some of these patterns have changed over the course of the decade. b. Negotiating entry—crossing the redefined organizational boundary The narratives indicate that the employment of CAM practitioners in the hospitals and the clinics is negotiated by informal rather than by formal bureaucratic processes. Personal contacts and networking appear to be the principal mechanisms and are multi-directional. A hospital physi— 80 —

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cian may feel that patients would benefit from a CAM practitioner in the department and seek one out, checking personally on candidates’ credentials and reputation. The most direct link of the hospital physician is to a CAM practitioner based in that hospital’s CAM clinic. In such cases, the hospital host depends on the ambulatory clinic for prior scrutiny of the CAM practitioner’s credentials. The reverse process was also found: CAM practitioners reported that they had taken the initiative in approaching a hospital or sick fund physician in order to persuade her/him that a useful contribution to the work of their department could be made by a CAM practitioner. In one case the organizational boundary was reported to be impermeable at the time of the study. This occurred in one of the four hospitals which had recently established an ambulatory CAM clinic on its premises, but had no CAM practitioners working with hospitalized patients. When the clinic director was interviewed, he stated that he was in the process of establishing contacts in the hospital with the intention of offering CAM services, but had met with considerable resistance on the part of the heads of hospital departments. Regarding the prospect of incorporating CAM care for hospitalized patients, one head of department was reported to use the phrase, “Over my dead body.” Nevertheless, the director of the CAM clinic at this hospital remained optimistic and continued his efforts. As noted by Gamus and Pintov (2007), a long educational process is a sine qua non for changing traditional attitudes of bio-medical physicians toward CAM. c. Boundary work—establishing legitimacy The relative newness of the changed organizational boundary contour raises the need to gain legitimacy for the presence of CAM practitioners within the structure of bio-medical organizations. The principal—most critical—reference group consists of bio-medical personnel within the organizations; consumers are an additional salient reference group. In several of the cases observed, legitimization for the presence of a CAM practitioner in a hospital department was attained by a bio-medical collaborator utilizing a labeling mechanism that lends credibility to their presence: the most frequent labels used to characterize the work of CAM practitioners was (bio-medical) “research” and “clinical experiments.” Thus, joint efforts by a physician and a CAM practitioner to improve the quality of life of patients in an oncology department were — 81 —

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referred to as clinical experiments and research that could demonstrate the efficacy of CAM treatment. In addition to conveying legitimacy in an atmosphere where evidence based medicine is normative, this labeling also makes clear the non-permanent presence of the alternative personnel who are clearly not part of the core of regular health care providers since such research projects and experiments are bounded in time and space. The re-structured boundary is also “worked” by use of a variety of forms of isomorphism utilized by the CAM practitioners (Gieryn, 1999). This is seen in their dress code, which generally resembles that of physicians or nurses. The furnishings and decor of their clinic settings are like those of their bio-medical colleagues. When there is more than one alternative practitioner working in the outpatient CAM clinic, they are likely to have regular case conferences modeled after bio-medical clinical conferences (DiMaggio and Powell, 1991; Meyer and Rowan, 1991). Another form of isomorphism is seen in the tendency of CAM practitioners working in bio-medical settings to highlight a specialization within their field rather than to emphasize their holistic orientation. In this manner, they model themselves on the dominant structure of the bio-medical role, i.e. specialization in a narrow, clearly defined area of practice. This in spite of the fact that most alternative practitioners— whatever their field—are strong advocates of a holistic approach to health care (Coulter, 2004; DiMaggio and Powell, 1991). Despite his holistic views, a chiropractor based in an orthopedic department of one of the hospitals focused his practice there only on spinal problems. At the same time, he stated that in his private practice he worked on a holistic basis on a variety of inter-related problems for every patient. And the practitioner working in a pain clinic as an auriculotherapist reported that in his private practice he treated a wide variety of health problems including allergies, asthma and other illnesses. Consumers of health care are an additional reference group which needs to be persuaded that the presence of CAM practitioners in biomedical institutions is legitimate. The initiative for this was undertaken by the bio-medical institutions in their widely-distributed information leaflets describing the alternative services. Both the hospitals and the community clinics emphasize the bio-medical supervision of CAM practitioners. For example: — 82 —

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All persons seeking care at a CAM clinic will first be examined by a physician who will determine the primary diagnosis—in order to avoid a situation in which a patient will be mis-diagnosed by a practitioner not trained in bio-medicine and will receive inappropriate treatment (Eitanim, 1995). (authors’ translation) Rather than offering evidence of the potential efficacy of CAM, such rhetoric leans on the presence of the bio-medical practitioners as gatekeepers whose knowledge-base provides legitimacy. The text conveys a message of reassurance, implying protection by the cognitive core of bio-medicine in the face of uncertainty. d. Epistemological contest? There is no evidence in our research that the organizational boundary changes described have been accompanied by overt challenges by representatives of alternative ideologies to the epistemological boundaries of the bio-medical system. As noted, isomorphic behavior by alternative practitioners tends to provide symbolic and behavioral evidence of “belonging” to the bio-medical family, thus reinforcing the image of identity and team-like association. These may be viewed as border crossings through which legitimacy is sought: there is no reason to believe that alternative ideologies have been weakened or discarded but rather that, viewing themselves as both “insiders” and “outsiders,” CAM practitioners working in bio-medical settings do not wish to endanger their status by entering into fruitless debate. Neither did we find evidence for epistemological controversy initiated by bio-medical practitioners. In the context of everyday practice, the latter are able to ignore the objections voiced by the Israel Medical Association with regard to the dangers of CAM to the welfare of patients (Israel Medical Association, 1997). Turning to the real world of medical practice, such physicians draw legitimation from the pragmatic fact that CAM practices often work. There appears to be an unverbalized contract sanctioning silence and an avoidance of substantive confrontation. In this manner, the boundary of the epistemological core of bio-medicine remains intact while the organizational boundary is redefined.

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e. Simultaneous inclusion and marginalization The findings show that changing the contour of the organizational boundaries of bio-medical health care institutions to include CAM practitioners does not endow them with the benefits and status enjoyed by bio-medical health care providers in the system. CAM practitioners working with hospitalized patients are in some cases categorized by the bio-medical staff as a form of para-medical worker. Virtually all of the CAM practitioners are employed on a parttime basis—most often two or three days a week; many maintain their own privately-based clinics elsewhere. None have regular tenured appointments to the clinic staff—as do the majority of the bio-medical practitioners; they have individual contracts with the employer or serve as volunteers. By way of contrast to most medical care in Israel, a major portion of which is covered by the National Health Law of 1995, patients in the community clinics pay for CAM on a fee-for-service basis. Although 74% of the population carries supplementary insurance which entitles them to reduced fees, the cost is not negligible (Kaidar and Horev, 2010). Thus, as noted in chapter 2, the higher socio-economic segments of the population are more frequent utilizers of CAM. CAM practitioners who also possess bio-medical credentials enjoy a higher status. But there is evidence in the narratives that their CAM identity may act to diminish their status in the eyes of some bio-medical colleagues who look askance at their presence in hospitals. Such skepticism is expressed less frequently in the outpatient clinics than inside the hospitals. In the former settings the professional environment is relatively homogeneous since the entire clinic is devoted to CAM. Working with hospitalized patients, CAM practitioners come in more direct and frequent contact with a predominantly bio-medical environment and its qualified practitioners, most of whom have little knowledge of CAM. For those CAM practitioners working with hospitalized patients, a forceful symbolic gesture attesting to their marginalization is their exclusion from one of the critical rituals of medical practice: hospital rounds. In situ observations show that they do not routinely take part in this all-important daily event and, if they are included, they are located at the tail end of the hierarchical procession which follows the head of the department from bed to bed (Mizrachi, et al. 2005).

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f. Boundaries within boundaries Although CAM practitioners in hospitals have crossed the broad organizational boundary marking the territorial domain of these bio-medical institutions, the narratives show evidence of internal boundaries marking off territories inside the institutions to which admission of CAM practitioners remains taboo. CAM practitioners working with hospitalized patients were not found to be practicing in surgery departments, intensive care units, emergency clinics, nuclear medicine or imaging units —namely in settings involving trauma or life-saving procedures. While numerous medical departments in hospitals include some CAM practitioners, those departments dealing with the “hard core” of bio-medical practice do not admit them. In this manner, the cognitive “heart” of bio-medicine remains untouched even though the external organizational boundaries have been re-contoured. Interviewees working with hospitalized patients pointed to an additional internal boundary line: they noted that the work of the CAM practitioners focused primarily on patients’ pain, suffering and quality of life. There is no CAM practitioner engaged in diagnosis, cure and life saving procedures. Thus, it may be said that the focus of CAM practitioners working with hospitalized patients is on illness rather than on disease (Kleinman, 1995). This is seen in the fact that CAM is used in settings specializing in palliative care (Lewis, et al. 2003). Thus, we see that there are meaningful boundaries within boundaries and the latter are associated with the content of work undertaken within the broader organizational boundary. The above patterns highlight the nature of the dual negotiative process adopted by the bio-medical establishment: opening the organizational boundaries to CAM workers by allowing them to perform some of the significant tasks needed in health care, while at the same time stringently maintaining certain of the internal boundaries defining the cognitive core of the profession’s work. Change and Stability over a Decade Returning after a decade to re-examine the patterns seen in 2000-2001, we found considerable stability and some important changes. The greatest stability was found in the structure and practice patterns seen in the community CAM clinics run under the auspices of the — 85 —

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sick funds and the hospitals. The initial pattern established at Assaf Harofe Hospital in 1991 provided an imprinting effect that was reproduced in all the CAM-dedicated community clinics of the sick funds and in the outpatient clinics run by the hospitals. These have persisted in their original structural form for a full decade and show little evidence of change. An important innovation was spearheaded by the Clalit sick fund, which established two unique, integrated community clinics in Haifa specializing in oncology. These provide ambulatory care for cancer patients under the auspices of integrated bio-medical and CAM practitioners. Over the period of a decade, the hospitals—long an impermeable fortress of bio-medicine—have become somewhat more accessible to CAM practitioners. Our early research in 2000 found CAM practitioners to be thinly spread in numerous hospital departments: orthopedics, oncology, pediatrics, internal medicine, obstetrics, premature infants, pediatrics, gastroenterology, neurology, and pain clinics. At that time, no one department contained a critical mass of CAM practitioners such as to be visible to the public or the staff. CAM practitioners working inside hospitals encountered numerous barriers which made clear that their presence was met with considerable reservation. At that time, there was little contact between hospital-based outpatient CAM clinics and in-patient care. By the end of the decade, we found that the CAM presence inside Israeli hospitals had increased and become more visible. For the most part, the changes were spearheaded by individual initiatives undertaken by energetic and determined physicians who were imbued with a keen desire to establish integrative medical care. Many are inspired by examples from the U.S., on which they seek to model their services, especially in the field of oncology (Sloan Kettering, Dana Farber, Anderson). The changes were brought about by individuals rather than by formal policy decisions of hospitals or of the Ministry of Health. For this reason, these changes are not uniform or systematic, but differ from hospital to hospital and depend to a large extent on the interests or specialization of the local bio-medical initiator. The most developed CAM programs in the hospitals at the end of the decade are geared to accompany conventional oncological treatment. Such programs have been established inside several hospital departments or near them. They offer patients a wide variety of thera— 86 —

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pies to assist in alleviating the side effects of radiological treatments and chemotherapy, reduce tension, lessen pain and strengthen coping strategies. The CAM techniques utilized include acupuncture, herbal remedies, naturotherapy, shiatsu, reflexology, touch therapies, hypnosis, bio-feedback, meditation, yoga, tai-chi, chi kong and others. Some programs offer workshops in yoga, tai chi, as well as psychological support services to patients and to their families. Information and guidance are provided on nutritive supplements and herbal products. Within this context, bio-medical modes prevail. Patients are assured of bio-medical supervision and consultation services in the CAM setting as well as coordination with their primary bio-medical oncological therapist in the hospital. Informed consent is a pre-condition for treatment by CAM. Specialization is seen in the fact that some hospitals treat only adults while children are treated in a setting which specializes in pediatric oncology (http://www.rmc.org.il). These services require payment of a fee with reduced charges offered to members of specific sick funds which have contracted with the CAM clinic. Members of other sick funds pay a full fee. As noted, in all cases the financial outlay for a series of treatments is far from negligible. There is some increase inside hospitals in activities supported by grants for research which seeks to provide systematic evidence for the effectiveness of CAM treatment. Hospitalized patients are not charged for these services. All of the CAM activities—which are directed by integrative physicians—make a point of highlighting their affiliation with clinical research and teaching programs which provide legitimation for their presence in a bio-medical setting. This strategy has been used in expanding CAM into the hospital system. Careful documentation of procedures and recording of patients’ reactions to various CAM modalities accompany the treatment processes. In a few hospitals, the research procedure legitimates entering the data into the patient’s medical record—an innovative process that has long been advocated by integrative physicians. Such records have a long-range impact in imparting legitimacy to CAM procedures. Like in other countries, the establishment of CAM services inside hospitals is sometimes dependent on a “motivated champion”—an individual or family who take the initiative to recruit support and funding for CAM services. Such champions are generally persons who have themselves benefited directly or through family members from CAM — 87 —

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treatment. In some cases, they mobilize support for CAM at a variety of levels in the bio-medical institutions. The initial arrangements for organizing these services are informal, and based on particularistic relations with bio-medical figures who are unable—or unwilling—to seek support for CAM inside the official administrative structure of the hospitals (Boon and Kachan, 2008). In recent years, the rhetoric used in labeling CAM in the hospitals has begun to change. In the past, physicians were careful to refer to CAM as “complementary” and this term was widely used in referring to the CAM clinics in the hospitals and sick fund clinics. Recently, some of the hospitals have expanded their formal titles to include the term “integrative.” This rhetorical change carries important symbolic implications. Rather than viewing CAM as a secondary complement to bio-medicine, the term “integrative” highlights the egalitarian quality of the partnership of bio and alternative medicine. While oncology is the most evident area into which CAM has expanded, it has been developed in other hospital departments as well. Among these are neurology, pain clinics, dermatology, gastroenterology, and orthopedics. In addition, a gynecology department offers CAM treatment to menopausal women. A pediatric CAM clinic at one of the hospitals offers care for sleep disturbances, digestive problems, respiratory difficulties, headaches, anxiety, depression and behavior problems. Pregnant women are offered CAM assistance by midwives before and during birth at a number of hospitals (see chapter 9). A preventive program in a cardiology department offers CAM treatment in addition to its conventional program, which calls for reducing high blood pressure, controlling unstabilized diabetes, preventing obesity and quitting smoking. In past years, departments of surgery, and especially operating rooms, have been strictly off-bounds to CAM in all Israeli hospitals. In 2010 an experimental program was activated in at least one hospital utilizing CAM in pre- and post- surgical settings. Techniques such as hypnosis, reflexology, acupuncture, bio-feedback, guided imagery and touch techniques have been used to control anxiety and tension, ease pain, reduce nausea, control post-operative complications and speed recovery. The experiment is defined as a research project: all of the CAM procedures are meticulously monitored including patients’ response to treatments. These are recorded in the patient’s bio-medical clinical — 88 —

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record. While the operating theatre itself remains closed to CAM, the boundaries of its surrounding, supportive territory in which critical pre- and post- surgical procedures occur, have been re-contoured to admit CAM practitioners, thus augmenting the territory in which CAM is viewed as legitimate. We may conclude that the presence and activity of CAM in Israeli hospitals has increased during the past decade—principally as a result of energetic efforts by individual directors of outpatient CAM clinics who embraced the mission of promoting integrative medicine in the hospitals. The introduction of palliative and rehabilitative care of cancer patients served as an effective spring board for the introduction of CAM into the heart of hospital practice because of its primary focus on care rather than cure. Creative use of evidence based research regarding CAM has promoted the respectability and acceptability of CAM in settings where it was previously rejected. It has also induced important changes in the protocol of hospital care, e.g. the inclusion of the record of CAM treatment in the patient’s file. In this sphere, as in others, isomorphism plays a role: the more CAM looks like and feels like bio-medicine, the greater its acceptability in the hospital system. The promoters of integrative medicine are essentially medicalizers of CAM—but at the same time CAMifiers of bio-medicine. The former is for the moment the more powerful force—but the latter is far from negligible and is likely to increase in future years. Discussion The early findings of this chapter show the patterns of co-existence of CAM and bio-medicine at the start of the year 2000 shortly after CAM was co-opted into the public bio-medical health care system in Israel. A second round of observations and interviews in 2010 made it possible to observe changes over the decade. On the organizational level, the data show entry by CAM practitioners into territories which have been viewed in the past as the exclusive domain of bio-medicine. Leading, publicly supported medical institutions in Israel have established ambulatory clinics for CAM and—on a lesser scale but carrying a forceful symbolic meaning—have allowed selected CAM practitioners to treat hospitalized patients in a variety of clinical departments inside a number of prominent, university affiliated hospitals. — 89 —

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In effect, the organizational boundaries of these bio-medical institutions have been expanded by co-opting CAM practitioners in a process which manages at the same time to retain the cognitive boundaries of the medical profession. This has been accomplished by providing CAM with the legitimacy of formal association with recognized bio-medical institutions and labeling their approach and techniques of healing as “complementary” to the dominant bio-medical procedures. Rhetorically, this term negates the notion of an “alternative” to bio-medicine; CAM practitioners “complement” bio-medical modes, but do not replace them. The bio-medical hosts prefer to employ CAM practitioners who are also trained in bio-medicine. However, the effort to recruit credentialed bio-medical CAM practitioners is not always successful. Thus, it was found that directors of CAM clinics yield to the constraints of market pressures and consumer demand—by employing a wide variety of nonbio-medically trained CAM practitioners in the CAM clinics. Admission to practice within the organizational boundaries is not accompanied by equal status. Evidence of the marginalization of CAM practitioners working within the boundaries of bio-medical organizations is seen in the informal modes of their recruitment, their remuneration patterns, their lack of official, permanent status in the employment structure and the part-time nature of their work. These processes were found both in the out-patient clinics and in the case of CAM practitioners working with hospitalized patients. This pattern fits Abbott’s proposal that the settlement of jurisdictional disputes can be negotiated by the dominant profession subordinating the contenders or by a division of labor among them (Abbott, 1988). A comparative look at the two types of settings—community clinics and hospital departments—showed an important difference reflecting additional status differentials between bio-medical personnel and CAM practitioners. In the case of hospitalized patients, internal boundary lines were drawn within the broad organizational territory. These were expressed in the type of medical work performed and in the demarcation of off-bounds areas. From a bio-medical point of view, the focus on “care” rather than on “cure” provides evidence of lesser status, as does the closure of the boundaries of selected core bio-medical territories within the larger organizational context. These two processes are evident when CAM practitioners work directly with hospitalized patients; their presence inside the strong-hold of bio-medicine is viewed by bio— 90 —

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medical practitioners as more threatening to the cognitive core of medicine. One mode of handling this threat is the tendency of bio-medical personnel to categorize CAM practitioners as para-medicals. In ambulatory clinics, where CAM practitioners set the tone, the formal supervisory role of bio-medicine over CAM is expressed principally at the time of the patient’s first encounter with the institution. The initial bio-medical screening of new patients is undertaken by a senior physician (“rofe me’mayen”) who then directs each patient to an appropriate CAM practitioner. This ritual screening expresses the supervisory role of bio-medicine required by law (Doctors’ Ordinance, 1976; Appendix B). What is striking, however, is that after the first visit, patients find themselves in a fully CAM-based environment with little if any direct bio-medical scrutiny. By way of contrast to the hospital environment, the CAM practitioners in ambulatory clinics are free to establish their own rules once they are admitted within the organizational boundary. All of the territory inside the organizational boundary of the clinic is open and accessible for both care and cure. Once the patient has been screened by the senior physician, the entire treatment process is controlled by the CAM practitioner and the clinical encounter takes place between him/her and the patient in the privacy of the treatment facility. In effect, bio-medicine and CAM operate side by side—in tandem—with little clinical interaction between them. In sum, the findings indicate that the boundaries of the cognitive core of bio-medicine are not necessarily congruent with the organizational lines of demarcation. The former is viewed by the bio-medical establishment as non-negotiable, while organizational boundaries are flexible and have been expanded to include CAM practitioners in many areas.

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Chapter 6

“WE OWN THE TRUTH”: BOUNDARY MAKING DURING BIO-MEDICAL AND ALTERNATIVE ENCOUNTERS Nissim Mizrachi

Introduction In this chapter, I examine the range of cultural repertoires applied by CAM and bio-medical practitioners during mutual encounters in medical settings. Recent developments in the sociology of culture (Mizrachi, Drori and Anspach, 2007; Mizrachi and Shuval, 2004; Mizrachi, Shuval and Gross, 2005; Swidler, 2003) provide us with the tools to explore how boundaries are negotiated when two therapeutic systems, one dominant (traditional bio-medicine) and the other popular yet still lacking institutional legitimation (CAM), meet. I will examine boundary work by looking at real people and their actions as the engines propelling events (Swidler, 1986). By doing so, I do not lose sight of the structural and discursive conditions within which people pursue their goals and interests (Mizrachi, et al. 2007). These two groups of medical practitioners are attempting to negotiate the deep institutional, legal and epistemological divides that separate one from the other. From our perspective, this process takes shape in daily conduct as well as during the formal determination of their professional jurisdictions (Abbott, 1988). In focusing on the informal in addition to the formal dimensions, we portray a complex, dynamic system of boundary definition at work (Mizrachi, Shuval and Gross, 2005). The bottom-up approach contributes to the analysis by helping us identify where these boundaries are permeable, where they are not, and just how scientific professional jurisdictions are placed in late modernity. This chapter therefore examines the nature of formal and informal jurisdictional claims in Israeli medicine. Jurisdictional claims embody a sizeable repertoire of formal and informal procedures used to delineate the boundaries of professional practice and knowledge. Gieryn’s (1999) notion of boundary work is particularly useful here. Boundary work, — 92 —

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according to Gieryn, is “the discursive attribution of selected qualities to scientists, scientific methods, and scientific claims for the purpose of drawing a rhetorical boundary between science and some less authoritative residual non-science” (Gieryn, 1999, p. 4–5). To identify the typical strategies of jurisdictional boundary work in informal arenas, we turned to ambulatory clinics where alternative care is regularly practiced and hospitals where alternative care is provided for some hospitalized patients. Ambulatory clinics specializing in alternative care have been established in one-third of the public hospitals and by three of the sick funds operating in Israel. Of the 11 alternative ambulatory clinics run by hospitals, 2 were chosen; among the community-based clinics associated with the sick funds, another 2 were also chosen. The research was conducted during the period 1999–2001. Seventeen practitioners were approached by telephone in the above 4 ambulatory clinics; 14 agreed to participate. Of the 14, 9 were licensed physicians also practicing CAM, and 5 were trained only in CAM. Twelve other practitioners treating hospitalized patients were interviewed, seven of whom were bio-medically trained CAM practitioners and five of whom were bio-medical hospital physicians practicing bio-medicine exclusively. In addition, data were obtained during 7 months of participant observation conducted in a university-affiliated government hospital in Tel Aviv where CAM practitioners worked with hospitalized patients. Observations were supplemented by informal interviews with bio-medical and CAM practitioners working together in the same hospital. All 12 practitioners practiced acupuncture, one of the few CAM specialties awarded legitimacy, albeit limited, by bio-medicine. Four alternative practitioners were also MDs. A set of open-ended questions provided a basic framework for the semi-structured interviews conducted. The first set of formal data was based on the report of the public committee appointed in 1988 by Israel’s Minister of Health to examine all aspects of “natural medicine,” including “homeopathy, acupuncture, reflexology, chiropractics, etc.” (Israel Ministry of Health, 1991, p. 1). The committee, composed of 9 physicians and 3 legal professionals, was chaired by Prof. M. Eilon, former Deputy President of Israel’s Supreme Court, hence its unofficial title, the Eilon Committee. Nineteen witnesses appeared in the course of 22 sessions. Almost all the witnesses were practitioners or specialists in one of the CAM fields. — 93 —

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The committee submitted its report in 1991, but few of its recommendations have been implemented to date (see also chapter 4). Despite the report’s lack of formal acceptance by any legislative or ministerial body, for the purposes of this study I view it as a policy proposal formulated by an officially appointed, highly qualified, respected and authoritative group. Another source of data belonging to the formal arena is a statement regarding alternative medicine, published by the Israeli Medical Association (IMA) in one of its widely circulated bulletins: Michtav LaChaver (literally, “Letter to Members”, 1997), six years after the Eilon Committee report. An additional statement appeared on the IMA Internet site in 2003. The more-detailed 1997 document provided the basis for the research even though some modifications were introduced in 2003. Two major characteristics or jurisdictional claims of the professional discourse were found to be particularly germane to the present analysis: (1) Procedures of exclusion, primarily by posing formal interdictions and by drawing a particular distinction between true and false knowledge, and (2) Procedures ensuring that “the control of knowledge always ultimately depends on controlling the subjects who know” (Larson, 1990, p. 32). In other words, the maintaining of jurisdictional claims in a professional field involves controlling knowledge by means of monitoring, regulating, differentiating and restricting those actors who carry different forms of knowledge. Reduction, Ranking and Framing 1. The Formal Arena One of the first decisions made by the Eilon Committee (Ministry of Health, 1991) concerned the clarification of its mandate and the simultaneous drawing of an unambiguous boundary between the bio-medical and the CAM professions. A simple rhetorical device was used to do so. Rather than using the ambiguous term “natural medicine,” applied when naming the Eilon committee and specifying its mandate, the committee decided to adopt the term “complementary medicine” because “the term ‘alternative medicine’ is misleading”; “complementary medicine” was thought to be more appropriate because it does not presume to be an alternative to conventional medicine, only its supplement (p. 4). Consistent with the Eilon Committee’s approach, all the host organizations adopted the term “complementary” (refu’a mashlima in Hebrew) when — 94 —

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referring to their work and naming their clinics. The Israel Medical Association (IMA) (1997) recognized the heterogeneous array of occupations included under the rubric of what is commonly called alternative, rather than complementary, medicine, and drew a distinction among three types of alternative medical practice: 1. Practices acknowledged “to provide some small benefit”: acupuncture, chiropractic, podiatry, meditation, etc. These forms of treatment should be practiced under the supervision of an MD. Practitioners should also undergo some formal training (p. 9). 2. Practices that bio-medicine does not fully accept as effective but which are acknowledged as a possible mode of care: homeopathy and herbal medicine. These forms should be practiced exclusively by an MD “according to his [sic] professional judgment” (p. 9). 3. Practices completely and unambiguously rejected by conventional medicine. Their practitioners are viewed as charlatans who encourage “idol worship.” The example cited for this type is the “use of manual transmission of electric currents.” Every deceptive form of medical practice should be forbidden (p. 9). The three-fold typology is distinguished by the extent to which CAM is recognized as effective by the bio-medical system. No clear statement of how effectiveness is determined appears in the document; presumably, “evidence-based” research is the principal criterion. The bio-medical system seems to relax its boundaries and tolerate CAM practices as long as the latter’s effectiveness can be articulated in bio-medical terms, its training can be controlled and its practice can be supervised by authorized bio-medical agents. CAM is therefore considered legitimate as long as it can be framed within the bio-medical discourse. 2. The Informal Arena We found the three-tiered typology suggested by the IMA to be loosely related to the ways in which CAM was practiced in bio-medical settings and perceived by bio-medical authorities. Bio-medical practitioners working in CAM clinics knew very little about the professional background, credentials and specializations of the CAM practitioners. In hospital settings, even bio-medical practitioners who clearly favored collaborative work between the two systems displayed minimal, if any, knowledge about CAM training. When asked to name the criteria for selecting the “right” CAM specialization, one key informant, Prof. K, — 95 —

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answered, “I simply accepted what Dr. M (a physician practicing acupuncture) had to offer.” In the field, alternative specializations appeared to have gained legitimacy according to the extent to which their logic of practice resembled that of bio-medicine or was reducible to bio-medical logic and epistemology. Dr. M explained the dominance of acupuncture among the CAM fields practiced in the hospital accordingly: “acupuncture is known to be effective and therefore it has become dominant.” In similar fashion, parallels between the practice of bio-medicine and of chiropractic medicine contributed to her approval: “he [the chiropractor] uses lab tests and X-rays. Only he is not allowed to prescribe medication.” Prof. F, head of a surgery unit in a prestigious Jerusalem hospital, explained his own collaboration with a chiropractor: With a chiropractor I have a common language. I understand what he is doing and how he is doing it. With reflexologists, for instance, I do not. I do not send them patients because I haven’t found a common denominator with them. I believe in what I see. The services offered at the out-patient CAM clinics located on hospital grounds were established in response to public demand rather than policy decisions made by bio-medical authorities. They included practitioners in a variety of fields: acupuncture, shiatsu, homeopathy, chiropractic, reflexology, the Feldenkrais and Alexander exercise regimes, naturotherapy, herbal medicine, biofeedback, aromatherapy, alternative nutrition and others. The appearance of these clinics indicated that the IMA’s suggested typology did not have a clear and direct effect on patterns of recruitment, positioning, remuneration, or practice. In the field, an alternative specialization’s recognition was acquired through collaboration. However, bio-medical practitioners continued to reduce CAM to a subordinate paramedical occupation, as expressed by Prof. F’s statement, “Chiropractics can help patients in pain. It includes physiotherapy. A chiropractor is like a physiotherapist teaching the patient different exercises.” — 96 —

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In the bio-medical field, reduction continued to be the only way for CAM to gain some recognition and legitimacy. Epistemological Gatekeeping and Boundary Work 1. The Formal Arena “Is it a science?” (Foucault, 1986, p. 85) is the pivotal question rationalizing the bio-medical discourse and permitting the subordination of alternative practices. Using the authority of science to differentiate conventional from CAM is most pronounced at the formal level of jurisdictional claims. As the IMA dramatically stated in 1997: “there is only one form of medicine that deals with care of human beings and only physicians are permitted to practice it.” The jurisdictional claims of scientific medicine, as declared in official documents, are based on the following criteria (Israel Ministry of Health, 1991, p. 10): 1. Scientific data based on laboratory experiments exploring the structure and functioning of the human body. 2. Observations made to determine causal relations between diagnosis and therapy. The data are obtained by reports of single or multicase studies, case control studies, cohort studies, and prospective experiments based on randomized experimental and control groups. 3. Continuous research based on the awareness of the possibility of error, expressed in on-going efforts at objective examination of treatment methods and openness to the possibility of change. In the same document (Ministry of Health, 1991, p. 11), alternative medicine is characterized as rooted in: 1. Anecdotal evidence of ancient vintage (in the case of Chinese medicine) or of recent times (reflexology). 2. Theories based on anecdotal evidence that have been transformed into ideological axioms (as in the case of homeopathy). 3. Evidence taken from single anecdotal cases or at most a series of cases. The scientific, or evidence-based, foundations of CAM are thus represented as poor or non-existent, unequal to the accepted standards of Western science and conventional medicine. This explains the rejection of the validity of the divergent training undergone by CAM practitioners, which is viewed as alien to the scientific principles of causal rela— 97 —

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tionships, predictive power and skepticism (see Merton, 1973). 2. The Informal Arena By “epistemological gatekeeping” we refer to the use of axioms differentiating “true” from “false” knowledge, in this case rooted in evidencebased science, bio-medicine’s ultimate epistemic authority. Gatekeeping is implemented on two levels, the formal level, where written statements, laws and regulations provide conceptual references for boundary work, and the informal level, where people, functioning as gatekeepers, transform the formal into informal-level behavior. In the hospital, the bio-medical field is behaviorally demarcated by the gatekeepers who introduced CAM into bio-medical settings while simultaneously restricting its jurisdiction within that same setting. Among the respondents, two key actors were identified. The first, Dr. M (a male MD trained in CAM), was head of the hospital’s outpatient CAM clinic; the second, Prof. K (a female MD), was head of the hosting internal medicine department. Dr. M offered his unit’s services to different hospital departments. As a medical doctor trained in CAM, he was able to translate CAM’s terminology into the bio-medical lexicon as well as anticipate professional tensions at the interstices between the two systems. His credentials facilitated his functioning as a negotiator (a traditional gatekeeping position) with bio-medical authorities, a role that allowed him to set the conditions under which collaboration took shape, and boundaries were set. Dr. M demarcated those boundaries by applying the disease-illness dichotomy: Complementary medicine1 can be helpful in cases of pain in general and in post-operative pain in particular, in cases of depression, rheumatism, chronic illness and breathing difficulties. You cannot introduce complementary medicine into other fields such as intensive care units, to name one. Hence, to Dr. M, the practice of CAM was to be restricted to patients’ experience of illness or to their functioning during illness; it was denied 1  The unit’s formal definition as “complementary” can be regarded as an overt institutional expression of alternative medicine’s inferior epistemological status. — 98 —

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entry into the realm of disease, which belonged to a higher epistemic level. This differentiation was based on the fundamental hierarchical division between body (disease) and mind (illness) that operates as an organizing principle for evaluating medical knowledge and securing biomedical supremacy. To Dr. M, any integration between the two systems depended on CAM’s ability to meet the criteria of science: research using incontrovertible scientific methods. The body’s epistemic superiority provided the source of the clinical gaze (Foucault, 1994) and the scientific foundations of evidence-based medicine. Hence, the translation of alternative knowledge into bio-medical terminology appeared to him as the only possible avenue capable of bridging the two. He explained the dominance of acupuncture among alternative specializations practiced at the hospital in the same vein: Acupuncture… (like bio-medicine), has a clear physiology, diagnosis, pathology and treatment. Physicians can grasp this kind of logic. It speaks to them. It is much harder for them to accept homeopathy, for example. It was therefore far from accidental that Dr. M referred to acupuncture, the most mainstream of alternative specialties (Grandinetti, 2000). Because acupuncture is the field of CAM most closely resembling the bio-medical evidence-based epistemology, the IMA (1997) and physicians in the field were able to express cautious approval regarding its entry into the hospital. Similarities in knowledge and practice thus facilitate the entry of some of the forms of CAM into the sphere of conventional medicine. Another route is that of treating illness, a relatively neglected realm in bio-medicine. However, its entry into the treatment of illness, even during the more open, informal encounters between the two realms, again requires gatekeepers, operating as mediators. Such a function was fulfilled by Prof. K. As a department head known for her open-minded approach to CAM, Prof. K was another of the hospital’s internal mediators, positioned between CAM and bio-medical practitioners: Intelligent people [bio-medical practitioners-NM] talk about complementary medicine as if it were the en— 99 —

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emy, a big threat, as if something is taken from them […] Conservative medicine [bio-medicine] is incapable of answering a lot of questions. It [bio-medicine] can sometimes do harm rather than help the patient. Complementary1 medicine can help patients. Prof. K later pointed to another important incentive for the current collaboration: We are understaffed, and complementary practitioners can dedicate more time to patients. A good word from a practitioner can make the patient feel better. They can spend time with the patients, time that we don’t have. Yet, despite its practical benefits in the treatment of illness, she continued to justify her cautious approach by demanding that research be conducted to validate CAM’s claims. Evidence 1. The Formal Arena In its report, the Eilon Committee (1992) formally recognized patient demands and expressed awareness of the higher levels of patient satisfaction with alternative medical care when compared with bio-medical cures. It stated that patient approval of CAM stemmed from the emotional support and personal attention offered to patients, as well as the lack of invasive procedures. The focus of bio-medicine on the diagnosis and treatment of “disease,” which often requires invasive methods, could therefore be considered one of the visible boundaries separating the two systems. In face of the conflict between market demand, based on consumer satisfaction, and the practice of bio-medicine, the Ministry of Health (1991) launched a discreditation campaign directed at consumers of alternative medicine: The people who choose alternative medicine are distressed and often have special emotional needs. These are patients with chronic or terminal diseases who have not found any remedy in medicine (IMA, p. 11). — 100 —

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Such discreditation can be viewed as another manifestation of the subordinate position that the patients’ experience occupies in the biomedical differentiation between disease/cure and illness/care. Put differently, CAM’s jurisdictional claims, as defined by bio-medicine, are based on inferior and subsidiary needs, those made by people who “are distressed and often have special emotional needs” or who, as in chronically ill patients, “have not found any remedy in medicine.” The cited instances represent areas where bio-medical practitioners expressed considerable “resistance to the affirmation of the patient’s experience of illness” (Kleinman, 1995, p. 1). Such statements, when issued by formal authorities, represented institutional negation and denigration (Anyinam, 1990; Dacher, 1995b; Launso, 1989; Radley, 1994; Turner, 1996). All bio-medical practitioners in the field2 perceived science as the ultimate reference point for medical truth. As Gieryn (1999) notes, “So secure is the epistemic authority of science these days that even those who would dispute another’s scientific understanding of nature must ordinarily rely on science to muster a persuasive challenge” (p. 3). The notion of “evidence,” restricted to the realm of visible and biological signs that can be explored by laboratory and experimental science (Kleinman, 1995), has thus provided the organizing principle behind the boundary work done when differentiating legitimate from non-legitimate medical care. Yet, in the contemporary hospital setting, physicians must reconcile the formal demands of their profession with the demands presented by their patients, whose needs are not determined by adherence to scientific principles. Research by a hematologist in the same hospital has shown that a considerable percentage of patients demanded alternative treatment. 2. The Informal Arena In both the hospital and the clinic, physicians are required to respond to 2 

“All biomedical practitioners in the field” refers to our interviewees and observed actors only. — 101 —

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patient needs, irrespective of formal injunctions against one or another source of treatment. Official negation contributes little to the alleviation of distress. Hence, hospital physicians such as Prof. K have emphasized the role of CAM practitioners in successfully alleviating patients’ pain: They can spend time with the patients, time that we don’t have. Complementary practitioners are successful in alleviating pain. Complementary medicine can help patients, although the way in which it works is unknown to me. The ability to treat illness rather than disease was therefore used to revise the hospital’s epistemic map and locate the epistemic spaces where alternative practitioners were denied entry: emergency rooms, operating rooms, radiology and imaging units, to name but a few. The first site, the emergency room, represents the heart of medical diagnosis; the second is related to invasive procedures; the third to visible images of disease. Interestingly, all actors in the field (physicians, alternative practitioners, and patients alike) appeared to read these epistemic maps in a similar manner, leaving no room for negotiation. And so, observance of the care/cure boundary was religiously adhered to in the hospital space. In practice, however, institutional and epistemic boundaries were more loosely observed, although the marginal position of CAM practitioners remained intact. Consistent with their position and together with structural, social and symbolic boundaries (Lamont and Molnar, 2002), unambiguous markers pointed to the unequal status of the two forms of practice. Alternative practitioners were topographically marginalized: none of the clinics providing alternative care were located in the physical center of the hospital facility. This was accepted with surprising compliance by alternative practitioners such as Dr. T, who says, “When I first came, I heard doctors saying, among other things, ‘He is taking up space,’ ... I don’t want to become a threat of any sort.” The spacelessness of alternative practitioners manifested itself throughout the facility, including the place where their instruments were stored. The tools of CAM, unlike the icons of conventional medical practice, were kept apart, separated from other bio-medical devices in the hospital. That is, there was no formal provision made for the proper — 102 —

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storage of devices used by CAM practitioners; instead, they were placed in non-clinical, administrative spaces. This physical and spatial removal reinforced the symbolic inferiority faced by CAM inside as well as outside the hospital. Marginalization of CAM practitioners within the hospital could also be observed at the level of social encounters, daily rituals, and professional interactions. When these practitioners joined case presentation sessions, the division between the two groups of practitioners emerged most clearly. These routine rituals, like many others, were conducted by physicians exclusively, who made the diagnoses and only then would patients be occasionally referred to CAM practitioners. Controlling and Monitoring Social Agents A professional discourse is considered to be hegemonic if it controls the procedures by which social agents are selected and monitored in the field. These procedures transform the professional discourse into a mechanism of social control by which lines are drawn between “in” and “out,” between “legitimate” and “illegitimate” professional agents. The social boundaries positioned are then considered to be “objectified forms of social differences manifested in unequal access to and unequal distribution of resources (material and nonmaterial) and social opportunities” (Lamont and Molnar, 2002, p. 168). Exclusion of CAM practitioners from remuneration, recruitment and accreditation enables the bio-medical discourse to refrain from positioning CAM knowledge and practice within the professional field of the hospital. While other paramedical professionals such as nurses, technicians, physiotherapists and others might differ in the nature of their practice, the length of their training, the degree of abstract knowledge and the level of academic education required (Abbott 1988), they are all inherently related to the scientific bio-medical system of knowledge. In one form or other, they all provide support services to physicians. The exclusion of CAM practitioners from the formal institutional structure of accreditation and site of practice enables biomedical authorities to control and monitor, often in bureaucratic guise, CAM practitioners’ access to the knowledge that plays a role in determining social status in addition to market value (Derber, Schwartz and Magrass, 1990).

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Epistemological and Moral Boundaries 1. The Formal Arena A clear epistemological hierarchy of social agents emerged from our interviews. Physicians (MDs), heirs to the epistemological supremacy of science and carriers of bio-medical knowledge, have access to medicine’s truth-value; they thus have the authority to set the standards for medical truth. CAM practitioners are, ipso facto, either incompetents or charlatans. The third set of participants in this system, the patients, are portrayed from a paternalistic stance as potential victims, unable to judge treatment options accurately and independently, and thus requiring protection. Patients’ experiences of illness and treatment are downgraded to an inferior epistemological rank, their satisfaction with medical treatment divorced from its professional worth. Growing patient demand for CAM is consequently viewed as mere fashion, determined by socio-economic forces. Because patients, as consumers, can rarely cite CAM’s explicit successes or bio-medicine’s failures, their experiences are not considered valid counter-evidence to bio-medicine’s truth claims. On the contrary, the increasing number of patients suffering from chronic and degenerative conditions—typical clients for CAM treatment—is considered a sign product of bio-medicine’s progress. 2. The Informal Arena Parallel to the hierarchy expressed in the formal arena, a well-maintained hierarchical order was found in the field. Patients were required to pass through a bio-medical “filter” prior to being referred to CAM practitioners. Physicians would first rule out the possibility of “real disease.” CAM practitioners never had access to the gatekeeping ritual of diagnosis; they were “relegated” to the task of alleviating pain and comforting patients, especially in cases of long-term chronic disease. All our interviewees, including hospitalized patients, shared three assumptions: (a) the value of CAM treatment was a matter of belief, not science; (b) such treatment belonged in the area of free choice as an option to be purchased rather than as a crucial component of medical treatment; and (c) the patient’s refusal to accept CAM treatment was considered legitimate. A negative response to suggested CAM treatment which included the theme of “Thank you, but I don’t believe in it,”—inconceivable in the bio-medical sphere—was considered acceptable in the CAM sphere. Such patient responses and CAM practitioner — 104 —

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reactions, within the context of the hospital and the ambulatory clinic, indicated their acceptance of the inferior epistemological authority of CAM knowledge and practice. This situation did not, however, prevent patients, despite their passivity and “ignorance,” from implicitly challenging these assumptions through the mechanism of consumption. Protecting the Public: Moral Contamination 1. The Formal Arena In response to the patient’s power as a consumer, bio-medicine began representing itself as a guardian of the public’s welfare. The Eilon Committee therefore highlighted the risks and perils of turning to alternative medicine (Ministry of Health, 1991, p.11): 1. Direct damage observed in infections, structural injury, discomfort, or harm from inappropriate medication and so forth. 2. Improper diagnoses caused dangerous delays in receiving appropriate bio-medical treatment. 3. The strong likelihood of misrepresentation and charlatanism due to inappropriate training and inadequate supervision of practice, observed in placebo effects and suggestion. This list betrays the implicit assumption, promoted by physicians, denying the presence of such dangers and risks within the boundaries of bio-medicine. The same paternalistic attitude found in the above list of “dangers” is repeated in IMA accusations that alternative practitioners were “deluding” the public by promising “care and healing,” promises “impossible to realize” given their training and methods (Israel Medical Association, 1997, p. 10). 2. The Informal Arena The rhetoric used by physicians in boundary work in the field excluded claims of protecting the public from CAM. Instead, bio-medicine’s claims for its guardianship were made primarily in the name of scientific validity and the implied moral authority. In the field, overt objections to CAM, voiced primarily by bio-medical authorities reluctant to collaborate with CAM practitioners, were based almost exclusively on boundary work in the form of jurisdictional claims. Yet, the small minority of hospital doctors embracing positive views of CAM practice and its potential contributions continued to base their opinions on patient well-being (caring) rather than curing. — 105 —

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It thus appeared that in the field, where judgments were more likely to grow out of actual collaboration and work experience, the likelihood of using moral contamination as a reactive strategy within the bio-medical discourse actually declined. The reactions of bio-medical authorities exposed to CAM practice tended to range from strong support to cautious recognition, exemplified in the comment made by Dr. B, head of the craniological unit at a major hospital in Jerusalem: I think that it’s excellent. I believe in complementary medicine. Not that I know much about it, but I have a positive attitude with regard to all ancient traditions. Natural is good. I do not accept everything but I think there is something right about it. Dr. B’s sympathy for CAM was not, however, shared by most of his colleagues: Some doctors in our department have more doubts than others. I think the reason is that we are not familiar with it. If they knew more about it, their attitude would be more positive. The majority echoed the following pronouncement, made by Dr. R: I am not willing to … provide alternative treatment instead of medication. Conclusion The research described in this chapter revealed boundary work to be a repertoire of mechanisms by which the bio-medical discourse demarcates its turf in both formal and informal arenas. However, boundaries did sometimes become more malleable with a change in context. In the formal arena, definitions were strict and rigid whereas moral and cognitive boundaries appeared fixed and extremist; together they marked a hardcore professional ethos and identity. In the informal arena of the field, however, knowledge and professional conduct were reflected and refracted through daily practice, with boundaries shaped and reshaped by local, immediate forces. “Workplace assimilation” (Abbott, 1988), fa— 106 —

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cilitated by the actions and interactions of real persons, was therefore transformative. The same bio-medical and CAM practitioners who appeared in formal jurisdictional claims as monolithic groups wore richer colors in the field. Nevertheless, the absolute epistemic authority of the scientific biomedical discourse, most manifest in the notion of evidence-based medicine, remained protected in the informal as in the formal arena. This was particularly prominent in the way that the care/cure boundary was observed. While the positive effect of CAM in the realm of “cure” was denied, doubted, or restricted on the formal level, bio-medical practitioners working together with their alternative colleagues at the informal level were able to express their recognition of the positive effect of CAM treatment but only on caring, not curing. And so, the care/cure divide, religiously observed inside the stronghold of bio-medicine, was cautiously crossed on the informal level within ambulatory clinics where CAM practitioners provided services. Further evidence for the hegemony of the evidence-based scientific discourse as practiced in bio-medicine was found in the paucity or narrowness of reactive strategies to CAM observed across bio-medical specialties. At the same time, variations in the formal classifications of CAM were also rare. Collaborative work appeared to be the most effective route CAM could take toward achieving recognition from bio-medicine. In contrast to the strict, legal restrictions imposed in the position statements, CAM practitioners were able to enter hospitals through informal procedures. Simultaneously, social and symbolic boundaries, especially in hospitals, maintained the exclusion of CAM practitioners from centers of power and control. In a similar manner, the strict epistemological hierarchy of science and its agents that characterized the formal level were challenged to some degree in the field. As opposed to the moral contamination attributed to CAM practice by formal authorities, mutual respect was expressed as a result of collaboration, with social and symbolic boundaries consequently altered. Moreover, patients appeared to affect boundary work by demanding CAM. As a stimulus to collaboration, the exercise of their economic and practical power therefore somewhat counteracted their inferior epistemic status. My search for the “boundary at work” (see Mizrachi, Shuval and Gross, 2005), the processes of boundary demarcation used by the bio— 107 —

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medical discourse, therefore revealed processes dynamically negotiated by the respective social actors. Repertoires used to marginalize and exclude “invaders” while minimizing conflict and softening resistance were realized somewhat differently in the field. We can consequently conclude that the boundary work responding to competition between two professional or scientific spheres is multi-dimensional, capable of containing and reconciling contradictions and grey areas while securing core principles. The changing contours of boundary work that appear to be bio-medicine’s reactive strategy to changing environmental demands and local forces has implications for our understanding of professional competition in other domains. These strategies enable us to differentiate hardcore professional domains from more negotiable areas, those where the bio-medical profession can relax its protective strategies. By changing the contours of its boundaries in the field, the bio-medical discourse manages to absorb its competitor within its professional jurisdiction while avoiding overt conflict and, at the same time, succeeds in securing the absolute epistemological hegemony of bio-medicine.

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CHAPTER 7

THE INTEGRATION OF KNOWLEDGE: PHYSICIANS PRACTICING HOMEOPATHY

Introduction We know little of what actually happens socially and psychologically to bio-medical physicians when they make the move to CAM practice. The intellectual encounter with curative theories outside or alien to their scientific outlook is of particular interest. The attempt to belong simultaneously to two worlds of knowledge and practice and the potential conflict of ideas could be a source of stress, and in some cases might even bring about a “schizophrenic break” as described by Simmel (1955). This chapter focuses on how bio-medical physicians who practice homeopathy have integrated the two knowledge domains. The subjects are Israeli physicians who, after undertaking additional training in homeopathy, made the latter a significant and inseparable element of their daily clinical practice. Nor is our selection of homeopathy accidental; it is a field which presents a real intellectual challenge to conventional physicians. Homeopathic theory rests on a unique set of axioms which, for the most part, contradict many of the fundamental premises of conventional medicine and its canon of practice. The research made use of grounded theory (Glaser and Strauss, 1967) and is based on semi-structured, in-depth interviews with fifteen physician-homeopaths: twelve men and three women. Their ages ranged between 40-72; they were all experienced practitioners with a minimum of two years experience. Ten worked in CAM clinics run by the sick funds or the public hospitals; nine also practiced in a private setting. Seven physicians also worked in a bio-medical setting as conventional GPs or in another specialty, without utilizing their homeopathic skills. The interviewees were selected by theoretical sampling in accordance with the approach of grounded theory. The data were processed with advanced Atlas.ti software for organizing and analyzing qualitative data. One of the study’s principal objectives was to understand the professional thinking and behavior of these physician-homeopaths as they — 109 —

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sought to combine the two bodies of knowledge on which their practice was based. This was done in the context of the overall sociocultural environment of the period which has been referred to as post-modern. The mood of the time which reached broad segments of the population—including physicians—encouraged the melding of knowledge drawn from disparate and even conflicting sources. As noted in chapter 3, the postmodern period legitimized differences and the acceptance of paradox and contradiction (Best and Kellner, 1997). The hierarchic and dichotomic thinking typical of the earlier modern period, with its insistence on clear-cut definitions and rejection of ambiguity, had changed by the 1980s (Baudrillard, 1983). Undoubtedly, some bio-medical professionals, having been exposed to these postmodern values, were willing to consider a more flexible stance regarding the earlier stringent dichotomies to which they had been educated—between the scientific and the unscientific or between evidence-based and non-evidence-based knowledge. This chapter will examine modes of reconciling different bases of knowledge in the context of this overall socio-cultural background. The Main Features of Homeopathy Homeopathy and bio-medicine are contemporaries and share a common cultural background. Both sprang from European ground, and both regarded themselves as faithful scions of Western scientific principles. Homeopathy was first developed in the late eighteenth —early nineteenth century by a German doctor, Samuel Hahnemann (1755-1843). It quickly gained popularity and spread to other European countries and to other parts of the world (Vallance, 1998; Kotok, 1999). Bio-medicine reacted to this development with vigorous hostility and with a succession of legal, social and professional initiatives which sought to eject the homeopathic method and its practitioners from the medical community (Nicholls, 1992). However, towards the end of the 20th century homeopathy sprang into new life, along with other non-conventional therapies, and a resurgent demand has now made it one of the central and most influential currents in non-conventional medicine (Kotok, 1999). Two principles are paramount in homeopathy’s canon of practice: the first is the “law of similars,” or the law of “like cures like,” which holds that a disease can be cured by a substance which produces similar symptoms in healthy persons. The second is the administration of compounds in a highly dilute state on the premise that the smaller the — 110 —

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amount and the more dilute the active ingredient, the more effective it is (Jonas, et al. 2003). Homeopathy’s definitional categories of health problems are also fundamentally different from the bio-medical typology, and treatment is guided by the totality of the patient’s symptoms and personality characteristics. In practice, diagnosis — as bio-medicine defines it — does not exist in homeopathy. There are different schools of thought among homeopaths. The two central groups are known as “classical” and “clinical.” In “classical” homeopathy, the practitioner examines the patient by means of a long and detailed history, after which he/she decides on “constitutional remedies.” Usually, classic homeopaths prescribe a single remedy in infrequent doses (Baars, et al. 2003; Jonas, et al. 2003). “Clinical” homeopaths generally use a combination of remedies to “cover” the symptomatic variations of a clinical condition in a manner similar to conventional drug treatment (Jonas, et al. 2003). The two approaches differ in the emphasis they place on the patient’s unique characteristics: in “classical” homeopathy the whole person as an entity is central, whereas in “clinical” homeopathy the illness takes a central place. Classic homeopaths remain closest to the original forms of homeopathy (Baars, et al. 2003). In Israel, classical homeopathy is the most prevalent form of practice, so that most of the physicians interviewed in this research are classical homeopaths. The response of bio-medicine to homeopathy has been one of consistent rejection (Jonas, et al. 2003). Chemically, pharmacologically, and biochemically, homeopathy’s theory and practice principles are incompatible with current scientific knowledge, and for that reason the majority of mainstream physicians have either shunned it or dismissed it derisively (Eskinazi, 1999; Federspil and Vettor, 1999). Lately, however, some researchers have tried to reconcile the two approaches using the “energy medicine” paradigm. This is based on theories relating to biological fields and electromagnetic waves, or theories which draw a connection between human energy systems and new insights in modern physics (Schwartz and Russek, 1997; Rubik, 2002). Researchers report, however, that despite the accumulation of significant amounts of research data on homeopathy’s mode of therapy, including data obtained under controlled experimental conditions, its therapy remains unexplained. Neither is there agreement among researchers regarding — 111 —

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the effectiveness of homeopathy. One of the latest developments in the homeopathic community is evidence based homeopathy. This approach seeks legitimacy by utilizing scientific methods to evaluate the results of homeopathic therapies in the hope, that through isomorphic processes, homeopathy may become an integral part of the medical mainstream (Wassenhoven, 2008). Deploying Medical Knowledge in Homeopathic Practice Our research indicates that most physician-homeopaths put their biomedical knowledge to use at certain stages of their homeopathic practice. They focus their bio-medical knowledge on two specific components of the clinical encounter: identifying the medical problem and deciding on the form of treatment. At the time of the first clinical encounter, many patients will have already undergone a series of conventional medical tests because CAM is usually their second option. Indeed, patients usually arrive with their bio-medical test results and diagnoses in hand. If the homeopath is practicing in one of the sick fund or hospital clinics, all of the patients will have undergone a preliminary screening process by the senior physician in charge, and their full bio-medical record will have been checked as a precondition of referral to a CAM therapist (see chapter 2). These are carefully scrutinized by the senior physician, and if the necessary tests have not been done or are incomplete patients are instructed to complete them under the auspices of their conventional physician. In the course of the interviews, the physician-homeopaths referred to these tests as “doctor tests,” but they confirmed that they checked the conventional records their clients brought with them and, if something was missing, insisted that the patient visit a “regular doctor” to fill the gap. Although all the physician-homeopaths gave consideration to the conventional medical test data, not all attributed equal importance to it. Their own outlook and training explains one source of difference, and their work setting also played a role. As noted, if they are practicing in a public CAM clinic, thorough bio-medical diagnosis is a sine qua non and this will have been carried out by the senior physician. As Dr. Limor, senior physician in a CAM clinic, said: Every patient undergoes a regular medical examination at the time of his/her first visit to the clinic, and if they — 112 —

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have not already done all the necessary tests they are sent to get them done. Only then are alternative medicine options taken into consideration. In private CAM practice as well, many practitioners take serious note of conventional test data, chiefly as a filtering device for determining who is suitable for alternative treatment and who is not. As Dr. Gilat said, “If there is a risk to the patient’s health, I first get the bio-medical tests done and then decide how to proceed.”One such risk might be rejecting a quicker-acting bio-medical treatment (antibiotics, for example) in favor of a longer-term alternative therapy. All in all, it is evident that conventional medical examinations and tests play a critical role in the choice of a mainstream or CAM therapy option: Of course, you have to take notice of objective information and for me, as a doctor, the regular medical anamnesis and test results are important factors…indeed I send my clients for more tests if I need them. Another interviewee put it even more succinctly: (Bio-medical) tests must be done…a diagnosis must be made. Homeopathy or no homeopathy, you have to know what you’re facing. At the same time, there are a few physician-homeopaths who give the conventional data short shrift. One interviewee only looked at the data “to show that you are really a doctor and you take your work seriously…” Another did not even mention conventional test and examination data in his account of his patient sessions. It is fair to conclude that, overall, the interviewees used bio-medical data (a) as an indispensable mechanism for detecting and preventing hazardous medical situations, and (b) as a tool for preliminary diagnosis. For most interviewees the bio-medical survey stage came first and the CAM phase second. The physician-homeopaths deploy their bio-medical knowledge a second time in the session—when they have to choose what treatment — 113 —

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mode to adopt, homeopathy or referral to a mainstream specialty. In fact, only a minority of the interviewees administered conventional treatment, despite being qualified to do so: the great majority applied only homeopathy and did not think of combining the two approaches. This crossroad—the choice of CAM over bio-medical treatment and vice versa—is a key point in the boundary work of the homeopathic doctors. Each time the choice is made, it recreates the separation between the jurisdictions of each school and so reaffirms the long-term boundary between them. This act of choice is thus a form of boundary work which consolidates a particular division of labor. Most of the interviewees believed that acute life-threatening cases, such as severe infections or surgical problems, require bio-medical treatment; the same was the case for organic and irreversible conditions. Thus, the concern for life threatening conditions is the critical factor determining the differentiation between use of bio-medicine or homeopathy. On the other side of the boundary, chronic illnesses and conditions for which conventional medicine could offer little succor were accepted as appropriate candidates for CAM treatment. In deciding which mode of treatment to use, the physician-homeopaths applied their bio-medical understanding of the diagnosed problem, in particular its gravity and its responsiveness to conventional methods. If an effective conventional treatment was available, they preferred not to utilize homeopathic procedures. Dr. Leon, for example, said with regard to blood pressure problems that he would not treat a patient whom bio-medical methods had brought into balance. Bio-medical knowledge is critical when a patient is already under conventional medication, a common occurrence since many people chose CAM only as a second resort. Most physician-homeopaths would not remove a patient from conventional treatment unless they felt it was essential; several spoke of the possibility of causing harm to the patient. But most were confident that if the homeopathic therapy was likely to be more effective, it was preferable to gradually reduce the conventional medication to a lower dosage. The ideal situation was for the patient to come to a homeopath free of all drugs so that homeopathy could take over as the frontline therapy. An example of a clash between conventional medication and homeopathy is when the patient is on massive doses of a conventional psychiatric, antibiotic or steroid medication. Such dosages render homeo— 114 —

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pathic treatment useless, averred several interviewees, and this is why a “clean body” was necessary before entering homeopathic treatment. Homeopathy and Science: The Views of Physician Homeopaths The interviews show that combining the use of bio-medical and homeopathic knowledge in day-to-day practice gives physician-homeopaths no particular difficulty. How are they able to reconcile the essentials of the homeopathic method with the axioms of Western science as expressed in bio-medicine? In an effort to explore this issue, they were asked for their views on the relationship between homeopathy and modern Western science. In Dr. Yaron’s opinion, modern science is totally helpless in the face of homeopathic practice: it cannot understand, investigate or confirm it; furthermore, the psychological-spiritual component of homeopathy is not measurable by “scientific” tools: Science doesn’t have the tools to comprehend the virtues of homeopathy because it rests on the five known senses while homeopathy has a psychological component which lies beyond these…Thoughts and emotions, understandings and traumas lie beyond the five senses…When you discuss science in such spiritual language …science just doesn’t know how to measure it. Moreover, he claims, research on homeopathy is hardly feasible considering the individualized aspect of its practice. ‘[In homeopathy,] each person has to be treated in accordance with their own individual qualities,’ and modern research methods find it hard to handle such an individualized approach in terms of the language and logic of science. They don’t know how to cope with this and so they assess homeopathy as irrational and unacceptable. Dr. Yaron concludes: At the end, you have two different languages: conventional medicine is the medicine of chemistry, while ho— 115 —

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meopathy is the medicine of information. Dr. Sarah believes that science is not sophisticated or advanced enough to explain how homeopathy cures. It is not that homeopathy’s ideas contradict science, but that contemporary science has yet to find the tools to comprehend them: “Science is too undeveloped to furnish an explanation.” To her mind, homeopathy’s theoretical fuzziness neither disqualifies nor impedes practical work in the field. In the final analysis, the deciding factor is the practitioner’s actual clinical experience, and she firmly refuses to be concerned by theoretical obscurities: I work, I have no ‘point of view.’ There are doctors who are theoreticians… I am a practitioner. I couldn’t care less what the theory is. … I don’t worry if it’s proven or unproven. If it works, it’s fine for me. I go by results, I cure people and that’s that. Dr. Irina’s approach to medical practice is of extreme pragmatism. It ignores one of the core principles of bio-medicine, which maintains an unreserved identification with science. Her standpoint is a-theoretical and—from a bio-medical view point—places her practice at the empirical level of trial and error. Some of the interviewees described the move across the boundary to homeopathic methods as a difficult process. Their rational, scientific, bio-medical training hampered an easy acceptance of the new therapeutic approach. For several physician-homeopaths, homeopathic and biomedical knowledge are—at least to some extent—opposite poles. One described his first encounter with homeopathy as “…like heaven and earth. It was all the exact reverse of what I had learned.” The transition to CAM entailed a painful acknowledgement of the gaps in bio-science and the acquisition of a professional standpoint which made room for uncertainty and phenomena that science found inexplicable. But, says Dr. Ephraim, to no small extent, this is also true of bio-medicine. There, too, practitioners have to learn to navigate with a good measure of uncertainty. Not that this licenses ignorance, but we have to realize and accept the sort of — 116 —

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reality we live and work in. The biggest obstacle in homeopathy is reconciling oneself to the existence of unobservable processes and phenomena: I found it very hard to accept the notion that things that we cannot see nonetheless exist. (Dr. Limor) Another interviewee compared his state of knowledge “before and after”: I knew when I was still just a conventional doctor that there was matter and matter only, and only things that could be proven… and seen, and felt and broken and weighed. And everything beyond that and which I could not see… did not exist…Anything that was not logical just did not exist. Emotional, intuitive stuff…certainly nothing could be done with it…Then suddenly it happened for the first time…All at once I saw that not only these material things, but things that could only be felt, that you could have an affinity for and could relate to… these also had meaning and could be worked with. For this interviewee, entering the world of homeopathy “changed everything.” This issue of “visibility” and the dispute surrounding it also appears in Dr. Ephraim’s response: The criticism of homeopathy by conventional medicine—that there is nothing in it, that the dilutions are too high, that chemically, physically it can’t work, that where there are no molecules there’s nothing—this is all the criticism there is. That it can’t be, that it’s all psychology. But experience in the field provides a different picture: When I see a 3-4-month-old baby with recurrent ear infections and I treat it and the infections clear up it’s — 117 —

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very hard to believe that it is coincidence, that it’s mere psychology. Even veterinarians are using homeopathy. And how does he feel working in a field that has no solid scientific grounding? He replies that he finds no interest in the theoretical issues. For him, homeopathy is “a tool, not a belief and not a philosophy.” The only consideration in deciding to administer a homeopathic compound is the probability that in the specific case under consideration it will work. He rejects the notion of denying the legitimacy of a therapy just because we do not know how it works: To my mind, there are a lot of things whose workings we do not understand. In my bio-medical work I use a lot of techniques that, if you were to ask me. ‘do I know exactly how and why it works?’…the answer would be ‘I don’t know.’ And I also think that the majority of doctors don’t know exactly how everything works.. And the story that you can’t use something if you don’t know exactly how it works, if there is no substantial proof…that too doesn’t seem to me …correct. For example, take aspirin: they discovered its effectiveness in 1920. Now they are starting to discover that it has all sorts of effects they didn’t know about…new things, good things they didn’t know about… theory changes every ten years. Dr. Nahum is a physician-homeopath of long standing. In his opinion, the contradictions between homeopathy and conventional medicine at the theoretical level present a difficult problem, but not a fundamental one. He agrees that two of the axioms of homeopathy—the “likeness” between substances and the minimal dosages administered—are hard to accept, but that recent theoretical developments in physics are paving the way to an understanding. He cites the fact that properly conducted research has been ongoing for years into the effect of low dosages in physics, chemistry and medicine. Dr. Alex agrees. Twenty years ago there was a genuine problem, but now “all sorts of research studies have been made with very interesting findings.” Dr. Natan took a different line, drawing a firm distinction between medical research and life sciences research. In his view the correct — 118 —

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approach is of the latter whereas current medical research is “one big bluff”: it committed the fundamental error of restricting itself to statistical interpretations of blind trials, where some subject groups were given the active ingredient and others a placebo. What sort of medicine is that?...That’s not medicine, that’s pharmacology…They’re waving the flag of scientific pharmacology as though it were the whole of medicine and want to manipulate it, to wrap up the whole of homeopathy in one little flag, that magnificent panorama called homeopathy. Dr. Meir cited the problematic aspects of mainstream science itself: I don’t like the word ‘science’…not because it’s not a good or a great word …Science claims to understand everything it sees and this is simply not true, simply not true. The patient seeking treatment is much more than his back pain. He does not fit into the precise compartments and categories of conventional medicine, which aspires to exactitude and everything within it is “very, very cut-and-dried.” Scientific truth is always changing, and is far from being an absolute and timeless thing. “I take nothing for granted,” says Dr. Meir. Homeopathy’s ambitions are modest and it is open to the unknown, to meanings which manifest themselves only after a lapse of time. The notion of constant innovation is alien to it: it focuses rather on working with its existing body of knowledge. Homeopathy and Bio-Medicine: Views of the Physician-Homeopaths Overall, the interviewees emphasized the points of difference between bio-medicine and homeopathy and scarcely noted their points of similarity. For instance: They look at each other—but there is no connection… Similarity? No way, nothing, zero. Asked to compare the significance of symptoms in the two schools of — 119 —

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thought, another interviewee responded In homeopathy, your mind is set up differently…You don’t go to war against symptoms …You regard the body as an active entity and as an active partner in the healing process. Symptoms are viewed as “good friends” without whom homeopathic care cannot even begin. Homeopathy attempts to tackle the root of the problem and not merely suppress external symptoms: Plastering over the problem just shifts it elsewhere… They give the patient a coat of paint and think they’ve cured something. In other words, treating the person and not just the “illness” is the key. When I studied and started to practice homeopathy, I felt that at last we were not talking about illnesses but about people. That’s so important… for me… that was the opening of a window. In contradistinction to bio-medicine, homeopathy ascribes illness to an imbalance. Throat infection, headache, digestive disorders — they are all symptoms and manifestations of a lack of balance; to define the exact nature of the imbalance the therapist “must gather together all the patient’s symptoms,” so that the homeopath’s observation is more all-encompassing than the bio-medical doctor’s and the treatment will vary from patient to patient. Whereas bio-medicine regards an illness as a phenomenon in its own right which has to be eliminated, homeopathy sees it as a lever to a more general improvement. Dr. Tzvi introduced the concept of an “energy disturbance”: Homeopathy believes that there is internal illness at the level of the bodily energies…an alien force interfering with your normal flow of internal energy…This force is like some sort of leech that has got in and fastened onto — 120 —

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the normal free energy flow, so that it is disturbed... So your vital forces start creating symptoms...in order to overcome this external disturbance…to start acting. For example, homeopathy does not regard tonsillitis as an illness, but as ‘a manifestation which the body has found as a solution to a problem’…the illness is a vital force. Dr. Natan is unique in his use of scientific rather than homeopathic language to explain the source of illness. The body is driven by messages sent to its glands…a gland secretes a slow-acting hormone…The immune system may be in distress…and expresses this by means of illness... Homeopathy intervenes in these processes, subtly, physiologically, to repair…There’s nothing mystical about it. Dr. Aaron introduces a new facet into the bio-medicine/homeopathy dichotomy: As a homeopath, I see illness as a reaction of our vital forces, something internal reacting to some external factor. This is not so different from conventional medicine’s point of view, but I see conventional medicine’s weakness in its incapacity to deal with the mental aspect, so that when you walk down the street and look at the passers-by, you see something sad in every face…and it’s always like that, you see, because no one has ever treated their psyche… Dr. Yaron points to a similar feature: According to homeopathic thinking high blood pressure or migraine are brought about by very complex causes… and mainstream medicine usually views them as ‘mystical’… These causes are a mix of the physical and the mental but bio-medicine takes no interest in them, not — 121 —

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because it does not know that they are there but because it has no therapy to offer. (Dr. Yaron). The internal imbalance or disorder expresses itself in a number of ways, physical and mental, and the task of the homeopath is to locate the internal disturbance, the “deep” or “root” cause. Some of the interviewees went so far as to acknowledge that, as fields of knowledge and practice, bio-medicine and homeopathy stood at opposite poles and were mutually contradictory. Homeopathy was more than just “another” or a “supplementary” approach. According to homeopathic philosophy, bio-medicine is a mistake. Not just an alternative option. A mistake…You give antibiotics, turn off the tap and push the problem deeper in. You make the damage deeper and next time it won’t appear in the ears but in the stomach or the heart or elsewhere…this approach is seen by homeopathy as a cardinal error. Dr. Natan termed homeopathy “medicine without lies” in the sense that it attempts “the real cure” of a problem. It also gives its practitioners more satisfaction because of the feeling that they are “really helping.” A frequent issue brought up in the interviews was the fundamental difference between homeopathic and conventional medication. The divergence lies not only in composition and dosage, but in the compound’s essential therapeutic function. If conventional medication seeks to eliminate the underlying cause of an illness, the homeopathic medication is designed to “refresh” bodily systems, to act themselves as agents of change and bring the body back into balance and sound functioning. A homeopathic medication is only a catalyst, it gives the first push to a complete process…which takes place in the body… in which the biochemical or psychic systems—and I make no distinction between them—then do the real work. The medication is only the ‘kick-off.’ The updating of homeopathy’s knowledge base is also different. The first skill demanded of practitioners is mastery of the pool of some four — 122 —

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thousand homeopathic medications, which are used to cope with most known health problems. The development of new medications is not nearly as significant an endeavor as in conventional medicine. The interviews showed that another critical skill required of homeopaths is the ability to extract pertinent information from a patient, to induce him/her into a state of cooperation without which it is impossible to determine the correct treatment. Building a therapeutic relationship is thus considered a vital factor for success. To be a good homeopath “you must be a good psychologist.” Since homeopathy is a combination of medicine and psychology, it is essential to be able to draw out deep-lying information. But while a psychologist can spread this effort out over years of therapy, the homeopath must accomplish this more quickly—possibly in only a single one-hour session. Unlike conventional medicine, homeopathy requires a good deal of dialogue. Although an expert homeopath has enough knowledge and experience to consider him- or herself an authoritative figure vis-à-vis the patient, in practice the interaction is one of equals. The three paramount skills needed are “listening, listening and listening.” This type of dialogue brings about a relationship which is not “an understanding between doctor and patient, but an understanding between two people”. This closeness, involving the exposure of intimate personal information, endows the relationship between the homeopath and the patient with a special quality: Practicing medicine, I hated the patients…Practicing homeopathy, I love them. There’s something in conventional medicine that causes this dislike. If [in conventional medicine] you’ve found an effective treatment for the problem, then you’re happy and he’s happy and he says thank you. And if you haven’t you’re angry because he’s asking for something you haven’t got…Conventional medicine doesn’t give you the tools to respond to what is really wrong with your patients. According to Dr. Yaron, the ideal homeopath is a “superman.” He has to be clever and wise because he is connecting body to mind, which is always interesting and compli— 123 —

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cated…he has to be a high-level performer, to know how to be persuasive… how to ask the patient not to take certain medications, and so on. He has to have a very good memory to remember a huge number of medications and symptoms. Conclusions The findings show that conventional doctors who studied and shifted their practice to homeopathy put both their bio-medical and homeopathic knowledge to use. Even practitioners who had long lost touch with conventional medicine had not relinquished their bio-medical training and the basic elements of examination and diagnosis. They utilized bio-medical tests and examinations to determine if a patient was an appropriate candidate for homeopathic treatment, and some even stated that bio-medical diagnosis was an essential prerequisite to homeopathic treatment. The classic homeopaths are an exception to this rule in that their mode of practice admits no inputs at all of bio-medicine. Unlike bio-medicine, in which physicians focus largely on objective data such as test results, homeopaths give considerably more attention to subjective data drawn from the patient. Individual narratives, feelings and emotions, form and style of speech—all these are meaningful to the homeopath. It is upon these and their interpretation that the form of treatment is determined. The elements of objective and subjective data remained separate and clearly differentiated. They are also ordered on a temporal axis. For many of the interviewees, the encounter with patients was divided into a brief “conventional” phase and a prolonged “CAM” phase—invariably in that order. It is reasonable to assume that this division helped the physician-homeopaths decide on the mode of therapy without too much inner conflict. If the bio-medical examination identified an acute medical problem, the patient would at once be referred to bio-medical treatment. Otherwise, homeopathic treatment was started. In the private sector, the situation is somewhat different. There, since the physician-homeopaths are not working under direct bio-medical supervision, they have more autonomy, and the intake procedure tends to combine the two approaches. They may start an intake with standard bio-medical procedures, or instead they may begin with questions that are essentially related to homeopathy. It is evident that, whereas in the — 124 —

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public sector the bio-medicine-homeopathy boundary is both visible and bright, in the private sector it is more blurred and diffuse. It is evident that the adoption of homeopathy changes the professional worldview of bio-medical physicians. They develop an increased tolerance of non-rational, non-scientific knowledge; they learn to live with uncertainty; they develop new ways of relating to patients in order to generate professional knowledge from the subjective and nonquantitative information they draw out of them. Physicians who decide to practice homeopathy develop a broader conceptualization of reality than the worldview instilled in them by their years of bio-medical training. This implies a crossing of several boundaries. One is the boundary between “modern” and “non-modern” concepts. Another is the boundary between “science” and “non-science”—they learn to provide health care without the support system of evidence-based bio-medical science. A third is the boundary dividing the “visible” from the “invisible.” Crossing it, homeopaths change their “clinical gaze” to recognize and utilize information and processes undetected by the eye or by sophisticated technical tools. A number of strategies and mechanisms are utilized for reconciling the apparent contradictions between the concepts governing the two schools of thought. Among the most popular are “translating” homeopathy into scientific language; finding areas of overlap between the two schools and ignoring the areas of incompatibility; concentrating on the effectiveness of day-to-day practice while ignoring theory and scientific questions. A more rarely chosen path is complete immersion, that is, total acceptance of homeopathy’s theoretical framework. For the individuals interviewed in the course of this study, finding a way to integrate the two bodies of theory was not a subject of primary concern. Their clear priority was to maximize the practical therapeutic benefit to patients, and they felt this was achievable without theoretical bridge-building. By giving greater weight to mastery of the skills and techniques of homeopathy, they indicated that they valued “clinical legitimacy” over scientific legitimacy, and that this provided more than adequate authority to define their practice and justify its existence. These physician-homeopaths displayed an unusual mindset: they practiced in a context involving the co-existence of types of knowledge rooted in two far-separated and mutually incompatible sets of axioms and beliefs. They kept this co-existence in balance by means of a range — 125 —

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of strategies and tactics which broadened their tolerance of non-rational knowledge and uncertainty and expanded the boundaries of their conceptualization of the reality in which they practice. The same expansion and change are found in the sources they looked to for legitimacy; science and scientific knowledge no longer stood as an exclusive “gold standard.” In sum, this group of practitioners has achieved a successful modus vivendi in the dual use of bio-medicine and homeopathy without an epistemological integration of the two bodies of knowledge. This may be viewed as a special form of pluralism in health care.

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CHAPTER 8

NURSES PRACTICE CAM—SPATIAL SEPARATION

Introduction In this chapter, we consider nurses who have incorporated CAM into their professional practice in Israel. By focusing on these nurses, we are dealing with persons who—like the physicians discussed in chapters 5, 6 and 10 and the midwives considered in chapter 9—are bio-medically trained, and who have opted at a certain stage of their careers to study and subsequently practice CAM. The nurses—like the physicians and midwives—utilize a variety of strategies to negotiate the crossing of biomedical boundaries. In this, they not only provide an additional example of these processes, but also present us with a type of boundary work that reflects their unique professional role and the history of their profession, as well as recent changes in their formal socialization (Frank, 2002; Lifshitz-Milwidsky, 2007; Scott, 1998). The Nursing Role: Affinity to CAM Until the 1950s, modern nursing was strongly anchored in the Nightingale tradition, which emphasized skills associated with nurturance, caring, obedience and “mothering”; it occupied a subservient position with respect to the dominant medical profession, highlighting practical care-taking functions in a context of dependence and lack of autonomy (Pankrantz and Pankrantz, 1974). After World War II, there was a growing awareness of the need to redefine the roles and functions of nursing in order to improve its professional status and increase its autonomy (Beardshaw and Robinson, 1990; Strauss, 1966). Nurses began seeking advanced academic degrees, initiating their own research and striving to increase their knowledgebase and skills (Guinee, 1970; Stevenson, 1981). Since the late 1960s, nursing education has sought to combine an enriched scientific bio-medical program anchored in empiricism, logic and evidence-based medicine with an orientation to holism and humanism which emphasizes the integration of mind and body, prevention of illness, support for self-healing and empowerment of patients by health — 127 —

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education. One of the concomitants of these efforts was an upgrading of the nursing schools to the university level in the United States and in other countries, including Israel. This structural change brought about an expansion of the nursing curriculum to include more advanced elements of bio-medicine, as well as concepts from the social sciences drawn from psychology, sociology, and communications theory. (Meyer, 1960; Salvage, 1992; Tousijn, 1998). These changed emphases in nursing education may be viewed in terms of the I/T model proposed by Jamous and Pelouille (1970) in their conceptualization of professional socialization. In that model, the “I” component refers to knowledge that is not entirely rational, is partly intuitive and is located in the domain of individual interpretation and judgment. In medical education, it focuses on processes relating to idiosyncratic aspects of the patient emphasizing holism. This contrasts with the “T” component concerns knowledge and skills which are rationalized and routinized (Adams, 2000). Changes in the curriculum of nursing schools and particularly the inclusion of the social sciences, reinforces both the “Indeterminate” (I) component of nurses’ education as well as the “T” component. In many cases the “I” component is likely to be stronger than that of most physicians whose training highlights the “Technical” (T) component. Thus, there is a duality in the professional orientation of nurses. Their socialization is strongly bio-medical, and for many that medical anchor provides security, status and closure in their epistemological orientation. At the same time, nurses are energized by other values which lead to a strengthening of “I” orientations. These stem from parts of their formal training which include the social sciences, notions of holism, integration of mind and body, patient-centered practice and empowerment. Many of these ideas are congruent with those of CAM (Hoffmann, 1991). In seeking a new professional identity, some nurses have sought to underscore the separateness and autonomy of nursing by re-emphasizing its earlier, caring model and moving away from an overly rationalist approach (Allen, 2000; Glazer, 2000; Johnson, 1990). They are critical of the technical orientation of contemporary bio-medicine, and see CAM as an attractive option. Tovey and Adams (2003) have shown that in the past nursing was identified with values which are now emphasized by CAM so that the current interest of some nurses in these fields can be — 128 —

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viewed as a revival of earlier trends which focused on humane, patientcentered practice. Nursing in Israel1 Until the mid-1970s, nursing was taught in Israel in diploma schools affiliated with a number of hospitals. In 1975, the first program leading to a four-year university degree in nursing for secondary school graduates was established by the Hadassah School of Nursing at the Hebrew University of Jerusalem. Subsequently, the other schools of nursing and several of the other allied health occupations up-graded their diploma schools to university level, which granted a bachelor’s degree to their graduates. In 2009, there were 56,656 nurses in Israel of whom 80% were registered nurses, while the remainder were trained as practical nurses. Nurses are employed in a wide variety of health care settings including hospitals, community clinics, mother and child-care centers, schools, day-care centers, geriatric and rehabilitation facilities and other institutions. Interest in CAM among nurses in Israel is not widespread. It developed in the context of changing values and norms in the profession noted above. Nurses practicing CAM at the start of the twenty first century, represent a small, marginal group among nurses in Israel. As in most developed societies, they have been influenced by post-modern values which have raised penetrating questions about the ability of science and technology to provide answers to human problems, including illness (Coburn and Willis, 2000). Data Collection In seeking to locate nurses who engage in one or more types of CAM practice in Israel, it was apparent that there was no comprehensive list of such practitioners. Utilizing informal sources of information, we learned that such nurses are located in a variety of health care institutions, often work in multiple settings and frequently practice more than one form of CAM care. Those who work in the public health care system, are identified primarily as bio-medical practitioners, and their CAM skills are used in other contexts. 1 

The information in this section is based on Adams,1986; Bergman, 1986; Ehrenfeld and Eckerling, 1995; Israel Ministry of Health, 2010; and Shuval,1992 — 129 —

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The findings are based on a qualitative analysis of 15 in-depth, narrative interviews carried out in 2004-2005 with nurses in Israel, all of whom are currently working or worked in the recent past in both biomedical and CAM settings. Three were practical nurses; the remainder were graduate RNs, most with university degrees in nursing and several with post-graduate training in nursing. Among the forms of CAM practiced were the following: homeopathy, naturopathy, reflexology, aromatherapy, yoga, Feldenkrais, alternative nutrition, Bach flowers, healing, shiatsu, acupuncture, massage therapies, bio-feedback. Persons interviewed were located by the snowball technique, but an effort was made to maximize variability among them. It is evident that in this type of qualitative study we are unable to estimate the numbers or percentages of nurses who have become CAM practitioners in Israel. All of the interviewees were contacted first by telephone and asked if they would consent to an interview of one to one and a half hours. Anonymity was assured by a coding process. Interviews took place in the CAM practice setting or in the interviewee’s home. There were no refusals. The interview was semi-structured and covered a wide array of topics relating to the individual’s background and training, motivations, experience in practice, and modes of negotiating among different health practice cultures. The interviews were conducted in 2004-5 by a graduate student* in the sociology department of the Hebrew University of Jerusalem. All interviews were taped with the agreement of the nurse and were subsequently transcribed into systematic computerized records. These texts provided the raw material for the substantive analysis. Intensive reading and re-reading of the texts led to the identification of the principal themes which related to the theoretical issues under consideration. The notion of boundary work as rhetorical devices (Gieryn, 1999) was expanded in the manner proposed by Allen (2000) to include practices utilized in the work context. Findings We will consider the content of the nurses’ narratives in the framework of three basic themes that emerged in the interviews: A. Structural characteristics of practice, B. Values and norms which underlie their professional work, and C. Social interaction.

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1. Structural Characteristics The most general structural finding concerns the multiplicity that characterizes the CAM nurses with regard to the settings and content of their work. They worked in a variety of settings. Most were employed full time or part time in a bio-medical institution as conventional nurses and worked as CAM practitioners after hours in a private clinic. Such clinics were often located in their home or adjacent to it. A small number of older or retired interviewees had given up conventional nursing entirely and practiced only CAM in their own private clinics. Multiplicity is also seen in the numerous fields of CAM practiced. One versatile nurse reported that she had trained and now worked in homeopathy, Feldenkrais, reflexology, Reiki, Bach flowers and bio-feedback—utilizing one or more of these specializations in accordance with the patient’s needs. Jurisdiction is demarcated, at least partially, by territorial boundaries which contour the locus of practice. Multiple practice settings provided a mode of negotiating boundary ambiguities: in the bio-medical hospital or clinic the nurse is able to act out her conventional professional role; elsewhere, generally in a private clinic setting, CAM skills are activated. The nurses are aware that the boundaries of bio-medical organizations are strongly guarded and, for the most part, the guardians do not welcome CAM. Bio-medical reference groups are recognized as powerful and potentially censorious; they could threaten a nurse’s credibility—or delegitimize her by defining her as “far out.” Thus, most nurses are reluctant to let their bio-medical colleagues and supervisors know of their CAM practice. Organizational norms establish the rules of practice. When working in a bio-medical hospital or clinic, its norms determine how medical care is practiced. Even when they have doubts about some of the hospital practices or are critical of physicians’ attitudes, the nurses know that overt deviance could cost them their reputation or even their job; conformity to bio-medical norms in a public context, is viewed as the safest form of behavior. I am an employee of the hospital and must keep to its rules. I don’t want any trouble. I never speak of my other (CAM) clinic when I’m in — 131 —

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the hospital…why should I look for trouble with the head of the department? Nevertheless, several of the nurses interviewed are convinced of the desirability of importing CAM methods into biomedical hospitals and clinics because of their conviction that they improve patient care. Some of the more enterprising are willing to undertake this risk, but are careful to ensure two conditions: the patient’s consent and assurance that they are not observed by other bio-medical personnel. I always ask the patient first... and look around to make sure no other nurses or doctors can see what I’m doing. My patients are referred to me by friends and acquaintances. I don’t advertise my private work. I’m not interested in everyone knowing about it. Several nurses noted that geographical separation did not cause them to differentiate their bio-medical and CAM knowledge and skills, which were often activated in both CAM and bio-medical settings, albeit with different emphases. Thus, in her private CAM practice she also utilized her bio-medical knowledge and training, while in her hospital work she activated a holistic approach and in some cases discreetly introduced non-invasive CAM practices to reduce pain or prevent suffering. 2. Values and Norms There is a duality in the nurses’ attitudes which is seen in their simultaneous respect for bio-medicine and their criticism of its shortcomings. The former is reflected in their high esteem for the efficacy of bio-medicine; they express respect for science and whenever possible seek to position themselves within the scientific discourse. Their criticism refers to an over-reliance on technology and medication, invasive practices, lack of holism, separation of mind and body, and inadequate sensitivity to the needs of patients. I feel that my theoretical training and background as a nurse contribute tremendously to my work as a homeopath and are important for my patients. What bothers me about doctors is their cold, imper— 132 —

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sonal attitude and lack of real human contact...when I treat a patient, I give them my full attention... I want them to feel I care about them... One of the nurses spoke openly of an epistemological conflict. She stated that before she herself started to engage in CAM, she visited a naturopath for help with her chronically sick child and was troubled by the conflict between her own bio-medical orientation and the axioms of naturopathy: At the beginning I had terrible pangs of conscience when some of the ideas clashed with my earlier training. And I struggled with myself...perhaps there is an irreconcilable conflict? Who ever heard of energy blockages? In terms of naturopathy…fever is not viewed as something to be promptly reduced—but as a phenomenon by means of which the body cures itself…germs are not a threat. During this time, she found her work in conventional hospital nursing to be “…very, very difficult—as I learned how CAM methods could alleviate patients’ suffering…I was terribly frustrated.” The epistemological conflict is attenuated by experience and education. The more advanced a nurse’s formal education, the greater her confidence in her ability to integrate the different systems. “After seven years of training, I am well equipped to make a decision as to the type of treatment a patient needs.”The epistemological dissonance is eased by avoiding confrontation. One nurse minimized her exposure to biomedical practice by working in an administrative post in a bio-medical institution rather than in clinical care and practiced alternative medicine privately. Another hospital nurse who also practices a variety of CAM therapies saw no conflict and considerable benefit in her participation in biomedical courses offered to nurses at the hospital. She described a course on the anatomy and pathology of the spinal column as “an important educational investment” for both types of her clinical work: I use all types of techniques… There is no single method — 133 —

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that is best for all problems. I combine many techniques. Reiki, yoga, medicine, aromatherapy, reflexology. Whatever helps the patient. The specialized knowledge of the physician establishes her/his authority. This is accepted and respected by nurses, nor is there evidence for any desire to cross this line. Life-threatening conditions provide an absolute marker for the priority of bio-medical intervention. Several nurses referred to the formal responsibility of doctors and to the potential dangers of legal action if they are not consulted for serious, life-threatening medical conditions. First I look at the (bio-medical) test results. These are essential. Only then do I decide what form of (CAM) treatment to offer. I ask the patient if she has been to see a doctor. If they say, “No, I preferred to see you”..., I say, “I am not a doctor; first you must see a doctor.” Even when they are critical of bio-medical treatment, nurses avoid expressing any criticism in the presence of patients, stating, “I never recommend that a patient quit their medical treatment or stop taking medication recommended by their doctor.” One nurse continued to accept the absolute authority and responsibility of the physician and refused to engage in “clandestine” treatment, stating that “The responsible doctor should be informed that the patient is receiving CAM.” This contrasts with another nurse, who prefers that the attending physician not know that she is providing CAM to a patient under his care. Some of the nurses noted that physicians fear on-going erosion in their authority and seek to maintain their turf in the face of the growing utilization of alternative health care practitioners. Conventional practitioners are afraid of losing their control… They’re fighting to retain their monopoly on medical care…even when other methods are obviously effective...

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While generally accepting the physician’s authority, CAM nurses support patient autonomy and encourage them to assert independence visà-vis their bio-medical practitioner. You should depend on yourself and on your own good judgment… if you feel the level of your sugar is improving, go to your doctor and tell him so. The nurses’ narratives referred explicitly to the types of knowledge and practice which they view as legitimate. Inevitably, these did not always conform to the views of many physicians. In a conference dealing with multiple sclerosis, a report was presented on successful treatment of patients by methods based on naturopathy. A nurse who was present and works in this field reported doctors shouting, “It’s all bullshit… absolute bullshit!!! They’re all charlatans.” In referring to the participating physicians she noted, “Educated professionals—neurologists, orthopedists, internists—close their minds and prefer to remain ignorant.” A nurse who proposed the use of Reiki treatment for premature babies reports that the senior physician refused, saying, “Do you think I’m crazy? Go away and don’t bother me with these absurd ideas.” But there are also instances when physicians are reportedly impressed by successful CAM treatment. One nurse, in describing her successful treatment of an asthmatic boy, reported that the child’s physician, who had failed for several years in his treatment of the same child, exclaimed upon examining the boy, “Wow, how marvelous!! What did you do to him…?” Several noted that, in recent years, physicians are more tolerant and accepting of selected alternative practices than they were in the past. Several expressed optimism that this positive trend would continue. In the past, doctors were all against our methods. But in recent years, they are more and more accepting of our methods… 3. Social Interaction Bio-medical physicians are an omnipresent reference group for these nurses. They tend to distinguish between the profession as a whole— — 135 —

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which is generally perceived as non-accepting or derisive of CAM methods—and selected physicians who are supportive. Thus, one nurse whose private clinic was in a kibbutz stated, “After many years of working alongside Dr. X, we have a real understanding, and he refers many patients to me.”But another felt a total lack of communication with doctors: We speak different languages. I feel I’m speaking Chinese and he is speaking Hotentot language. I never consult with physicians...if I have a question or need another opinion I speak to my former teacher (of homeopathy). Never with doctors...They don’t know anything... To hospital nurses, it is important not to be labeled as deviant. One nurse said that her study of CAM during the years she worked as a conventional nurse caused her to be labeled as “far out,” an “outsider”: “They thought I was crazy. You and your hocus pocus methods.” Awareness of the relevance and power of the bio-medical reference group led several of the nurses to emphasize the importance of using the term “complementary” rather than “alternative” in their interaction with physicians. In addition, some noted that bio-medical vocabulary, rather than esoteric alternative terms (e.g. energy, blood stagnation…), should be used in communicating with doctors in seeking to maintain good relations with them. One noted the importance of knowing the semantic and conceptual codes of both worlds: “You’ve got to adjust your language to the situation and person you’re talking to…” It is not surprising that nurses stated that they preferred to interact professionally and socially with persons who practiced or were positively disposed to CAM, where they sense a more accepting environment. Discussion What can we learn from these findings concerning the strategies used by nurses to reconcile a variety of theoretical and practice modes? How has the boundary work been negotiated? Do boundaries differ in terms of salience and permeability? How do the nurses feel about crossing these boundaries? The territorial boundary, which is unambiguously demarcated, is the easiest to cross and is the most-travelled route for nurses who practice — 136 —

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CAM; those who are currently employed in bio-medical institutions cross it regularly and comfortably. By separating the locus of their bio-medical nursing role from their CAM role, nurses are able to operate in a variety of epistemological modes. They are sensitive to what is acceptable on either side of it and are selective in their use of the modes of treatment. Such differentiation provides for epistemological duality—a form of “dual citizenship.” By practicing CAM in a private setting that is physically outside the geographic boundary of a bio-medical hospital or clinic, nurses attain an environment that is minimally invaded by values or controls that challenge CAM. They do not need to look over their shoulder to make sure that more powerful others are not showing disapproval or activating sanctions. Nevertheless, such territorial separation does not provide a completely insulated environment. Even when separated physically, elements of each system are imported into the other. This process is asymmetrical and depends on the direction taken: moving from bio to CAM is different from the reverse process—both in terms of frequency of movement and the quality of the process. Nurses’ strongly imprinted bio-medical training remains relevant and active even when they practice CAM in their private clinics. In many cases, boundary work is needed to alleviate guilt or discomfort in the process of crossing into a different healthcare culture. The findings indicate that this boundary work takes the form of rhetoric and practice which visibly evoke cognitive and epistemological elements of their biomedical background, importing them over the territorial boundary into a predominantly CAM setting. As discussed by Gieryn (1999), boundary work involves the construction of a social reality by means of rhetorical devices. In their choice of rhetoric, none of the nurses interviewed perceived themselves as violating the axioms of bio-medicine. Indeed, they repeatedly referred to their bio-medical credentials as providing cognitive legitimation to choose what they view as appropriate techniques for treatment. Several see themselves as expanding the boundaries of bio-medicine by the addition of methods which improve the patient’s quality of life and reduce suffering. This direction of cross-boundary importation is carried out frequently, confidently and in some cases even flamboyantly: while repeatedly declaring that she is not a physician, she lists a long list of bio-medical — 137 —

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procedures (tests, examinations, visits to the doctor) which are defined as a sine qua non for undertaking alternative care. This means that the territorial and cognitive boundaries of alternative medicine are permeable to certain bio-medical practices. The frequently heard declaration “I am not a doctor. I have not studied for that profession,” expresses the nurses’ acceptance of the bio-medical boundary defining the physician as the senior authority in clinical practice. None of the interviewees showed a desire to cross that boundary. Their CAM practice endowed them with considerable authority in relation to their patients and autonomy in their professional work. The latter is clearly an important goal for some nurses, and one that is not always attained in bio-medical practice. Some nurses lean on their bio-medical background to “scientize” their practice of alternative health care (Wardwell, 1994). This is accomplished by use of isomorphic mechanisms (DiMaggio and Powell, 1991) which symbolically indicate a bio-medical approach to health care: specialization in specific fields of practice, on-going study and keeping up with the literature, acceptance of the research standards of bio-medicine, interviewing of patients and systematic record keeping, performing standard tests and scrutinizing test results. Research in Israel suggests that nurses—more than other allied health professionals—use their bio-medical identity to gain status, prestige and legitimacy in ambiguous contexts (Shye, et al. 1990). Boundary work is geared to enhance nurses’ legitimacy in the eyes of patients. It generally is the first element in the nurse’s presentation of self in the encounter with her patient, a symbolic “calling card” which carries a ritual centrality. No doubt, these procedures serve as protective techniques to avoid error and possible malpractice suits; but an additional—no less important—use is to gain legitimacy by using the aura of bio-medicine to enhance their CAM practice. Despite their epistemological and practice deviance, this provides an affirmation that they have not disengaged from their mother profession; while they have entered terra incognita, they remain loyal to the basics of their early training. Crossing the territorial boundary in the other direction, from CAM to bio-medical practice settings, is more problematic. There is marked asymmetry in the degrees of permeability of the systems; the boundaries of bio-medical organizations are better guarded and less accessible to alternative ideas and practices. Nurses express caution and discretion — 138 —

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in importing elements of CAM practice into bio-medical institutions. Bio-medical reference groups are recognized as powerful and potentially censorious. Some nurses prevent their bio-medical colleagues and supervisors from knowing of their CAM practice. In particular for younger nurses at the start of their careers, a hospital job provides more security than private alternative practice. Older practitioners with better established private alternative practices are confident and display a more carefree stance. Several idealistic nurses were convinced of the desirability of crossing the organizational boundary into bio-medical institutions with the purpose of importing CAM into hospitals and clinics. They believe that such importation would improve patient care despite its risks to their job and reputation; but only the more enterprising are willing to undertake this risk. The cognitive boundary, which demarcates the knowledge and practice bases of bio-medicine, is criticized by nurses in CAM who focus on both of these components and express a need to change their contours. Biomedical knowledge is challenged for what it lacks: information regarding the efficacy of CAM. The practice component is overtly attacked by many nurses for lacking a holistic orientation to care and insensitivity to patients’ needs and feelings. CAM nurses are judgmental and disapproving of the excessive technical component in bio-medicine (T); several stated that physicians all but ignore the “I” component (Jamous and Pelouille, 1970). The CAM nurses tend to view the “I” component as the essence of their own approach to health care. A number of the nurses mentioned that the cognitive and organizational boundaries separating bio-medicine and CAM have become more flexible in recent years. More physicians are coming to recognize the positive role of certain CAM practices and are willing to refer patients and even cooperate with practitioners. Research in Israel has shown that this change has been conditional on the part of physicians: selected hospitals and outpatient clinics have re-contoured the organizational boundaries and admitted CAM practitioners on two conditions: a. that they are labeled as “complementary” rather than “alternative,” and b. by defining their practices as “techniques” which are structurally analogous to the techniques used by bio-medical allied health professionals, e.g. physiotherapists, occupational therapists. The latter condition assures a relatively low status position for such alternative practitioners. These mechanisms guarantee that the epistemological and cognitive boundar— 139 —

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ies of bio-medicine remain intact even if the organizational boundaries have been re-contoured (Mizrachi, Shuval and Gross, 2005; Shuval and Mizrachi, 2004). The fact that many of these techniques have not passed the test of bio-medical research criteria does not disturb the nurses since they are more than convinced of the efficacy of their methods. They embrace the notion that the proof of the pudding is in the eating: if it works, it is acceptable—even if the causative process is not understood. We have seen in chapter 6 that selected physicians have also adopted this pragmatic view. In sum: CAM nurses do not seek to change the epistemological and authority boundaries established by bio-medicine. However, many believe it would be appropriate to include CAM within the cognitive and organizational boundaries of bio-medicine. They are convinced that such a broadening of the boundaries would benefit patients. Nurses feel blocked in this goal by physicians who, for the most part, keep the cognitive and organizational boundaries of bio-medicine hermetically sealed. Several nurses decried the close-mindedness and ignorance of such doctors. Over half a century ago, Everett Hughes, provided one of the first sociological analyses of the nursing role (Hughes, 1951). In discussing social change in occupational roles, he focuses on the changeability of boundaries of the health professions which requires the on-going adoption of developing technologies and skills and the discarding of older ones. The findings of the present research indicate that some nurses are pushing against the boundaries of bio-medicine in an effort to expand them. Indeed, our findings provide evidence that several of the boundaries separating bio- and alternative health care are negotiable and in some cases have been re-contoured.

*The authors are grateful to Liat Lifschitz-Milwidsky, M.A. for her devoted and skillful work in interviewing the nurses in this study (Lifschitz-Milwidsky, 2007).

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CHAPTER 9

MIDWIVES PRACTICE CAM: FEMINISM IN THE DELIVERY ROOM Judith T. Shuval and Sky Gross

This chapter considers the case of nurse-midwives, who constitute an additional group of bio-medical practitioners who have opted to study a variety of CAM skills and practice them in hospital delivery rooms in Israel. We will refer to this population as “CAM midwives.” Our focus here is on the feminist quality of the norms and values that underlie their professional ideology. We seek to demonstrate the congruence of selected elements of feminist ideology to the epistemology of CAM midwives in Israel. Midwifery in Israel1 Midwives in Israel are qualified nurses who have completed an additional 1,000-hour training course in midwifery. The course combines theory with clinical experience and includes supervision of the trainee in at least fifty births. It focuses on the obstetrical model of care as taught in bio-medical contexts. Successful completion of the course involves passing a government administered examination, which provides the midwife with a license to practice. At the end of 2009, there were 2,205 licensed midwives in Israel of whom 1,441 were under the age of 60 (retirement age). They constitute 10.8% of the nurses with specialized training and 4.3% of all nurses. There are about 150,000 births a year in Israel. Almost all take place in hospitals—a condition for the woman to receive a government maternity grant (the equivalent of $300 for a first birth and $100 for subsequent births). This policy was established by law in 1954 to encourage women to deliver in hospitals. In 2009, there were 700 planned homebirths (Tel-Oren, 2009). 1 

References for this section include Cohain, 2004; Israel Midwives Association, 2005; Israel Ministry of Health, 2010; Reches, 1978; Slome, 2004; and Tel-Oren, 2003. — 141 —

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Midwives deliver 80% of the births in Israel which are defined as “uncomplicated” (Slome, 2004). In the obstetrical department, hospitals have at least one rotating midwife working in a section set aside for early labor. This midwife checks the woman and fills in her chart before she is admitted to the labor ward. After admission, most hospitals have separate labor rooms for each woman. The woman is placed in a bed, attached to a fetal monitor and an IV routine is started. Vaginal checks occur about every hour. When there is a 4-5 cm opening, the woman is encouraged to take epidural, an injection which anesthetizes the lower part of the body below the point in the spine where it is given. In 2010, 57.4% of the births received epidural. The routine tasks of midwives include rupture of membranes when deemed necessary by a physician, attachment of fetal monitoring, injection of intravenous fluids, and delivery in lithotomy position (i.e., lying on the back with knees bent and elevated above the hips with the thighs apart). Midwives practicing CAM at the start of the twenty-first century represent a small, marginal group among midwives in Israel. Their interest in CAM developed in the context of changing values and norms in other health professions and in different segments of the society (Samuels, et al. 2010). As in other developed societies, Israeli midwives have been influenced by increasing exposure to Eastern spirituality and to postmodern values, which have raised penetrating questions about the ability of science and technology to provide answers to human problems including illness (Coburn and Willis, 2000). Growing interest of midwives in CAM may be seen by their enthusiastic participation in courses in CAM geared specifically to their profession. A number of these have been held in the past five years in six different hospitals, in several cases under the direct sponsorship of the hospital administration. The curriculum of a 108-hour course for midwives in CAM health care techniques offered at an elite Jerusalem hospital in 2004 included the following subjects which were presented by expert practitioners in each field: shiatsu, reflexology, imaging, natural childbirth, naturotherapy, Paula technique, Reiki, touch therapy, aromatherapy, herbal medicine, Chinese pressure points, and body movement during labor. Most emphasis was placed on reflexology, Reiki, imaging, and natural childbirth (over 10 hours of instruction for each).

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Feminism and CAM Midwifery Rushing has noted that midwives in the U.S. and Canada have sought legitimation for their practice through a juxtaposition of science and feminism (Rushing, 1993). Following the views of Davis-Floyd and Davis (1996), we propose to consider those midwives who incorporate CAM techniques into their practice as a special category of feminists. In Klassen’s terms (2001a), their stance may be viewed as postmodern and “post-bio-medical”: they do not deny the usefulness of bio-medicine, but they challenge its exclusive hegemony by offering the additional benefit of CAM knowledge and practice. Much of the ideology that lies behind their approach to birthing is anchored in a set of beliefs that are related to ideas which are essentially feminist; these parallel those of feminists who advocate home birthing. This distinguishes them from the majority of midwives, who generally show few overt signs of active feminism in the work context. Midwives’ feminism does not relate to such prominent feminist issues as wage equality, conditions of work, occupational advancement, or gender gaps in status and prestige. As a wholly feminine occupation, it is not seeking to gain entry into more prestigious occupations traditionally dominated by men. Indeed, the “semi-professions,” traditionally classed as women’s work, have not played an especially active role in the mainstream of the feminist movement (Bernhard, 2003; Lewin, 1977). It appears that the midwives have singled out a specific set of feminist concepts which are meaningful in the context of their work. For midwives, CAM provides an increased sense of autonomy, enabling them to move beyond the control of the physician. Thus, they seek to promote patient empowerment, a concept viewed by some as incompatible with the obstetric model of care (Adams, 2006). This feminism is context-specific; there is no evidence that these beliefs spill over to create a more general feminist stance among the CAM midwives. Neither is the closeness to certain elements of feminism necessarily an explicit or conscious choice. It would seem that the midwives in CAM practice seek to emphasize the uniquely female contribution of their practice. This is seen in an emphasis on so-called female qualities, e.g. emotions, feelings, fear, meaning of experience, individual support, care rather than cure (Shuval and Gross, 2008b). We will examine the empirical findings to see in what manner the — 143 —

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Israeli CAM midwives adhere to ideas which are related to the broader context of feminist ideology. Data Collection The nature of the research dictated use of qualitative methods to obtain in-depth information from a small number of midwives engaged in CAM practice. Thus, the findings are based on narrative interviews with 13 CAM midwives, most of whom are currently working in hospital delivery rooms in Israel. In seeking to locate such persons, it quickly became apparent that there was no comprehensive list of such practitioners. Utilizing informal sources of information and the snowball technique, we located the subjects who often practice more than one form of CAM care. All of the interviewees were contacted first by telephone and asked if they would consent to an interview of one to one and a half hours. Anonymity was assured. Interviews took place in hospitals or in the interviewee’s home. The interviews were semi-structured and covered a wide array of topics relating to the individual’s background and training, motivations, experience in practice, and modes of negotiating among different health practice cultures. The interviews were conducted in 2004-5 by two graduate students.2 All interviews were taped—with the agreement of the interviewees—and were subsequently transcribed into systematic computerized records. The analysis is based on grounded theory as developed by Glaser and Straus (1976) and more recent scholars (Miller and Fredericks, 1999; Strauss and Corbin, 1999). The narratives provided the raw material for the substantive analysis. Intensive reading and re-reading of the texts led to the identification of the principal themes relating to the core beliefs of the CAM midwives. In the course of the narrative interviews, the midwives spoke freely and were keen to help us understand their stance with respect to these ideological positions. A selection of their statements is presented below as empirical evidence for their adherence to what we have defined above as the principal components of the CAM midwives’ epistemology.

2 

Sky Gross and Liat Lifshitz — 144 —

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Findings 1. Some Relevant Structural Characteristics of the Profession All of the midwives interviewed in this study worked routinely in delivery rooms of public hospitals in Israel, full time or part time. A small number also offered prenatal care within the context of a hospital program or privately. Thus, most of the CAM care provided by midwives is given within the context of a hospital, an obviously bio-medical institution. In this respect, they differ from nurses practicing CAM, whose main locus of CAM care is in a territorially-separate, non bio-medical setting, generally under private auspices—as discussed in chapter 8. As noted, in Israel all uncomplicated births are delivered by licensed midwives in hospitals, i.e. 80% of all births (Slome, 2004). The midwives and their support personnel constitute the active staff of the delivery rooms. Physicians are generally situated in adjacent locations and are summoned by the midwife only in case of need. This structural differentiation unambiguously defines the physician’s domain as one of “pathology,” while the midwife’s territory is formally limited to “uncomplicated,” i.e., healthy, non-problematic births. When there is no medical problem, physicians play no active role in the delivery. The CAM fields of practice used by midwives include a variety of CAM methods noted above, but focus on techniques used during labor and childbirth: reflexology, Reiki, imaging and natural childbirth. Upon arrival in the delivery room, a woman in labor is assigned to an attending midwife. Those midwives interested in using CAM methods and minimizing the use of epidural view every arrival as a potential “client.” Some stated that they could tell, when first meeting a woman, whether she was open to persuasion. They are, however, always careful to obtain informed consent and to respond to requests for conventional procedures during labor—if the woman is unwilling to continue with CAM techniques. CAM midwives are well aware that physicians differ in their views regarding CAM and its application in childbirth. Many doctors are known to be adamant in their opposition and hostility to CAM, while others hold different views with regard to the various forms of CAM practice; these range from extremely negative to positive with a variety of levels of approval between the two poles (Shuval and Mizrachi, 2004). However, the fact that many obstetricians in Israel favor natural childbirth provides important legitimation to one of the central tenets of the — 145 —

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midwives’ beliefs, and serves as a major area of consensus for physicians and midwives. Interviewees noted that some of the physicians—while not present in the delivery room—were well aware of their use of CAM methods and efforts to minimize the use of epidural in the interest of promoting a completely natural birth. Thus, introduction of CAM methods by the midwives is neither clandestine nor fearful; they report doing it with confidence even in the presence of physicians. At the same time, CAM midwives are aware of the legal and moral responsibility they carry and of the possible consequences to them and their career of failure to comply with the doctor’s instructions. They are therefore extremely cautious and circumspect in introducing CAM methods when they know that a specific doctor objects. Several strategies are used to make the introduction less controversial: this includes a gradual process of persuasion over time and avoidance of conflict; making sure the women’s consent is duly obtained. They also openly accept the premise that life-threatening conditions always call for bio-medical intervention, thereby ensuring the doctor’s ultimate authority. Midwives who work in hospital delivery rooms in Israel provide a unique example of the autonomous introduction of CAM techniques into a hospital setting. In the relative freedom of their separate practice setting, midwives are able to exercise initiative and independence in introducing these methods to predisposed consumers. Their confidence in doing this is bolstered by the presence, albeit virtual, of physicians— who are nearby and on call in case of need. At the same time, they relish their autonomy, which is fully legitimized by the medical community; this is expressed in the deliberate allocation of the vast majority of uncomplicated births to their care. As licensed bio-medical workers, they have the authority to judge the appropriateness or inappropriateness of procedures used during labor and birth. In a new birthing facility set up at an elite hospital in the Tel Aviv area, one midwife stated proudly: There are no doctors around... We midwives run everything. You don’t even feel that the doctors are in the vicinity. It’s a wonderful feeling!! 2. The Feminist Ideology of CAM Midwives The following set of themes emerged from an analysis of the narrative interviews. — 146 —

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a. Rejection of the medicalization of birth Many obstetricians adhere to a pathology-oriented view, emphasizing the risks and danger of pregnancy, which often require active medical intervention (Evenson, 1982). Yet, while the medical establishment has turned birth into a potentially pathological event, CAM midwives highlight the normal and natural elements of birthing (Davis-Floyd and Davis, 1996). The notion of resisting the medicalization of birth was originally led primarily by feminist activists seeking bodily autonomy for women. In most cases, pregnancy is not experienced as illness and in most cases includes few elements of risks (Young, 1990). The medicalization of birth is strongly opposed by many midwives who are convinced that childbirth is not usually a medical condition (Klassen, 2001b). However, these views are especially strong among midwives in CAM practice, who see this medicalization as self-serving and misinformed (Weitz and Sullivan, 1986). b. A strong belief in the “naturalness” of childbirth Birth is viewed by CAM midwives as a natural process which should be allowed to take its course with minimum intervention. The use of epidural and other chemicals should be avoided, as they are viewed as interfering with the natural course of events. The time sequence and developmental process of a birth is dictated by the individual woman’s needs and should be allowed to proceed at its own pace with minimum intervention. The natural process permits women to “experience the whole of birth—its rhythms, its juiciness, its intense sexuality, fluidity, ecstasy, and pain” (Davis-Floyd and Davis, 1996). It is viewed as “natural” to consider the individual as an inseparable whole in which physical, and emotional needs are intimately related; one set of needs cannot be considered without dealing with the others. c. Rejection of the overuse of technology Bio-medicine tends to emphasize and encourage the use of sophisticated technology. This orientation is prevalent in delivery rooms where women are immediately connected to a monitor where their progress can be carefully supervised and controlled. High-tech manipulation or technical control are strongly rejected by midwives in CAM practice, as — 147 —

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these are thought to render the woman invisible and inaudible. DavisFloyd and Davis (1996) describe the “technocratic model” of birth as the core paradigm underlying contemporary obstetric practice, which results in depersonalization of women (Davis-Floyd, 1992). Under this model, knowledge is vested in machines and in those who know how to manipulate and interpret them. Obstetrical procedures are rituals that convey cultural core values to birthing women and separate the birth process into a set of identifiable and controllable segments which transform it into a mechanistic process. From this viewpoint, it is noted that Western culture values machines over bodies and technology over nature. Thus, attaching women to these technologies gives them an illusion of safety (Davis-Floyd and Davis, 1996) CAM midwives seek to help women distance themselves as far from the reach of the technocratic model as they can. Drugs, needles, and the distant interpretation of lines on a graph depersonalize women; they are a poor substitute—in the view of CAM midwives—for the warm exchange of breath and sweat, of touch and scent, and emotions that characterize birth (Davis-Floyd and Davis, 1996). d. Empowerment of women CAM midwives believe that the birthing experience is empowering for women and should be utilized to provide an imprinting experience of control over their bodies. The issue of control is strong in the context of birth. Who holds the authoritative knowledge? What is the content of this authoritative knowledge: science and technology or intuitive, womanly feelings? Who should make the decisions (Hays, 1996)? Indeed the feminist literature on pregnancy has noted the conflict between “haptic” knowledge which is essentially sentient, and “optic” knowledge which is bio-medically-based. The claim is made that women’s feelings can be fully expressed only when the former type of knowledge is not controlled by the latter (Browner and Press, 1996; Duden, 1993; Haraway, 1991; Shildrick, 1997). The meaningfulness of giving birth and its uniqueness in the human experience is emphasized and extolled as a profound event with wide-ranging implications for the woman’s autonomy and for her child (Evenson, 1982; Klassen, 2001a). e. Nostalgia, reverence for the past “The past,” when things are thought to have been simpler and less — 148 —

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complex, is viewed with nostalgia and longing. CAM midwives regret the passing of a less sophisticated time, when life is thought to have been less complicated, when births took place in the home, a warm, supportive, and less threatening environment than the contemporary hospital. In their research among nurses utilizing CAM, Tovey and Adams (2003) state that the current interest of these professionals in CAM can be viewed as a revival of earlier patterns, which focused more on emotional needs and patient-centered practice than on technology. f. Centrality of intuition, feeling, emotion CAM midwives emphasize the centrality of emotions and feelings in the childbirth process. Their approach may be viewed in terms of “Indeterminate” knowledge as defined by Jamous and Pelouille (1970): The “Indeterminate” (I) component refers to knowledge that is affective, lacks rationality, and depends on personal feelings. By way of contrast, these authors speak of the “Technical” (T) component of knowledge which focuses on logic and rules. The “I” component plays a central role in the professional orientation of CAM midwives. Davis-Floyd and Davis (1996) refer to a “deeply embodied” kind of knowledge that defies rationality or logic. As the CAM midwife is opposed to a linear, mechanical epistemology, she prefers to use intuition as a basis for action. This provides for an alternative “logic” or way of thought. In terms of recent neuro-anatomic findings regarding the structure of the human brain, the left hemisphere belongs to analytical (male) logic, while the right one favors Gestalt perception and thought (female) (Springer and Deutsch, 1993). The approach based on “I” is different from what we would expect from the bio-medical encounter (Davis-Floyd and Davis, 1996). Indeed, the language of instinct, involving both animality and spirituality, acts as a powerful legitimator of birthing decisions that often differ from the ways preferred by medical experts (Klassen, 2001b). g. Active advocacy Listening to the CAM midwives’ narratives, one cannot but be impressed by the special quality of their rhetoric. They do not view their doctrine passively, but seem to feel a deep obligation to disseminate it among others. This is expressed in their zeal for the ideology they have adopted and by their dedication to spreading it (Davis-Floyd and Davis, — 149 —

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1996). Indeed, they view it as their obligation to propagate their doctrine among pregnant women, obstetricians, and other midwives who have not yet been informed or persuaded of its many benefits. We will now consider the empirical evidence for each of the seven components of the midwives’ unique feminist ideology. a. Rejection of the medicalization of birth Not all of the CAM midwives express their objection to the medicalization of childbirth in an explicit manner; most prefer to convey their convictions indirectly, through an expression of concern with the importance of natural childbirth and what they perceive as an overuse of technology. Monitoring the baby’s progress has turned into a search for pathologies which in most cases are not there, or go away by themselves. It makes no sense to assume that every birth is a high risk. Every woman does not need to be on the monitor. Midwives can determine if there is a risk. 85% of births are completely normal and need no medical intervention. The location of childbirth in hospitals rather than in the home is viewed by some of these midwives as the quintessence of medicalization. An advocate of home births emphasized the dysfunctions of hospital birthing. Giving birth is a healthy act…it has nothing to do with pathology, and therefore should not be carried out in a hospital—unless there is clear evidence of a problem. Putting a woman in a place like a hospital puts her in a public place with rules and regulations that ignore her personal needs for privacy, family, and emotional support. b. A strong belief in the “naturalness” of childbirth The belief in natural childbirth is a dominant theme that is common to all of the midwives interviewed. If there is one central tenet that serves as the heart of the CAM midwives’ practice, it is this belief, which was repeated in one form or another in almost all of the interviews: — 150 —

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Giving birth is a healthy phenomenon, part of the natural flow of life. Interference in this normal process can only have negative effects. The natural process is an ideal, primordial goal. The body knows what to do. Birth is a primitive process and should remain natural. We are animals. It has nothing to do with logic. Pain in giving birth is natural, but is neither good nor desirable in itself. It can be eased considerably by a variety of CAM methods so as to allow the natural processes to progress at their own pace. Epidural should be used only if the woman feels that the pain is unbearable. Let nature take its own time. I object to speeding up labor; it’s better not to use epidural to reduce pain, but rather massage and other techniques that are not invasive or drug-based… Midwives who do not practice CAM are criticized for their “bio-medicalism” and for failing to adhere closely enough to the natural order in childbirth. Midwives [who do not practice CAM] have learned a lot of medical techniques. They need to get back to nature, to touch the natural process… A belief in the centrality of mind-body “holism” is expressed in the following remarks: There is a unity of mind and body…the body is not a machine. Giving birth is a most profound moment when body and mind and soul come together. c. Rejection of the overuse of technology Our findings point to the fact that CAM midwives are virtually unanimous in their objection—sometimes expressed in heated tones—to the over-use of technology in the birthing process by physicians. — 151 —

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Interfering in the natural process with painkillers reduces the unique, dramatic experience to a technical event. Drugs interfere in the process and should be avoided. You never can know what effects they will have on mother or baby. Epidural is the opium of hospitals. It is used as a “silencer” to keep things quiet, unemotional and under control. d. Empowerment of women Childbirth is viewed by CAM midwives as a form of empowerment of women. A natural birth is a great accomplishment and serves to give women a sense of achievement and power. The midwife looked deep into the eyes of the woman and said triumphantly: ‘You did it!!’ … In order to give her a sense of triumph, of having done a splendid and wonderful thing. When giving birth, a woman should be free of inhibitions—to scream, soil herself, weep… she should be able to act totally natural, animal-like, uninhibited. She should ignore all social norms and constraints. Some midwives see the birthing experience as a trial that fortifies the woman’s inherent stamina; by passing the test, she demonstrates her strength and resilience to herself and to others. One interviewee used the example of the Israeli army’s tough traditional trek to Masada, at the end of which soldiers are given a special cap, a symbol of success in that trying test of endurance. The pain makes you stronger. It’s like the trek to Masada. Going up by cable-car is not the same as climbing by foot. You get a special sense of achievement that fortifies you for the rest of your life. e. Nostalgia, reverence for the past Many midwives express a nostalgic yearning for the past, which is — 152 —

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viewed as simpler, more “authentic,” less superficial, and less encumbered by technologies. It is seen as superior to the present and imbued with greater depth and meaning. In ancient Egypt we know that midwives used touch methods to help against pain…and even now we are told by immigrant women who came here from Morocco that they gave birth with midwives who helped them with massage and herbal brews. Years ago, when a woman began to feel her first contractions she got the children to bed, made up a big pot of soup, summoned the midwife, and had the baby right there in her own home… No problems… Why do we need to make such a big fuss over a normal birth? Some midwives express a longing for the good old days when midwives performed a variety of tasks, which added up to a meaningful whole that stretched over the pregnancy period, the delivery and the postpartum months. These individuals feel that, in those days, midwives’ expertise included knowledge and use of herbal products, massage techniques, positioning the woman for comfort and ease during labor, delivering the baby, provision of support and help after birth in breast-feeding and infant care. In recent years, there has been an emasculation in the midwife’s role with the transfer of many of her traditional responsibilities to other specialists. Delivery of twins and shifting the position of the baby in the womb are done by doctors because they are seen as risky. Use of aromatherapy and herbal treatments are done by doolas. Yoga teachers and other specialists have taken over the preparatory tasks. Baby nurses take over the care of the child immediately after birth. Specialists in breast-feeding and care of newborn infants offer postpartum help. All we midwives can do is deliver normal births. There is a widespread belief that the older methods of delivery were based on a warmer, kinder, more compassionate approach. — 153 —

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In the past, babies were delivered by caring, gentle, considerate people who helped the woman feel support and love. In the hospital today there is so much paper work and technology that there is no time to be kind to the woman. In addition, contemporary methods of delivery and infant care are thought to be accompanied by numerous pathological effects, which were rarely seen in the past: allergies to non-breast milk, digestive problems, breast infections, postpartum fever, loss of the bonding experience of breast feeding, and ill effects of drugs. That being said, in Israel one finds rabbis and other religious, charismatic figures offering health care based on a variety of traditional beliefs and practices, and many focus on problems of fertility and issues associated with childbirth. Their modes of healing are based on the use of ancient texts, traditions, and claims of access to spirits or deceased figures; their practices may involve astrological formulas, oracles, interpretation of dreams, use of special water, blessings over a holy grave, or manipulation of sacred names and verses (Shuval, 1992). Despite the frequently expressed nostalgia, midwives who use CAM methods were concerned to make clear their separateness and difference from these traditional practitioners and their belonging unambiguously to the bio-medical community: We have nothing to do with people who use cards, talismans, holy water. What good does a rabbi’s blessing do? It won’t make you get pregnant!! What’s the use of visiting someone’s ancient grave?… I’m all for spirituality…but not everything can be included in CAM. f. Centrality of intuition, feeling, emotion The Indeterminate (I) component of care, which emphasizes feelings and emotions, plays a central role in the professional orientation of CAM midwives. They accentuate the idiosyncratic aspects of each woman’s experience and tend to be critical of physicians who are highly Technical (T) in their behavior and practice, emphasizing rationalized, — 154 —

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routinized tests, and technically prescribed procedures. The CAM midwives highlight the drama, uniqueness, meaningfulness, spirituality, and miraculous quality of the context in which they work. Both the woman delivering an infant and the midwife herself are caught up in the drama and emotionality of the experience. Giving birth is a deeply emotional experience that requires support and empathy. Every birth is different, individual. It’s never the same and its success depends on the intuition of the woman and of the midwife. You can’t do it by the book. The womb is a bridge between different worlds. There is a crossing over a boundary… Birth is a profound experience… A miracle. A midwife who specialized in reflexology emphasized the “softer” aspects of reflexology as contrasted to the “aggressive” techniques used by some practitioners: Some reflexologists use cold, ‘blunt,’ overly structured techniques, whereas I prefer a warm, sensitive, individualistic, empathetic approach to patients. g. Active advocacy Many of the CAM midwives feel that they have a mission, a “calling” to spread the message regarding the important contribution of their approach in improving the birthing experience: reducing fear, increasing a sense of achievement, and strengthening the relationship with the child. This orientation is accompanied in many cases by considerable zeal and passion. This may sound presumptuous, but I feel I have an important mission. It’s like a religious feeling. This is not only a job... I have a ‘vocation’ in my life. Women do not have to suffer so much in childbirth. I feel a deep sense of mission. It imbues me with dedication… to help women overcome their fear. Not to depend so much on painkillers….To strengthen their — 155 —

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bonding with the baby. In their zeal and commitment, some of the midwives criticized their colleagues who were less moved with a sense of mission, referring to them as “bureaucratic” in their approach. Many midwives [i.e., who do not practice CAM] have no real emotional commitment to their work. They don’t feel the experience of each woman as a meaningful one. All they want is to move the women along. It’s like a mass-production line…just get as many cases as possible through. Midwives [who do not practice CAM] are busy with many women in labor. They rush around among them…they see separate, disconnected parts of the woman’s experience… But they never are able to see the entire process through… From beginning to end… CAM midwives seek to convince women in labor of the effectiveness of their methods. In line with their respect for the autonomy of women during childbirth, they approach selected women, when they arrive at the delivery room, to convince them to use CAM methods during labor. If after trying CAM techniques a woman insists on receiving epidural or a drug to encourage dilation, the midwife always agrees despite her own beliefs that other CAM methods could be effective. Discussion and Conclusion The CAM midwives’ epistemology includes a set of axioms and values which are congruent with selected elements of feminist ideology. Although there were few specific statements in the course of the interviews making this connection explicit, we have referred to a number of texts in the feminist literature which discuss most of the ideological themes to which the midwives adhere (Browner and Press, 1996; DavisFloyd, 1992; Davis-Floyd and Davis 1996; Duden, 1993; Evenson, 1982; Haraway, 1991; Hays, 1996; Klassen, 2001a, 2001b; Rushing, 1993; Scott, 1998; Shildrick, 1997; Weitz and Sullivan, 1986; Young, 1990). There is no evidence that the CAM midwives are conscious or active feminists in the broader sense of the term. Their beliefs are context— 156 —

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specific and do not seem to go beyond the arenas of pregnancy and childbirth. What is similar to some branches of the feminist movement is the quality of their beliefs, which are imbued with considerable zeal, passion, and a determination to disseminate them to a wide and heterogeneous public. We have identified seven substantive themes, which together may be viewed as the CAM midwives’ epistemological tenets: criticism of the medicalization of childbirth; an emphasis on natural processes in childbirth; objection to physicians’ over-reliance on technology and drugs; empowerment of women through childbirth; nostalgia for the past when childbirth was a more meaningful experience and midwifery was a more broadly defined occupation; emphasis on the expressive meaning of the birthing experience; a sense of zeal and mission to spread their message. The first three themes (i.e., the rejection of the medicalization of birth, the strong belief in the “naturalness” of childbirth, the rejection of the overuse of technology) are interrelated in the sense that they are all critical of the approach of wide segments of the bio-medical profession to childbirth. Since midwives’ work is essentially practical, they tend to contextualize their objections to medicalization with rhetoric focusing on “natural” processes and invasive technology. CAM midwives also express their disapproval of the medicalization of childbirth in an indirect mode through criticism of their colleagues who do not embrace CAM practices and who do not accept its many benefits. It is probably less threatening to criticize other midwives than to criticize physicians. These co-workers are berated for their conformity to the requirements of bio-medical obstetricians, who encourage use of epidural and interference in the natural developmental rhythm of labor. The CAM midwives also criticize the failure of such midwives to relate to the whole individual and her needs during childbirth. They disapprove of the routinization of their work and their failure to relate to the meaningful experience of each woman. Like the obstetricians, they are only concerned to move the women along through the “production line.” The notion of “empowerment” of women is one of the central tenets of feminism. It is transformed by the CAM midwives into a contextspecific concept relating uniquely to childbirth. In their use of the concept, it is endowed with a special meaning, which is anchored in the essentially female experience of childbirth. The uniqueness of the birth — 157 —

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experience and its exclusiveness to women are singled out as sacred, magical, “a lifetime experience that is perfect, glorious...and unfrightening.” This unique, empowering experience endows a woman with a lifelong sense of achievement. Emphasis on intuition, feeling and emotion is the most explicitly “female” of the CAM midwives’ themes. These traits represent the quintessence of the traditional female and serve as a sharp contrast to such “male” qualities as rationalism, logic, control, analysis, and evidencebased medicine, all of which are perceived as “cold.” The “I” qualities of intuition, subjectivity, spirituality, emotion, and feeling celebrate the special femaleness of childbirth by highlighting the importance and centrality of a specific set of qualities associated with the uniqueness of woman. We have noted that the notion of “active advocacy” provides a mission-oriented component to the CAM midwives’ ideology. Among the extremists, this borders on religious zeal and fervent belief in their importance and efficacy: a strongly held conviction, a sense of mission, a “calling” to spread the word to as many people as possible. These include pregnant women and women in the labor room where every woman is a potential client, as well as obstetricians and other physicians. Nostalgia and a reverence for the past provide a mechanism to distinguish the CAM midwives from the dominant bio-medical orientation toward up datedness, newness, and the latest scientific knowledge and technology. Visualizing the past as better and more meaningful provides legitimation for rejection of major elements of the present—especially in a bio-medical context. Midwifery is essentially a traditional occupation, which has been modernized to acceptable bio-medical standards; the CAM midwives accept this modernization, but seek to retain or return to certain of their earlier roots. This provides them with a unique identity, which separates them from mainstream midwives. In sum: the CAM midwives in Israel are able to act out their ideological stance in delivery rooms of bio-medical hospitals where they enjoy considerable autonomy. As long as labor and delivery are deemed “uncomplicated” by bio-medical criteria, the midwives are in complete charge. For the most part, the physician’s presence is virtual, i.e. maintained through the monitor. Once they have obtained the woman’s consent, the CAM midwives feel free to introduce CAM techniques to control labor pains and reduce use of drugs, thus expanding the bound— 158 —

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ary of CAM legitimacy into the heartland of bio-medicine. The physician’s presence—virtual or real—in the close vicinity of the delivery room provides an unambiguous message indicating when CAM treatment must be terminated, i.e. when the birth is “complicated.” Thus, the midwives’ use of CAM is contingent on the pathology of the case as defined by bio-medical criteria. The midwives engage in CAM inside bio-medical settings with confidence and transparency. In this regard, they differ from nurses in CAM practice (chapter 8), who are cautious in exercising their CAM skills inside bio-medical institutions (Lifshitz-Milwidsky, 2007; Shuval and Gross, 2008b). The CAM midwives are based inside the organizational boundary of bio-medicine and practice comfortably within it. Their selfassurance is reinforced by the full responsibility they carry for 80% of the births (which are “uncomplicated”). The findings show that there is some flexibility in the definition of “uncomplicated,” and determined CAM midwives sometimes negotiate the boundaries of that condition. Finally, the fact that many obstetricians support the notion of “natural” childbirth provides them with legitimation for many of their CAM practices.

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CHAPTER 10

INTEGRATIVE MEDICINE IN FAMILY PRACTICE1 Judith T. Shuval and Revital Gross

A special form of integrative medical practice is seen among family practitioners who have incorporated one or more forms of CAM into their regular clinical work. In their family practice clinics, they selectively combine elements of both into an integrative treatment plan (Bell, et al. 2002; Boon, et al. 2004; Coulter, 2004; Kailin, 2001; Launso, 1989). The delicate balance accorded to bio-medicine and CAM lies at the heart of this form of integrated practice. These doctors differ from those discussed in chapter 7. In the latter, the physicians essentially practiced as homeopaths—having placed their bio-medical training in a latent stance to be used principally as a means to avoid possible medical errors and to screen out cases for which bio-medical attention takes priority. Those physicians, for the large part, had made a career choice—opting for homeopathy over bio-medicine in their clinical practice. The doctors considered in the present chapter made a different career choice. They believe in a purposeful integration between bio-medicine and CAM; as family practitioners, they seek to offer patients the best of both worlds in a single practice setting. The forms of CAM most frequently practiced by these family doctors were homeopathy and acupuncture, but several practiced more than one CAM specialty, e.g., a combination of acupuncture, healing and biofeedback or a mixture of homeopathy, Chinese, herbal and anthroposophic medicine. The decision to incorporate CAM into their daily practice was an informal one reached individually by the practitioners themselves; it did not require permission from the sick fund employers. Such a laissezfaire approach is based on the assumption that a qualified physician may choose clinical methods of practice at her/his own discretion (Israel Medical Association, 1997; Yishai, 1999). The sick fund authorities that employed these physicians took no official stand regarding this inclu— 160 —

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sion of CAM in their clinical work. Some were aware of the phenomenon; most preferred to ignore it, while others expressed acceptance or approval. This stance stems from the fact that three of the sick funds in Israel have addressed the widespread popular demand for CAM services on a formal, structural level by establishing their own network of CAM clinics. In the fourth sick fund (Leumit), which covers 9% of the population, CAM practitioners work in the context of the regular primary care clinics. Since the National Health Law of 1995 does not include CAM in its set of universal entitlements, patients pay for CAM on a fee-for-service basis in the sick fund clinics; those who carry supplementary insurance policies, pay a reduced fee. In 2009, 74% of the population carried such supplementary health care insurance (Kaidar and Horev, 2010; Rosen and Samuel, 2009). The type of integration practiced in the sick funds’ CAM clinics has been described in chapter 5 as a form of co-optation with structured control by the biomedical establishment. In fact, it is a physician who occupies the critical senior post in each clinic (“rofe memayen,” i.e., allocating doctor). He/she screens all patients at the time of their first visit checking their eligibility for CAM by biomedical criteria and the patient’s preference. The patient can change to a different CAM practitioner only with the permission of the senior physician. It has been noted that this procedure serves to highlight the boundary separating bio medicine and CAM by establishing a form of parallel practice (Averbuch-Smetannikov, 2010; Shuval and Mizrachi, 2004). This system is different from the type of practice discussed in this chapter, where the same physician uses both bio-medicine and CAM, at his/her own discretion, in the context of the regular sick fund clinics. Method Unlike Germany, Holland, France and New Zealand where there is a high frequency of integrated practice in the context of primary care (O’Brien, 2004; Pirotta, et al. 2000), this form of practice among family doctors is relatively rare in Israel and there are no lists that permit an estimate of its frequency. The recent establishment of a formal organization of integrative practitioners within the Israel Medical Association suggests that the number of such practitioners is growing, as is the case in other countries. — 161 —

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The nature of the research questions dictated the use of qualitative methods (Marshall and Rossman, 1995; Pope and Mays, 1999). We sought analytic generalizations relating to the theoretical issues raised rather than statistical generalizations which refer to frequencies of phenomena in the population (Yin, 1984). Accordingly, our data collection was based on in-depth interviews with a small number of individuals (Bogdan and Biklen, 1998). Fifteen family practitioners who utilized CAM as an integral part of their regular family practice were selected by means of purposeful sampling (Bogdan and Biklen, 1998). This number was reached after it was felt that theoretical saturation had been attained (Miles and Huberman, 1994). Interviewing took place between December 2007 and October 2008. All of the physicians were employees of the sick funds which provide health care to all Israeli citizens (Rosen and Samuel, 2009). An attempt was made to maximize the heterogeneity of the subjects in terms of gender, age, sick fund employer and location in the country. In the course of the research, we found that some had separate offices for private and public practice. The principal research instrument was a semi-structured questionnaire. All questions were open-ended, and respondents were encouraged to speak freely about their training, experience, impressions of integrative practice and the issues it raises for them (Gross, et al. 2009). The interviews were carried out by two experienced researchers trained in interviewing techniques.2 Interviews took place in the physician’s clinic or home and lasted between one and two hours. Interviewers took notes and recorded the interviews. Data analysis began early in the course of the interviewing so as to evaluate the need for additional interviews and introduce changes in the interview protocol. Analysis of transcripts involved coding of the principal themes in an effort to discern thematic patterns relating to the theoretical issues (Bogdan and Biklen, 1998; Miles and Huberman, 1994). Findings In the following section, we will consider the empirical nature of a number of boundary issues raised by practitioners in the course of the interviews. Specifically we will examine the following boundaries: boundary of practice which separates bio medicine from CAM; epistemological boundary; boundary of identity; cognitive boundary; organizational — 162 —

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boundary; social boundary. This list is not exhaustive but represents the most visible of the boundaries which emerged from the empirical data. 1. Boundary of Practice The boundary of practice, separating bio-medicine from CAM, is the critical line that must be negotiated in this form of integrative practice: which type of medical care will be used in a specific clinical situation? The data indicate that there is a clear temporal process which occurs among almost all practitioners: their first choice is to focus on the appropriate bio-medical tests, diagnosis and treatment options, and only after these have been considered and dealt with is a CAM option considered. A clear priority is given to bio-medical procedures in order to avoid error or misdiagnosis, especially in life-threatening conditions. After the basic bio-medical record has been scrutinized and necessary treatment prescribed or deemed un-necessary, CAM treatment can be introduced. This priority is observed even when a patient declares that she/he chose to come specifically for CAM treatment. The introduction of CAM may take place in response to a patient’s request. It may also occur at the physician’s initiative through suggestions for dietary changes or revisions in the patient’s style of life. The patient may not even be aware that CAM has been introduced. Such an unobtrusive introduction is relatively easy for homeopaths or naturotherapists, who advise on natural cures and food additives. Averbuch-Smetannikov (2010) has noted that physicians prefer to offer CAM care to patients who they believe are likely to benefit from it; they naturally want to accumulate therapeutic successes and avoid ineffective treatment as this is likely to affect their reputation. Thus, they avoid using CAM with patients for whom they feel that the likelihood of success is limited. Patients whose expectations are too high or unrealistic with respect to the benefits of CAM are often deemed unsuitable for integrative care. I always start on the patient with a conventional, biomedical approach. This is the top of the pyramid. I always begin with it. (#10) A patient arrives with a cold, back pain and all sorts of other problems. I first give him a conventional (bio) — 163 —

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examination, but at the very same time I consider his case from a holistic viewpoint. I consider all the options available…it makes no difference if they are defined as conventional or alternative. (#7) I often direct the conversation in a subtle manner… using Chinese diagnostic questions: relating to diet, balance of hot and cold foods, nature of the menstrual flow, personality traits, emotions…pulse and tongue examination...without the patient realizing that I have introduced Chinese diagnostic methods. (#2) 2. Boundary of Identity—Who am I? All of the doctors included in the study had more than one professional identity: one as a bio-medical family practitioner and at least one as a CAM practitioner. In several cases, physicians had more than one CAM specialty and therefore carried multiple CAM identities. How do the physicians define themselves—to others and to themselves? Which of her/his identities are patients seeking when they chose to come to him? Since all the physicians in this study work as family practitioners in one of the sick funds, their formal, public identity is predominantly bio-medical. At the same time, at least one of the interviewees overtly straddled the boundary: a sign on her door identified her as a family practitioner who also is qualified to practice acupuncture. (#4) Most feel that their bio-medical identity is what gives them confidence and authority. This stance may be viewed as a form of boundary work which enhances their status and power-relationship with patients. Most are proud to be bio-medical doctors and overtly emphasize that identity. I don’t know what I would do if I were not a full-fledged doctor. It’s what gives me a tremendous amount of knowledge. I wouldn’t feel really confident dealing with patients without this basic knowledge. (#3) At the same time their CAM work is of high priority and, while few — 164 —

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used any public labeling mechanism to let patients know that they also practice CAM, their reputation as integrative physicians spreads informally through patient networks and among patients’ families and friends. Many reported that patients sought them out precisely because of their CAM specialty, hoping to benefit from the integrated mode of medical practice. When the physicians feel that CAM is more appropriate than bio-medicine, they make an effort to convince the patient to try CAM. Some patients chose me because they know I integrate CAM in my practice, but some don’t know and view me as a family practitioner. The sick fund does not identify me as an integrative doctor in its list of practitioners…” (#1) I would rather not use Western medicine when I know that CAM is more effective... It all depends on the specific situation… I try to convince the patient that CAM is better. (#1) 3. Epistemological boundary The integrative physicians are divided in their views on the extent to which an epistemological boundary divides bio-medicine and CAM. The most extreme view sees two different paradigms which cannot be reconciled. The opposite view perceives no separation and believes in “one medicine” in which there are overall goals (e.g., the patient’s health) and a variety of methods, which must be judiciously selected and utilized to attain them. Another view minimizes the conflict in paradigms and sees CAM practices as functional additions to the arsenal of clinical options offered by bio-medicine. There is no conflict because acupuncture and Western medicine deal with different subjects: Western medicine with an immediate, urgent problem and Chinese medicine with the sources of the problem. In other words, Western medicine provides a solution to an immediate problem while Chinese medicine is concerned with the roots of the problem. (#1)

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There are lots of conflicts...about food, attitudes, overall approach… Certain indicators are not meaningful in the context of conventional medicine but highly significant to a CAM practitioner. (#12) I see no conflict. There is only one medicine. It is composed of many concepts…[it] includes conventional approaches but is expanded to include additional ideas and methods. In the final instance, it amounts to different levels of orientation and not to conflicts… All this on condition that high quality medicine is involved. (#10) We’re talking of two different closed systems; they talk different languages; take it or leave it. They can’t be evaluated by the same criteria. Each system has its own beauty and fascination and also its own weaknesses. (#4) 4. Cognitive Boundary Cognitive boundaries define the types of knowledge and practice which are viewed as legitimate. In explaining their reasons for choosing to practice CAM, many of the interviewees expressed extensive criticism of the knowledge base and practice norms of bio-medicine. From a holistic viewpoint, the latter were depicted as segmented, impersonal, overly invasive, drug dependent and mechanistic. Their opinions focused mostly on modes of practice and medical education, and only occasionally on theoretical objections. A mixture of systemic and ad personam criticisms was voiced. They [conventional doctors] receive too many patients— often 12 an hour—so that it’s impossible to relate to their needs fully; therefore, they depend too much on antibiotics. I provide support, talk to the patients, try to understand what’s happening, and explain how to change their behavior and style of life. (#5) Conventional doctors work mechanically, especially in hospitals—according to formal protocols of procedures. — 166 —

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There is little personal input of intuition or understanding of the body’s natural needs. (#10) Doctors in conventional practice are focused on the disease rather than on the patient… There is little awareness of the bio-social-psychological model… The medical system does not provide fair, egalitarian, caring medicine... the global drug companies determine how conventional medicine operates. (#12) 5. Organizational boundary All organizations have boundaries. As discussed in chapter 3, these are expressed in formal and informal regulations and norms which define membership to determine who is in and who is out as well as the obligations of members and would-be members. The sick funds, which employed the physicians under study, maintain important boundaries which the integrative doctors need to consider in the course of their daily practice. Certain of these are unambiguously defined; others are diffuse and malleable. A crucial fact is that the sick funds maintain special clinics where CAM is offered under formal bio-medical auspices. These clinics have an inherent interest in recruiting patients who pay for the service, albeit at a reduced rate if they carry supplementary health care insurance. As noted, the subjects of the present research, practicing in the context of family-medicine clinics, offered a different form of integrated practice; integration was personal in that each physician also practiced one or more forms of CAM directly in the context of her/his on-going bio-medical work. Clearly, these doctors preferred to work within a bio-medical organizational structure and chose the context of family practice. A number noted that this setting provided a strategic site from which to disseminate information regarding CAM among patients and colleagues. At the same time, these physicians offered a measure of competition to the sick funds’ CAM services. This context resulted in some ambiguity with regard to the form of integrative practice under consideration here. Of most salience here is the regulation by which salaried doctors are not permitted to engage in private practice in the context of their work. Thus, practitioners could not be compensated for the inclusion of CAM in their practice because — 167 —

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all were salaried personnel employed by the sick funds. The timetable of practice made it problematic to allot time slots for those CAM practices which required extra time, e.g., acupuncture. However, motivated by a compelling desire to provide the benefits of CAM to their patients, physicians incorporated elements of homeopathy and Chinese medicine into on-going clinical procedures; this is also true of major elements of naturotherapy, herbal medicine, and healing. At the same time, the issue of private practice looms large for these practitioners. Quite a few of the 15 interviewees maintained private clinics in different geographic settings since they could not take fees under the sick fund’s auspices. These settings offered an opportunity to augment their incomes. Several interviewees mentioned that they found the situation uncomfortable since they felt it was inappropriate or unethical to refer patients to their own private clinic. What would be considered more acceptable would be referral to one of the CAM clinics run by the sick funds. Some physicians did report doing this. But others spoke of a reluctance to refer patients to these CAM clinics because of their reservations about the quality of care provided there. Several expressed the view that the more skilled CAM practitioners did not work in those settings. A number of physicians mentioned that a solution to the above dilemmas would be for physicians to allot half an hour or an hour gratis to patients needing CAM therapies—at the end of their working day right in their public clinic. My problem is that it is illegal for me to provide private care (fee for service) to members of the Macabbi sick fund in my clinic—ever, at any time...what I can do is refer them to Macabbi Tiv’i (the sick fund’s CAM clinic network). (#1) I myself wouldn’t work for the sick fund’s CAM clinics… they only opened them to make money and they have no ideals or principles…they impose lots of technical limitations on the length and number of treatments…all to make sure they make a profit. (#1) I have a private clinic where I give CAM treatments...but — 168 —

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I generally don’t suggest it to patients in my family practice clinic…it doesn’t feel right…I prefer to refer to the sick fund’s CAM clinic…it’s also cheaper for members of the sick fund to go there. (#14) 6. Social boundary Professional networking, and exchanges of opinion and information between practitioners are essential in maintaining high quality medical practice. Physicians who have shifted to a predominantly CAM practice frequently find themselves professionally and socially estranged from or even stigmatized by conventional doctors (Averbuch-Smetannikov, 2010). The physicians in the present study are unique in that they viewed themselves as integrative practitioners who sought to practice in both worlds. Still, for most their primary identity was with bio-medicine. Indeed, several indicated that they felt accepted by other physicians—even though some of the latter expressed reservations regarding their “questionable” type of practice. The bio-medical community serves as a salient reference group for these practitioners, and several expressed their interest in maintaining on-going contact with it. One of the interviewees noted that he made a point of attending a journal club in which he had no hesitation in raising issues related to CAM and felt comfortable even in the face of frequent criticism. Another noted that more research on the efficacy of CAM is important because that is what will help convince the bio medical community to accept this type of practice. [More research] will help convince the medical community…if they see that CAM treatments really are effective. I don’t feel rejected by other doctors… (#1) Anyone who knows me realizes that I am a physician and that my work is fine. I am a member of a journal club… and lots of times I talk about CAM. Some probably think I’m peculiar and change their attitude toward me…others call later to ask all kinds of questions. First and foremost I am a physician in diagnosis, ethics, — 169 —

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commitment to science and in my ability to maintain contact with others members of the medical profession. (#11) 7. Some additional boundaries There are other instances of boundary crossing worth noting briefly. There are boundaries between the many varieties of CAM; several of the practitioners practiced more than one form of CAM and moved freely among them in accordance with the patient’s needs. The holistic approach of CAM practitioners results in a deliberate effort to consider as many aspects of the patient’s life as possible in the process of diagnosis and treatment. Thus, spheres of life which are generally differentiated and kept separate by clear boundaries are permeated and incorporated in the treatment process. For example, relations among family members, work, and leisure activities are all relevant when a holistic approach is taken. One of the interviewees noted that family medicine attracted him precisely because it incorporates an open, holistic approach and is therefore more accepting of CAM. The boundary between physician and patient which—in bio-medical practice—is generally characterized by a measure of formality and distance is casually crossed by CAM practitioners who seek to gain a closer, less formal relationship with their patients and infuse it with warmth and intimacy. Discussion In a striking consensual gesture, all of the interviewees declared their inherent and unequivocal presence on the bio-medical side of the practice boundary. This is expressed in statements that bio-medicine is always utilized as the first choice priority at the start of every integrative medical encounter. With some patients—depending on the clinical conditions and the patient’s individual approach—the boundary separating bio-medicine and CAM is never crossed. At first glance, one might conclude that the form of integrative practice considered here represents an effort at the medicalization of CAM. Fadlon (2005) coined the term “domestication” to describe the process by which the tenets of CAM, which differ from those of bio-medicine, are transformed and rendered more culturally acceptable as well as less exotic and challenging. The data suggest that the converse may be — 170 —

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a more appropriate description of the processes seen in this research: an effort at “CAMification” of bio-medicine. The widespread criticism of the practice and structure of the bio-medical system represents an overt declaration that the adoption of CAM can result in more effective clinical results and can avoid many of the weaknesses and errors of biomedicine as currently practiced. The integrative physicians are for the most part imbued with keen beliefs and zeal for the integration of CAM with bio-medicine. For most, CAM is not a minor or purely professional preference, but an integral part of their total life-view determining their personal values and behavior. Indeed, some noted explicitly that their chosen specialty, family practice—with its broad-based, flexible approach and acceptance of the bio-psychological-social model—is an ideal setting for the integrative process in which they believe. Once having established their unmistakable bio-medical identity, most seek strategies to introduce CAM into the medical encounter. The epistemological and cognitive boundaries do not appear to pose any problem for these integrative physicians. Many deny the existence of boundaries separating epistemological paradigms with the declaration that “there is only one medicine” which embraces all effective means of diagnosis and therapy. The absence of evidence-based criteria for the inclusion of treatment methods in much of CAM is brushed aside by the belief that these criteria are not always applied even within bio-medicine and that a pragmatic criterion, i.e. what works, should be the determining factor for acceptable and desirable procedures. Thus, all methods which serve the patient to alleviate pain, provide cure or prevent disease are acceptable. With respect to the cognitive boundary, the widespread criticism of the structure and practice of contemporary bio-medicine serves to legitimate boundary crossing. In the view of these integrative physicians, the failures and drawbacks of bio-medicine are both numerous and extensive; CAM provides effective alternatives to many of these failures, as well as many additional benefits. By crossing the cognitive boundary, these physicians believe they are improving patient care. As long as CAM is not included in the set of entitlements provided by the Israel National Health Law, the organizational boundary of the sick funds continues to pose a number of structural problems for the integration of CAM into family practice. The proscription of private practice — 171 —

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in the context of a sick fund clinic imposes a boundary which is highly salient and largely impermeable. Those seeking to practice integrative medicine in the context of the sick fund clinics have no choice but to seek ways to negotiate this boundary. The simplest solution—but one that is not always satisfactory to the physician—is referral of patients to the sick funds’ CAM clinics. While this solution seems straightforward, it is problematic for those who are critical of the quality of CAM offered in these clinics. It is also frustrating for the physician not to feel free to make use of her/his own CAM skills when they appear to be applicable and useful. The data show a number of boundary strategies utilized to overcome this problem. Two of these approach the issue of private practice by temporal or spatial differentiation. Setting aside an hour at the end of the working session for patients to receive CAM gratis may be seen as the introduction of a new temporal boundary which makes the practice of CAM acceptable in the sick fund clinic. Another strategy involves the creation of a new geographical and organizational boundary by establishing a private practice in another location where CAM can be practiced legitimately. In many respects, this is a preferred solution, although several physicians noted that they felt uncomfortable in referring their patients from the sick fund clinic to their own private practice. A widespread mode of negotiating these boundaries is to introduce CAM in a discreet, low profile style into the ongoing clinical encounter. This is done without a purposeful declaration or identification of the CAM procedures. The most amenable areas for this unobtrusive approach to boundary crossing are those CAM branches which can be introduced almost unnoticeably, e.g. those that relate to diet, lifestyle, relaxation techniques, and use of herbal or homeopathic products which can be obtained over-the-counter. Practitioners are carefully attuned to their patients’ expectations: they avoid use of CAM with those who express reservations and offer it freely to patients who seem positively predisposed or explicitly request it. On the occupational level, the integrative physicians are characterized by multiple identities distinguished by boundaries which separate their roles; in all cases, they are MDs with a specialization in family medicine and practitioners of at least one CAM specialty. But many have studied and now practice several CAM fields. Despite their strong beliefs and zeal for CAM, the integrative physicians generally prefer to identify — 172 —

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publicly with their bio-medical role. Several stated explicitly that this role provides them with confidence and status and assures their membership in the mainstream medical community. Indeed, with regard to the social boundary between bio-medicine and CAM, these integrative physicians make it clear that they are physicians and not CAM practitioners. In this regard, they differ from the homeopathic physicians discussed in chapter 7 who had the same type of training but had made a deliberate choice to maximize the CAM components of their practice, using bio-medicine in a minor mode essentially to assure prevention of error. Averbuch’s-Smetannikov’s (2010) subjects often experienced professional isolation from the mainstream bio-medical community, which in many cases rejected their crossing the social boundary into the mainstream professional community. Most of the integrative doctors in the present study made a point of keeping up their social and professional ties with mainstream practitioners—precisely to prevent closure of the social boundary between them. Conclusion The epistemological multiplicity of this context offers an opportunity to explore a wide variety of boundary issues: how are they imposed, defended, bridged, subverted, and transformed? The ease with which boundaries are crossed in the complex social context described is characteristic of post-modern societies. Indeed the integrative physicians described in this study are inherently “post-modern” figures who reject the impermeability of many long-established boundaries. They do not hesitate to re-contour and cross them frequently and casually with little discomfort or self-consciousness. They live and work in several worlds simultaneously, and in most cases are not troubled or aware of the apparent anomalies implied. It has also been noted that post-modern persons frequently cross boundaries; with the purpose of occupational changes, marriage, divorce, travel, migration to seek better jobs, level of lifestyle, changes in style and taste, such change is ubiquitous (Bauman, 1991, 1997; Lyotard, 1979; Smith, 2000; Zerubavel, 1991, 1999). In considering this fluid social context, Giddens (1991) suggests that informal social networks perform a special function in providing security, predictability and meaning to the individual confronting uncertainty and ambiguity (Simmel, — 173 —

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1971; Snow, 2001). Our findings show how strongly and publicly the integrative physicians adhere to their “parent identity”: bio-medicine. They seem to sense the dangers of the “stranger” status referred to by Simmel (1971) in which boundary crossers are stigmatized or isolated from the mainstream community. As the most powerful and prestigious of the several identities available to the integrative physicians, they seek actively to embrace bio-medicine despite their explicit critical views. At the same time, many are imbued with remarkable zeal to promote the use of CAM alongside bio-medicine so as to benefit patients and improve the quality of medical practice.

Endnotes 1 Yael Ashkenazy, MPH, Irit Elroy, MA and Liora Schachter, MD played a significant role in the data collection and analysis for this chapter. See, Gross R, Ashkenazi I, Elroy I, Shachter L and Shuval, J.T. (2010). Perceptions of Physicians, Patients and Policy Makers on Integrating Complementary and Conventional Medicine Jerusalem: Myers-JDC-Brookdale. Hebrew. English Summary. 2 Yael Ashkenazi and Revital Gross

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CHAPTER 11

TO REGULATE OR NOT TO REGULATE?: THE PERSPECTIVE OF POLICYMAKERS ON INTEGRATED CARE Revital Gross, Yael Ashkenazi and Leora Schachter

Introduction In recent years, conventional physicians in Israel and other countries have been learning and applying CAM in their regular practice of patient care (Averbuch-Smetannikov, 2009; Mizrachi and Shuval, 2005; Samuels, 2002; Shuval and Mizrahi, 2004). We refer to this new pattern of care as “Integrated Care” (IC). In Israel, as in many other countries, physicians are legally permitted to provide any treatment that can improve the patient’s condition, including CAM. Nevertheless, a review of the literature reveals that IC poses medical, legal, ethical and financial dilemmas in many countries, and these arouse debate on the need for regulating CAM practice even when it is delivered by licensed bio-medical physicians. 1. Safety of CAM Use Some CAM treatments (e.g. medicinal herbs) may have unfavorable side effects or adversely interact with prescription drugs. Yet the products, their active ingredients and safety remain unsupervised such that they may cause harm even though prescribed by physicians (O’brien, 2004). Many physicians are unaware of the potential dangers of consuming herbs and food additives (Silverstein and Spiegel, 2001). Studies have documented a whole series of undesirable effects of CAM, of which physicians may not be aware of (Caulfield and Feasby, 2001; Cohen and Kemper, 2005). 2. Physician Knowledge of the Effectiveness of CAM Treatments A substantial number of physicians are uninformed about research findings on CAM effectiveness, administering treatments that have no proven value or may be harmful (Cohen and Kemper, 2005; Winnick, 2005; Woolf, 2003). This may delay the receipt of conventional care by — 175 —

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patients, aggravate their condition and incur higher costs for the paying party. In addition, administering treatment without adequate knowledge of its effectiveness raises ethical questions about a physician’s professional judgment (Adams, et al. 2002). 3. Training, Licensing and Supervision The extent of regulation varies widely among countries. Some countries have government regulations about the practice of CAM therapies, licensing and training requirements, while in others standards are set by associations of practitioners. Still other countries have no supervision of institutions teaching CAM or binding standards for training practitioners, including physicians (Dixon, 2008). Physicians (like other CAM providers) without appropriate training may offer poor or harmful treatment (CAMDOC alliance, 2010; Mills, 2001; O’Brien, 2004). 4. Legally-Defined Physician Obligations in the Provision of CAM Legally and ethically, a physician practicing CAM must obtain a patient’s informed consent and the patient must be fully advised of the treatment’s risks and effectiveness (Golan, et al. 2006; Kerridge and McPhee, 2004; Nicolai, et al., 2006). Due to unproven effectiveness, physicians sometimes withhold necessary information. Their provision or recommendation of CAM could expose them to suits of medical negligence or charges of breach of discipline for unprofessional conduct should the treatment stray from accepted standards (Caulfield and Feasby, 2001; Cohen and Kemper, 2005). 5. Paying for CAM Treatments Administered by Physicians There is wide variation between countries in the extent to which the public system finances CAM treatments (Dixon, 2008). CAM treatments are not included in Israel’s basic set of entitlements provided by the National Health Insurance Law, 1995, thus raising ethical questions about paying for CAM treatments provided by physicians employed in the public system. If a physician provides CAM treatments for a fee, this poses a dilemma about charging for private care in the context of a public framework, as well as issues of equity in access to CAM treatments. If the treatment is offered at no additional charge, it indirectly increases the burden on the public basket of services (See chapter 10). These issues have triggered debate on the need to regulate CAM — 176 —

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treatments provided by bio-medical physicians. In some countries, including the US, Canada and Australia, the process of regulation has already begun (CAMDOC Alliance, 2010; Caulfield and Feasby, 2001; Goldner, 2004; Horrigan and Block 2002; Mills, 2001; O’Brien, 2004; Sturm and Unutzer, 2001). In Israel, several public committees have been appointed to recommend regulation of CAM practices, but their mandate does not include regulation of IC in which CAM treatments are administered by licensed bio-medical physicians. This chapter examines policymakers’ perceptions of IC, its advantages, the problems involved and regulation issues. In considering their attitudes to medical, legal, ethical and financial problems raised by IC, it will highlight implications for formulating policy regarding the practice of CAM by physicians as well as the necessary regulation. It will address problems impeding regulation of IC in Israel and suggest ways to overcome them. Methods The study adopted a qualitative approach which is suitable for exploring a new, unfamiliar phenomenon for which there is no prior knowledge or guiding theory (Bogdan and Biklen, 1998). The study was approved by the Ethics Committee of Bar-Ilan University. This chapter presents partial findings of a comprehensive study on the topic of integrated care, which included interviews with policy makers, physicians and patients (Gross, et al., 2010). After interviewing physicians and patients, in early 2009 we sent a summary of the findings to senior policymakers at the sick funds, the Ministry of Health and the Israel Medical Association, all of whom are in key positions to influence regulation either nationally or at the sick fund level. We interviewed 16 senior policymakers responsible for financing and developing health services as well as licensing and regulation of health care both nationally and in the sick funds. Fourteen were themselves physicians (of different specialties) and two were lawyers. In-depth interviews of about an hour-and-a-half were conducted using a semi-structured interview protocol, which enabled a deeper understanding of the phenomenon by obtaining the viewpoints and interpretations of interviewees familiar with the topic from different angles (Lincoln and Guba, 1985). Interviews were recorded manually in real time and fully reconstructed shortly afterwards. The data analysis — 177 —

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was circular and simultaneous with the interviews; the findings of the latter helped to choose additional interviewees and adjust interview questions. The analysis was based on classification and categorization to identify patterns, trends and conceptual categories (Miles and Huberman, 1994). Findings 1. Attitudes to Integrated Care IC can take numerous forms—as is made clear in the chapters of this book. In the present chapter, we chose to elucidate policy makers’ attitudes to a specific model of IC practiced by primary care physicians who are employed by the sick funds (see chapter 10). Thus, we opened each of the interviews with the policymakers with a description of the form of IC on which we sought their views. This description included three characteristics of the IC under consideration: 1. Primary care physicians use CAM methods as well as bio-medical tools and treatments 2. CAM is administered by the physicians themselves 3. IC is provided by physicians employed in the public system of health care Policymakers were generally ambivalent regarding each of these characteristics of practice, most of them pointing out both their advantages and disadvantages. We will present their arguments for supporting or opposing this type of IC and try to understand their reasoning and the considerations they take into account when formulating their opinions. To comprehend the attitudes of policymakers to IC, we first asked about their acquaintance with and general approach to CAM. We found that nearly all the policymakers know physicians practicing CAM, and most had some personal experience with it. Some had themselves studied CAM methods or used them in treatment; a few said that they or their relatives had received CAM treatment. Not all the experiences were favorable. Some deemed the treatment to have helped to some extent; others—that they had not helped at all. Some interviewees dismissed all CAM methods; some dismissed specific fields while saying that they believed in the effectiveness of others or in CAM’s potential health benefits or its responsiveness to patients’ needs. We found no — 178 —

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relation between personal (positive or negative) experience with CAM and the attitudes expressed in the interviews. a. Physicians’ use of CAM methods in the bio-medical encounter One major reason for supporting use of CAM by physicians was their belief in the effectiveness of some of the CAM methods as gauged either by scientific/objective measures or subjectively by patients: Whatever works for the patient is acceptable…a placebo is as good a remedy as anything else…the main thing is to help the patient (#1). The real test is if people feel that it helps (#4). If doctors integrate additional tools to improve the patient’s situation, it is blessed (#16). Other arguments in favor were: The fact that it is a holistic, mind/body approach: One of the main mistakes [in conventional medicine] is separating mind and body. My approach is that there are no sicknesses; there are sick people (#2). It responds to a public need: Alternative medicine is there and definitely answers some needs of patients. People find succor in it (#5). The public wants it very much…it answers their expectations…although I am not sure there is something real in it or if it really can improve their situation (#4). It responds to physicians’ needs: A good hedge against burnout…increases [physician] satisfaction in the physician/patient relationship…(#5). Chief among the disadvantages of IC cited by interviewees was the absence of evidence of the effectiveness of CAM treatments, raising concern that physicians may offer these treatments just out of greed for — 179 —

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financial reasons. The effectiveness of alternative medicine has never been proved (#7). No scientific literature provides evidence of effectiveness…no research (#15). I am concerned about deceit and charlatanism even if CAM is administered by physicians since money is dazzling. It’s easy, ready money… Because of the money, there will be many rotten apples (among the doctors) that forget where they came from and will offer only the alternative treatments (#8). b. CAM is provided by bio-medical physicians Many interviewees (supporters and opponents of CAM alike) considered it an advantage that CAM be administered by physicians, rather than other practitioners, because of their medical knowledge: Being able to identify the ‘red lines’/danger points (#6). At least an MD has knowledge (#2). A doctor is preferable, an alternative practitioner cannot diagnose…a doctor is more aware of possible harm and will be more cautious (#10). Several interviewees held that it was preferable for the treatments to be given by CAM practitioners (not MDs): They specialized in that specific field and are more professional (#14). They can devote more time to the encounter than a doctor (#15). Other disadvantages of physicians providing CAM included compromising the physician’s expertise and use of conventional medicine: The ability to absorb knowledge is not infinite, it may be at the expense of expanding his scientific knowledge (#9). — 180 —

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Concerned that it may be provided instead of effective conventional treatment… [it may] harm the patient (#16). It is inefficient to allocate time to these practices given the cost of a physician’s training: Doctors are rare (there is a shortage and training is expensive)… to take a doctor and divert him to practice this [CAM] is therefore not rational for public medicine. What’s good for the patient is not necessarily good for the system (#1). c. IC is provided by physicians employed in the public system As noted in chapter 10, the physicians in this study found ways to practice IC by negotiating “organizational boundaries” relating to the setting of care (sick fund’s clinic vs. private clinic); payment (for extra fee vs. free of charge); and selection of patients (does or does not treat patients who are on their lists at the sick fund). Physicians differed in their choices, yielding three forms of IC practice. We asked policy makers to relate to the following forms of practice and the extent to which they see them as an acceptable/legitimate mode of practice by family physicians employed by public sick funds: providing CAM free of charge as part of the regular encounter at the sick fund clinic; seeing sick fund patients for CAM treatment at a physician’s private clinic; and providing CAM at a private clinic only for patients the physician does not treat at the sick fund. 2. Providing CAM free of charge as part of the regular encounter at the sick fund clinic Many interviewees supported this type of IC, because they feel that CAM provides physicians with additional treatment tools that can benefit the patient, and this method creates no legal or administrative restrictions on doing all they can for the patients: Every addition adds strength [to treatment] (#3). Wonderful, medical altruism on their [the physician’s] time (#1). — 181 —

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According to the sick funds’ regulations, this is the only way possible [to practice IC]. If he wants to spend more time with the patient—he can do it. It’s alright (#7). At the same time some policymakers expressed reservations about the ability to provide CAM within the short amount of time allotted to a patient on a routine visit, without taking time from other patients: It’s alright but not practical…no time…there is no way to find [more] time because it is at the expense of other patients (#12). The legal advisor of one of the sick funds stated unequivocally that legally, physicians cannot provide CAM services during regular work hours at the public clinic: Clause 20 of the National Health Insurance Law stipulates that income from public funding sources is to be used by the sick fund solely for the provision of services included in the NHI basket of services … (#10). Another legal advisor noted another reservation—when IC is offered in sick fund facilities, the fund is legally liable even if it did not know of the practice since it is responsible for knowing what transpires under its auspices. The sick fund must know who is providing alternative treatments…failure to object is a sign of endorsement/ consent (#8). Some expressed reservations if physicians offer CAM medications (which are not covered by NHI in Israel) during the encounter in the public clinic. The grounds for objection were potential harm to a patient, a legal suit for improper practice if prescribing ineffective or harmful substances, fear of a commercial conflict of interests if the physician has financial interests in the medication, and the financial burden on patients. — 182 —

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He/she doesn’t know what else the patient is taking— should check if it doesn’t conflict…if he prescribed something that is not state of the art, it’s a problem…if he gives an herbal plant instead of antibiotics he can be punished ( #8). There is a concern not about physical risk to patients, but rather about causing patients expense regardless of their means (#11). 3. Seeing sick fund patients for CAM treatment at a physician’s private clinic Almost all the interviewees objected to this sort of arrangement, for two main reasons: it defies both sick-fund regulations and professional ethics as the boundaries between private and public practice are not clear-cut. Interviewees noted a similar problem regarding the referral of public patients to private clinics for conventional care. To illustrate: Self-referral [to private practice] is unethical and prohibited by most sick funds (#4). It is taking advantage of the weak, fraud, unethical… I do not have words to describe how strongly I object to it. Such a doctor betrays the patients and betrays the profession (#6). It is bad from every perspective… It is unethical not only regarding CAM, also surgery etc…. He could be sued on the grounds of “improper behavior.” He may also be charged for bribery (#8). 4. Providing CAM at a private clinic only for patients the physician does not treat at the sick fund Almost all interviewees regarded this type of IC as legitimate. The main justifications were freedom of occupation and that it was both ethical and legal regarding the boundaries between private and public practice. I am the first to support a doctor’s right to sell his services. I see it as the freedom of occupation (#11). It is ethically acceptable (#4). — 183 —

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It is ok if the two are kept separate as required by law (#13). Some, however, noted concerns regarding this model: I don’t believe that his public patients will not come to his private practice. I don’t like mixing (#8). It’s an option but without peer review he [the doctor] may do it just for the money… When a person works alone there are temptations…it is more likely to occur in CAM because he can treat as he wishes, there is no evidence base (#12). There is still a problem about the effectiveness/efficacy of care... (#10). Given the aforementioned advantages of IC, some of the interviewees said that it should be consolidated within the public system. Several ways to do this were mentioned. It was recommended that all physicians receive and expanded knowledge of CAM. They should certainly know about it just as a specialist should know what the National Insurance Institute is and offers since a large portion of the population will need their services one day. The same is true of alternative medicine (#3). Another thought was that physicians should be trained in the interpersonal aspects of CAM as part of their medical studies: For instance, empathy, holistic medicine, contact, attention, warmth, love (#1). Regarding this aspect of CAM, interviewees were divided. Some thought that the holistic aspects of CAM can be offered, as needed, during regular doctor visits, and that many family physicians do so: I can list many physicians who practice this way without — 184 —

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the ‘alternative’ aura (#12). Others said that in effect it is impossible to employ a holistic approach during a regular visit, except in extraordinary cases. The visit’s brief duration surfaced repeatedly as the main impediment to the holistic approach in conventional medicine. If you need to examine ten patients in one hour, you cannot give what they need and that is indeed the case (#15). If we allow doctors more time with patients, we will need to employ more doctors… it has a price (#12). The vast majority [of doctors] are motivated by financial considerations…to maximize their income they will see more patients and provide less ‘soft aspects’ of care (#11). Additional factors mentioned for not using a holistic approach in bio-medical care were: physicians’ burnout, personality and education; peer pressure to provide the standard care; and the therapeutic tools, which do not make the holistic approach a condition of success, as is the case in CAM. Some interviewees suggested additional ways to integrate IC into the bio-medical system: A physician can specialize in alternative treatments and offer services to the entire clinic…the system needs to support this (#16). Physicians can learn these skills or work in cooperation with CAM practitioners…there are models in oncological centers abroad…it may support conventional care and improve patients quality of life (#9). Some interviewees also supported further institutionalization by considering inclusion of some CAM treatments in the National Health Insurance entitlements, with the main criteria being proof of effectiveness:

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If we find that some type of [CAM] treatment is effective and can heal, it should be included in the basket of entitlements after prioritizing [of all treatments considered for inclusion that year] (#10). Only what is proven effective: chiropractice, guided imagination…other things like reflexology or shiatsu or twina or massage are pleasant, make you feel good but not eligible for the basket (#2). Some policy makers opposed additional institutionalization of IC in the public system, presenting the same reasons for their opposition to the existing IC models: the absence of evidence of CAM effectiveness, inefficient use of the expensive resource of the physician, and concern about financial exploitation of patients (see above section). Regarding inclusion of CAM treatments in the set of health entitlements, the main arguments presented by the opponents were: (a) insufficient knowledge about CAM effectiveness, the target population per treatment and the acceptability of the technology; (b) CAM treatments do not deal with severe, life-threatening medical problems and thus, in setting priorities, there is no chance of adding them to the basket. Not enough money for conventional treatments, don’t believe [CAM] has priority (#13). Low probability that CAM technologies would be selected…would not stand the competition with other technologies (#1). Some felt that it is important that the patient pay for CAM treatments: Paying causes her/him to be a better, more discriminating consumer (#13). Payment has an effect [on feeling the treatment helped] (#5). 5. Attitudes to Regulating the IC Model As noted, all the policymakers interviewed are in a position to influence regulation either nationally or at the sick fund level. A major interview — 186 —

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topic thus revolved around their perception of the need and means to regulate different aspects of IC practiced by physicians. They were asked about aspects of regulation that are currently being considered in other countries (see Introduction) and are relevant in particular to the IC model. These include: licensing, training, restricting fields of CAM and overseeing quality of care. Overall there was no consensus on this issue. Many interviewees preferred to discuss the need to regulate the field of complementary medicine as a whole and the work of CAM practitioners in particular, which was perceived as more salient than regulating the practice of CAM by physicians (i.e. the IC model). We will now present their perspectives and illustrate them in their own words. 6. Licensing The main objection to special licensing for physicians to practice CAM was that, legally, licensing was unnecessary: The Doctors Ordinance permits physicians to practice any field whatsoever…there is trust in their ethical judgment…it is unlikely that a doctor will utilize a method he is not fully familiar with (#15). No need [for special license]…they have a medical license and they should know how to set their own limits (#6). According to the law, any doctor can even perform brain surgery in his clinic, or heart surgery (#13). An additional objection related to the principle of “freedom of occupation”: I accept the principle of freedom of occupation…he can practice CAM if he does not cause damage… I believe that any person who studied medicine has knowledge, some ethics and integrity and can administer any treatment that may help the patient. The license for practicing medicine is very comprehensive (#9).

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A further argument related to practical difficulties, and was raised both by MOH officials who are responsible for licensing and policy makers from provider institutions: It is optimal that the state should regulate training and methods of CAM practitioners… It’s the ideal but there’s no chance…the state does not have the ability to do it. How will they check? How many years should they study? In which school? They do not have a clue how to check these (#2). If we give licenses we will need to collect scientific materials and ascertain if Tibetan medicine is mumbo jumbo or if it will save the world, how many years should one study it and where…it is endless…we have no way to make rational decisions [on these issues] and we do not have the capacity to deal with it (#4). The chief reason cited in favor of licensing was to ensure doctors competence in this field. Licensing—unequivocally yes…regarding where they studied, skills, training…applies also to doctors (#12). Of course they should be licensed as it [CAM] is not taught in medical school (#15). 7. Training Nearly all interviewees stressed the importance of ensuring appropriate training for both CAM practitioners and physicians practicing CAM, while expressing more concern regarding the training and skills of practitioners who did not have an MD degree. A high proportion of them [CAM practitioners] are charlatans and a higher percent have insufficient education and training—that is a problem (#15). There were two main arguments in favor of regulating the training of physicians who provide CAM: ensuring that patients receive appropriate care and protecting the physician against suits of negligence. — 188 —

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You need formal training for doing things that can have a potential to harm… (#9)). A doctor who wants to practice it [CAM] has to study it. There must be training…if he deviates from the limits of his knowledge, he is risking his license (#14). Nevertheless, interviewees noted the difficulty of regulation of training (similar to licensing), since currently available knowledge is insufficient to determine training criteria or endorse training institutions. It is necessary to study it [CAM] but there aren’t any standards or supervision. One can study two years and another may say that a weekend is enough, and that is part of the problem. There must be formal studies at a reasonable level and practical training at a reasonable level (#15). 8. Restricting/limiting types of CAM practiced Despite the reservations raised by interviewees about certain areas of CAM (e.g. homeopathy), few favored prohibiting physicians from practicing some types of CAM. They offered a variety of reasons relating mainly to physicians’ autonomy and discretion: Any licensed doctor is allowed to decide what he learns and how to implement it (#14). Doctors have to show that they acted reasonably and they are legally responsible for their decisions (#4). Even in conventional medicine not all treatments are evidence-based (#15). Those advocating restrictions on certain types of CAM practices argued that only treatments of proven effectiveness should be permitted to protect patients from fraud. There is a need to regulate the field of CAM…limit the field to those practices where there is reasonable evi— 189 —

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dence of effectiveness…[use of] tarot cards for example is not reasonable (#5). Instead of us deciding, public demand is what defines [what is provided]…financial interests are the engine pushing it all (#2). 9. Oversight of quality of care Some interviewees claimed that it is impossible to supervise the quality of CAM treatment, as there are no standards and no measurable outcome criteria. The problem is that you cannot supervise if the treatment is not validated and everyone does it differently… first you have to decide what’s valid and what isn’t (#7). Can’t supervise, if there are no standards and no rules [for administering the treatment] one cannot assure quality (#6). Others argued that it is necessary to supervise the quality of CAM care and cited measures that can be monitored: Quality assurance should relate to training, teamwork… (#12). Yes, using the regular measures for quality assessment: keeping records, informed consent (#4). Patient satisfaction is a soft measure but a good one. Need to supervise reasonable care—no harm…maybe training should be regulated…there needs to be a minimum level of training (#5). 10. Discussion and Policy Implications Policy makers’ attitudes to the IC approach was non-consensual, deriving primarily from varying conceptions about CAM’s effectiveness. The holistic approach of IC physicians, while seen as an advantage, was attributed chiefly to the amount of time devoted to a patient’s visit rather than to IC itself. Many interviewees noted that the approach was also possible in conventional medicine given enough time. Mixing private and public medicine was perceived as the chief danger of IC; most inter— 190 —

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viewees favored a model of IC with unambiguous boundaries separating private and public patients. There is evidently a great deal of trust among the policy makers in physician professionalism and integrity, giving rise to the widespread conception that their judgment is reliable when providing IC as well as other treatments. Such confidence was also an underlying theme in their attitude toward regulation of IC, which they either did not see as necessary or of high priority. Supporters of licensing, regulated training and supervision of quality of care argued that these were necessary for the patient’s good and to prevent greed-driven charlatanism. Opponents argued that physicians may be trusted and that there is insufficient knowledge of CAM to set standards, which makes it impossible to supervise IC and the areas of CAM that fall within it. The policy makers did not express much concern that IC was currently not regulated, and many noted that it was more urgent to regulate CAM practitioners who are not MDs. Their trust in physicians’ discretion regarding the care they provide rests on physicians’ legal status which, according to the Doctors Ordinance, empowers them to offer any sort of treatment they see as appropriate. It is also related to their personal responsibility in case of negligence claims which ensures that they will act cautiously when offering CAM treatments. Nevertheless, some policy makers did voice their concern that physicians would provide ineffective or harmful treatment due to lack of sufficient knowledge about CAM or for monetary gain. A review of regulation of CAM practices in Europe (CAMDOC Alliance, 2010) revealed diversity in many aspects. In Middle and Southern Europe, CAM is primarily provided by physicians, and practice by nonmedically qualified practitioners is illegal, while in Northern European countries it is allowed. In 18 of 29 EU and EEA countries, specific CAM therapies are statutorily regulated, although wide variations exist throughout Europe regarding the types of CAM that are regulated. In a few countries, diplomas for doctors who have taken a full course of a particular CAM modality are issued and recognized by the national medical associations. A physician practicing CAM may be sued for malpractice or professional misconduct if the treatment does not conform to standards of acceptable care and harm was caused to the patient. To address this issue, several state medical boards in the US adopted rigorous guidelines — 191 —

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for physicians to examine the justification of providing CAM in patient encounters, taking into account the known risks and benefits of the treatment (Cohen and Kempfer, 2005; Horrigan and Block, 2002). Similar guidelines have been developed in the European Union for the appropriate practice of CAM therapies by bio-medical physicians. In January 2006, a consortium of organizations representing 132 medical CAM associations across Europe published guidelines for the use of official medical licensing bodies in educating physicians providing CAM therapies and regulating their practice. The intention was to provide guidelines that are clinically and ethically appropriate and consistent with accepted standards of care to protect legitimate use of CAM while avoiding unacceptable risk. These guidelines are similar to those developed in the US by a Special Committee for the Study of Unconventional Health Care Practices and approved by the Federation of State Medical Boards in 2002. The guidelines refer to both conventional and CAM therapies provided by the physician, and aim to ensure appropriate processes of care by addressing the following stages: evaluation of the patient, treatment plan, consultation and referral of patients, documentation of medical records, quality assurance and clinical research (Nicolai, et al. 2006). The issue of regulating CAM practice in general, as well as IC (where CAM is provided by physicians), is driven by the belief that it is “the responsibility of the state to protect the public through the regulation of the practice of medicine” (Nicolai, et al. 2006, p. 6). Protection includes ensuring that “physicians in all practices either conventional or CAM comply with professional, ethical, and practice standards and act as responsible agents for their patients” (Nicolai, et al. 2006, p. 6). Regulating the provision of CAM by bio-medical physicians poses an ethical dilemma to regulatory bodies, as it implies approving the CAM methods they use. However, this is not necessarily the case, as is illustrated in the regulation of IC in the province of Alberta, Canada (Silversides, 2002). The Alberta College created a system to register doctors who practice CAM after they provide proof of rigorous training and education. “We don’t approve the therapy but we approve the physician providing the therapy” (Dr. Brian Ward, assistant registrar, Alberta college).

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Policy Implications Based on the insights emerging from this study and the current approach to regulation in other Western countries, we will present some policy recommendations for regulating provision of IC by primary care physicians employed in the Israeli sick funds. The recommendations do not relate to the broader question of regulating the practice of complementary medicine in the overall health care system. We recommend a gradual approach to regulation addressing the most obvious areas in which the public needs to be protected, and developing the regulation in cooperation with all stakeholders to gain their support. The study highlighted two main areas in which regulation is called for: ensuring appropriate physician training in CAM, and defining how IC can be provided by physicians employed in the public system. 1. Regulating Training of Physicians Providing IC The study found a range of opinions and reasons for and against regulating training of physicians providing IC. There were doubts about the ability to regulate IC without regulating CAM as a whole (licensing, requisite training, authorized training institutions etc.). Furthermore, there is no legal basis to demand that a physician be licensed to practice CAM, nor any need for it as far as the law and insurance authorities are concerned. Moreover, policymakers expressed trust in the integrity of physicians, their broad knowledge, and their motivation to provide appropriate care to their patients, assigning a low priority to regulation of their training in CAM. At the same time, policy makers voiced fears about IC physicians misleading patients (even if innocently), having insufficient knowledge in the field of CAM, or, indeed, charlatanism. Policymakers’ views on regulating IC were congruent with views of patients and physicians interviewed for this study (Gross, et al. 2010). Although some supported setting training standards for physicians practicing CAM in order to ensure quality of care, they too emphasized the more pressing need to set standards and license CAM practitioners who are not MDs, expressing considerable trust in physicians providing CAM. Consequently, many, but not all, perceived the regulation of IC as of lower priority. Precisely because of the widespread trust in physicians and in the quality of their work in the public health-care system, we believe it — 193 —

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important to consider regulating training in order to protect patients, especially if IC becomes more frequent as numerous physicians enter the field, some possibly for purposes of monetary gain. We propose following the approach of the Alberta province, registering physicians providing CAM after they provide proof of acceptable education and clinical experience (Silversides, 2002). A staged approach is recommended, beginning with registration of bio-medical doctors employed in the public system (e.g. sick funds and hospitals). As employers, these bodies have the authority to obtain information on training in CAM since they may bear indirect liability in the case of a lawsuit against a physician employed by them. The process of registration could be voluntary, allowing a physician to choose whether or not to participate (so as not to infringe on her/ his autonomy and legal status to practice in any field, as provided by the Doctors Ordinance). Incentives may be offered for physicians to participate: e.g. listing the physician’s CAM training in the sick fund directory or some other form of public information. As for training criteria, it is recommended that the minimum requirements used today in the sick funds for CAM practitioners (e.g. in Maccabi Tiv’i)1 be applied to physicians. Alternatively, criteria can be based on international standards set by CAM professional associations (CAMDOC, 2010). In the future, as the field of CAM is regulated in Israel, it may be possible to apply the same criteria that will be developed to physicians as well, with the necessary adjustments. 2. Regulating Provision of IC by Physicians Employed by the Sick Funds The interviews revealed that IC poses an ethical problem relating to its financial status. CAM is provided to patients for a fee since it is not included in the NHI benefits basket. This presents a danger of mixing private and public practice if physicians refer their public patients to their private clinics to receive CAM. Treating only patients not seen at sick fund clinics limits the practice of IC to patients seeking treatment 1 

Examples of standards required by Maccabi Tiv’i at the Maccabi Healthcare Services: acupuncture: physicians or practitioners who completed the full course meeting requirements established by the professional association, with at least 5 years proven clinical experience; homeopaths—physicians or pharmacists only with prior experience (length of experience not defined); reflexology and shiatsu—preference for practitioners who completed 3 years of profession studies, preference for graduates of a number of fields of study; massage and Tawina—preference for graduates of two years of study and proven clinical experience. — 194 —

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for special problems and does not allow integration on a daily basis in their regular primary care practice. Physicians are thus unable to offer IC to all their patients even when they believe in its effectiveness. Providing CAM free of charge in the public sick fund clinic has financial implications as well, as it uses the public infrastructure and time to provide services at the expense of other patients. However, the essence of IC is provision of CAM treatment for all patients (including public patients treated at sick fund clinics), thus implementing a holistic approach and optimizing the advantages of integration. Clearly, in order to protect values underlying the public system there is a need to regulate the “rules of the game” of IC provided by physicians employed in the public system, with a focus on two distinct issues: the patients that a physician is permitted to treat, and the manner of payment to the physician for CAM treatment. Regarding the treatment of sick fund patients, there may be room to consider more flexible rules so as to permit physicians to offer CAM to patients they treat in their sick fund clinic, since this is the heart of IC. To avoid the ethical problem of charging public patients for private services, other organizational arrangements for payment could be considered. For example, patients receiving CAM treatment from their physician (at his/her public or private clinic) can be charged a copayment by the sick fund, and the sick fund will pay an agreed rate to the physician providing IC to his patients. Conclusion Despite implementation difficulties, policymakers in Israel should accord high priority to regulating IC, especially since it is provided by biomedical physicians in the public system. It thus underscores the role sick funds and the Ministry of Health should assume to protect patients from poor, ineffective or unnecessary care. The need for regulation is critical, since IC involves high costs for patients and high income for physicians who may thus be tempted to enter the field, possibly compromising the quality of training in CAM methods. Regulation may be feasible if policymakers adopt a phased rather than an “all or nothing” approach, beginning with minimal measures and developing standards in cooperation with all stakeholders including physicians and CAM associations, while drawing on international experience.

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Acknowledgements We thank the interviewees for sharing their thoughts with us, and the National Institute for Health Policy and Health Services Research for funding the study.

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CHAPTER 12

PATIENTS’ VIEWS: CULTURAL AND HEALTHCARE PLURALISM IN NORTHERN ISRAEL Yael Keshet and Eran Ben-Arye

Introduction This chapter highlights the perspectives of patients from different cultural groups in Israel toward the integration of traditional, complementary and alternative medicine (TCAM) in the healthcare system. More generally, the chapter explores the connection between healthcare pluralism and cultural pluralism within the context of knowledge-power relations. Healthcare pluralism is not a new concept. People have always been able to choose between self medication and consultation, and between different kinds of healthcare practices and practitioners. There have also always been multiple ways of understanding health and illness. People of different cultures and social groups differ in the ways they explain the causes of ill health, the types of treatment they believe in, and to whom they turn if they fall ill (Kleinman, 1980). The key concept in medical pluralism is that of respecting the different ways people understand health and illness and their choice of treatment, be it self-medication or consultation with different kinds of healthcare practitioners. Healthcare pluralism is influenced by globalization as well as by localization processes: the increasingly heterogeneous blend of global and local practices by which global forces and influences are localized or indigenized (Robertson, 1994). In Western developed countries, biomedicine, which is based on principles of the natural sciences, and in particular biology and biochemistry, has secured a position of social, economic and ideological hegemony (Cant and Sharma, 1999). As part of the globalization process that has intensified social relations and generated increasing interdependence worldwide (Giddens, 2001), Western bio-medicine has been exported to countries in Africa, Asia and Latin America since the beginning of colonialism. Certain forms of healing have likewise been exported by countries within the developed world, — 199 —

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such as homeopathy from Germany and osteopathy from the USA. In the opposite direction, a variety of traditional healing forms have been imported into Europe and North America, especially from Asia. These have been adopted, adapted and termed complementary and alternative medicine (CAM). Examples include acupuncture, Traditional Chinese Medicine, meditation and Ayurvedic (traditional Indian) medicine. A further global process that influences medical pluralism is migration. Traditional-folk healers generally share the basic healthcare worldview of the indigenous communities in which they live (Helman, 2007; Kleinman, 1980), and sometimes migrate with their kinsmen, bringing with them various forms of healing practices and beliefs (Helman, 2007). Local cultural and economic factors influence healthcare pluralism. In developed countries, the affordability, availability, and cultural familiarity of traditional medicine contribute to the ethnic minorities’ continued use of traditional medical providers and medicines alongside, or even in place of, conventional medicine. Citizens of countries that have medical insurance schemes may have access to bio-medical procedures performed in hospitals that are covered by their policies, but may not be able to afford the out-of-pocket expenses for less invasive CAM services. In other countries, certain sections of the population cannot afford conventional bio-medical services and find traditional medicines and practitioners more affordable and accessible (Bodeker and Kronenberg, 2002). In recent years, in many developed countries CAM has penetrated mainstream medical institutions. This process has captured the attention of various scholars (e.g. Boon and Kachan, 2008; Broom and Tovey, 2007; Hollenberg, 2006; Shuval, Mizrachi and Smetannikov, 2002). The various medical models proposed for integrative medicine have been criticized for tending to downplay the tensions and contradictions inherent in the different paradigms of medical and health-care practice: “…the mainstream discussions bypass the issue of incommensurability between knowledge paradigms…and assume the blending together of biomedicine and CAM modalities as unproblematic“ (Adams, et al. 2009). The structure of health services is shaped by social processes that reflect power imbalances and marginalization, and are often dominated by a particular form of knowledge held by powerful professional and cultural groups (Adams, et al. 2009). — 200 —

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Conceptualization of integrative care should be based on empirical research that highlights the dynamics between health care practices and general sociopolitical relations. Little attention has been given to the wider structural and cultural contexts governing integrative medicine in practice. A critical social science perspective has an important role to play in deepening our understanding of integrative healthcare (Adams, et al. 2009). Attention should be paid to the complex knowledge-power relations influenced by inter-professional dynamics in medicine, to the political status of diverse population groups, the cultural capital of ethnic populations and the resulting strategies of inclusion and exclusion. One of the sociopolitical issues that should be taken into consideration when integrating healthcare is the wide variety of healthcare preferences among diverse social and cultural population groups; this is particularly apparent when observing majority and minority populations. As recently as the 1970s, cultural researchers associated the use of traditional “folk medicine“ with lower income, less educated populations, as well as with ethnic and religious minorities (Hufford, 1988; Mackenzie, et al. 2003). The proliferation of CAM among well educated and higher socioeconomic status groups has led scholars to modify this belief. Moreover, the blurring of borders between CAM and folk-traditional medicine has changed researchers’ attitudes toward the latter. Some researchers now employ the term traditional, complementary and alternative medicine (TCAM) (e.g. Broom, Doron and Tovey, 2009; Wootton, 2006), while others include traditional-folk medicine as part of the term CAM (e.g. Herman, et al. 2006; Mackenzie, et al. 2003). The increasing utilization of TCAM has been studied in diverse countries. One example is a US national survey that found that the use of TCAM was equally prevalent among white, African-American/black, Latino, Asian, and Native American populations, whereas the characteristics of utilization varied considerably by specific TCAM modality (Mackenzie, et al. 2003). A further example is a UK-based study that found that people of African ethnicity in London were more likely to use over-the-counter alternative medicines (Cappuccio, et al. 2001). The evidence concerning ethnicity and TCAM use is complex and it is difficult to ascertain general trends (Bishop and Lewith, 2008). It can, however, be concluded that any examination of ethnicity and TCAM use — 201 —

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would appear to benefit from focusing on specific types of TCAM rather than studying TCAM use in general (Hsiao, et al. 2006; Mackenzie, et al. 2003). It is fruitful to examine integrative medicine in the context of cultural pluralism, considering the preferences of diverse ethnic and social groups and their preferred modes of integration. This chapter reviews a series of studies that have examined attitudes toward integrating diverse health care practices against the background of the broader sociopolitical and cultural context. We address knowledge-power relations while examining patterns of reported use of TCAM and attitudes towards integrative healthcare in northern Israel’s multi-ethnic population. The population of Israel is composed of a Jewish majority and an Arab minority. The Jewish population (about 80 percent) comprises native-born Jews and immigrants who have arrived in several waves over the past 120 years from dozens of countries: Ashkenazi Jews from Western countries and Sephardic Jew mostly from Arab and North African countries. The most recent large group of immigrants arrived in Israel during the 1990s from the former Soviet Union. The Arabs— Muslims, Christians and Druze—form the largest minority group in Israel, comprising about 20 percent of the country’s total population. A sub-group among Muslims is the Bedouin population, comprising 18 percent of Israel’s Muslims and 3.5 percent of Israel’s entire population (Israel Central Bureau of Statistics, 2010). The Arabs in Israel generally consider themselves part of the Palestinian nation and represent about 23 percent of the world’s population of Palestinians (Kanaaneh, 2002). Formally, Israeli Arabs are full citizens of the State of Israel, but as the Arab community in Israel has maintained relations with the greater Arab world, which is in constant conflict with the State of Israel, they in fact face considerable prejudice and occupy a marginal position (Dayan, 2005; Hamiasi, 2005). The population of northern Israel, the Galilee (northern and Haifa districts, including the sub-districts of Haifa, Hadera, Zefat, Kinneret, Jezreel, Acre and Golan), has a different demographic composition than that of the overall population of Israel (see chapter 2 and appendix A). It is a multi-cultural region characterized by a diverse population: 55 percent Jews and 41 percent Arabs. Muslims comprise 30 percent of the area’s total population, Christians 5 percent and Druze 6 percent, while 12.7 percent of the Jews are immigrants who arrived in Israel — 202 —

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since 1990 from the former Soviet Union (Central Bureau of Statistics, Israel, 2008). Western bio-medicine occupies a dominant and monopolistic status within the Israeli healthcare system. As noted in chapters 2 and 5, CAM treatments are offered by all Israeli sick funds and by one third of the hospitals in out-patient clinics, but, as these are not included in the benefits provided by the National Health Law, patients are required to pay for them. A pattern of simultaneous acceptance and marginalization of alternative practitioners was revealed in a study of collaboration between CAM practitioners and physicians in hospital settings in Israel (Shuval, Mizrachi and Smetanikov, 2002; see also chapter 5). Until recently, patterns of CAM use have been studied only among the Jewish urban Israeli population. In the year 2007, 12.2 percent (N=752) of this population reported consulting with CAM providers during the previous year. Consultations with acupuncturists and homeopaths comprised over half of the consultations. Like in other Western countries, the principal correlates of CAM usage in Israel were gender and education; the highest usage of CAM was found among women (15.1%) and among university or college educated persons (17.2%). (Shmueli, et al. 2010; see also chapter 2). While CAM healthcare modalities are used privately as well as within institutionalized healthcare organizations, they are not formally or legally recognized or regulated by the state. Indigenous Arab Israeli folk-traditional medicine has scarcely been researched. Islamic-Arab medicine is among the best-known traditional systems of medicine, having thrived at the end of the first millennium and through the Middle Ages as a dominant medical school of thought mediating between European and Far-Eastern medicine (Brewer, 2004). Israeli Arabs are oriented toward traditional Islamic medicine and use a significant number of herbal remedies (Azaizeh, et al. 2006). Islamic medicine includes faith healing through prayer, spiritual healing, magical practices and the use of herbs and minerals, as well as diet and lifestyle changes. It is partly rooted in Muslim theology and practices, mainly the Qur’an (the Islamic Holy Book) and the Prophet’s Sayings (Hadith) (Adib, 2004). Traditional Arab women healers in Israel, known by a number of different terms (sheikhah, darvishah, hajjah, fattaha), mostly attend the needs of women in their communities (Popper-Giveon, 2007). Research into Jewish folk-traditional medicine has focused on patterns of referral to traditional religious healers, especially among — 203 —

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Moroccan immigrants (Bilu, 2009) and contemporary integration of healing practices with the Kabbalah, the discipline concerned with the mystical aspect of Judaism (Huss, 2007). The Research Findings In this chapter we consider a series of research findings that focus on healthcare pluralism within the mosaic of ethnic and social groups that characterizes the population of northern Israel. The research addresses the following questions: which treatment modalities do people from different cultural backgrounds use? What combination of TCAM and conventional services do they expect to receive? What kind of healthcare integration do they prefer? Can social and ethnic preferences for traditional medicine be integrated into the design of conventional health services in order to accommodate consumers? We included findings of a cross-cultural study conducted in northern Israel, which examined rates of use of TCAM among patients attending conventional clinics and their attitudes toward the integration of TCAM within the healthcare system. These include research papers that report on comparisons among a variety of types of patients: 1) Arabs and Jews; 2) Muslim, Christian and Druze Arabs and Ashkenazi and Sephardic Jews; 3) women and men; 4) Jewish and Arab women; 5) Bedouins and non-Bedouin Muslims; 6) Arab and Jewish patients with diabetes type 2; 7) Jewish immigrants (after 1990) from the USSR and non-immigrants (Ben-Arye, et al. 2007a, b; 2009a, b, c, d, e). These studies were designed by a group of family physicians, dualtrained and practicing CAM, who sought to develop educational and practical CAM integration models1 (Ben-Arye and Frenkel, 2001; BenArye, Frenkel and Hermoni, 2006; Ben-Arye, Bar-sela, Frenkel, Kuten and Hermoni, 2006; Ben-Arye and Frenkel, 2008; Frenkel, Ben-Arye and Hermoni, 2004). Having compared the perspectives of primary 1 Since 1998, they have taught elective courses in CAM. The courses were taught to residents and specialists in the department of family medicine of the Faculty of Medicine of the Technion. In 2002, this group formed the Complementary and Traditional Medicine Unit within the Department of Family Medicine affiliated with the Rappaport Faculty of Medicine, the Technion-Israel Institute of Technology in Haifa, and with the Haifa and Western Galilee District of the Clalit Health Services. The courses were designed to expose family physicians to common CAM methods, to provide these physicians with an additional perspective that would allow them a better understanding of the patient–doctor relationship, and to provide sufficient information to enable physicians to provide their patients with informed, evidence-based, safe and balanced advice. — 204 —

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care physicians, CAM practitioners and patients regarding integration of CAM into primary care (Ben-Arye, Scharf and Frenkel, 2007a; Ben-Arye, Frenkel, Klein and Scharf, 2008), the researchers arrived at the understanding that CAM integration models should take account of patients’ social and cultural diversity. This diversity was assumed to influence patterns of TCAM use and patients’ attitudes toward the integration of TCAM modalities and their expectations of family physicians. The questionnaires for the research were developed on the basis of information gathered in a comprehensive literature review of the topics of CAM and integrative medicine, gender and cross-cultural themes. A preliminary questionnaire was refined and tested for comprehensibility using two patient focus groups. The definition of TCAM that was used was broad and understandable: “Therapies often named alternative, complementary, natural, or folk/traditional medicine, which are not usually offered as part of the medical treatment in the clinic.“ A list of CAM modalities was added to this definition: herbal medicine, Chinese medicine (including acupuncture), homeopathy, folk and traditional medicine (including traditional healers and homemade traditional remedies), diet/nutritional therapy (including nutritional supplements), chiropractic, movement/manual healing therapies (massage, reflexology, yoga, Alexander Technique, Feldenkrais Method), mind–body techniques (meditation, guided imagery, relaxation), energy and healing therapies, and other naturopathic therapies. The questionnaires included eight questions about the participants’ background and 15 questions about their attitudes toward TCAM. The research was carried out at family clinics of the Clalit Health Services, the largest of Israel’s four sick funds (health maintenance organizations), which provided health care to 53% percent of Israel’s population in 2010 (3,885,000 patients). Seven clinics that serve diverse socio-demographic and ethnic populations typical to northern Israel were selected. Three were located in urban settings, two in a mixed rural and urban area, and two were rural. Participation in the study was offered to 3,972 patients aged 18 years and above who came to these seven clinics to receive medical or administrative services over a 16-month period during the years 2005-2006. Hebrew, Arabic and Russian-speaking research assistants requested the patients to complete a questionnaire about TCAM. All patients who attended any of the — 205 —

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following four service areas during the study period were approached: administrative, medical, pharmaceutical, or nursing services. Patients were given the option of filling out the questionnaire themselves or having the questions read to them, with the answers recorded by the research assistant. Of the 3,972 individuals approached, 132 refused to participate (a response rate of 96%), while a further 127 refused to report their religion. Data suitable for statistical analysis was thus obtained from 3,713 patients. P values less than .05 were regarded as statistically significant (Ben-Arye, et al. 2007a, b); 2009a, b, c, d, e). The research has some limitations. The research population does not represent the entire population of the region since we approached patients who actually came to the clinics, all of whom belonged to the Clalit sick fund that serves a variety of groups with distinctive cultural characteristics located in a relatively small area covering 260 km2 of northern Israel. On the other hand, a considerable effort was made to minimize ethnicity selection bias by offering participation in the study to every patient who entered both the rural and urban clinics, that serve Jews and Arabs, for any medical or administrative reason, with no language restriction. Another limitation is that the present chapter is based on findings drawn from the papers referred to above, without additional statistical analysis. Since most of the findings in those papers are based on univariate analysis, the empirical presentation below is limited. Nevertheless, although only univariate distributions are presented here in their original form, they address the issues of pluralism in health-care. By sensitizing us to the differences—or absence of differences—between culturally diverse groups, these distributions improve our understanding of the ways in which integrative healthcare can be adapted to the needs of different groups. 1. OVerall Reported Usage of TCAM and Consultation witH Practitioners A high proportion of the participants, who attended conventional primary clinics, reported using some other healthcare modality as well: 43.7% of the participants reported using one or more TCAM modality during the previous year, and 32.9% of the participants reported consultation with a TCAM practitioner. Folk/traditional medicine and touch, — 206 —

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manual and movement therapies were reported as the most commonly used among the participants who reported using one or more TCAM modality during the previous year (table no. 1). Table no. 1: Percentage of participants who reported TCAM use during the previous year2 (N=1499)

2

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Table no. 2: Comparison of rates of reported overall TCAM use and consultation with TCAM practitioners among different populations

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Table 2 indicates that the extent of reported use of at least one TCAM modality during the previous year varied among the diverse cultural population groups examined. The largest and most consistent differences were found between Bedouin and non-Bedouin Muslim respondents. Fewer Bedouin participants reported overall TCAM use and consultation with practitioners; this, as detailed below, includes folk-traditional and herbal medicine (Ben-Arye, et al. 2009d). Smaller, but consistent and significant, differences were found between women and men: more women than men reported TCAM use and consultation with practitioners. The differences between the other groups, Arabs and Jews, Arab women and Jewish women, immigrants and non-immigrants, and Jewish and Arab patient respondents who reported suffering from diabetes, were either small and inconsistent or insignificant (Ben-Arye, et al. 2007 a, b; 2009a, b, c, d, e) (Table no.2). 2. Specific TCAM Modalities The study of TCAM use by diverse ethnic groups calls for the examination of specific modalities, rather than observing TCAM use in general (Bishop and Lewith, 2008; Hsiao, et al. 2006). Large variations among participants from culturally diverse population groups were found concerning the specific preferred modality. More participants belonging to Israeli minority ethnic groups, mainly Arabs, tended to report using folk-traditional and herbal medicines, while more Jewish participants reported using diet therapy, nutritional supplements, homeopathy, chiropractics, energy healing and mind–body practices. Arab participants reported use of folk-traditional medicine significantly more often than Jews (50.4% vs. 28.0%, P < .0001), and the same trend was found for herbal medicine (35.0% vs. 27.8%, P =.004) (BenArye, et al. 2009a). Significantly, more Arab women than Jewish women used folk/traditional medicine (50.8% vs. 29.3%, P< .0001), consulted with herbal (40.7% vs. 16.4%; P< .001) and traditional medicine practitioners (25.7% vs. 8.0%; P< .001), as well as nutritional-supplement consultants (25.3% vs. 15.0%; P = .001) (Ben-Arye, et al. 2009c). Arab patients with diabetes also reported higher rates of use of traditional medicine than Jewish patients (61.4% versus 25.5%; P< .0001) and more frequent consultation with practitioners concerning herbal (45.8% vs. 27.7%; P= .022) and traditional medicine (39.6% vs. 7.7%; P < .0001) and nutritional supplements (33.3% vs. 13.8%; P < .006) (Ben-Arye, — 209 —

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et al. 2009e) (Graphs no. 1 and 2). Immigrants reported greater use of herbal medicine than non-immigrants (38% vs. 23%, non significant) (Ben-Arye, et al. 2007) (Graphs no. 1, 2).

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Compared to non-Bedouin Muslims, Bedouin respondents reported significantly less frequent use of folk/traditional medicine (28.2% vs. 59.1%, P< .0001), dietary supplements (22.3% vs. 41.3%, P< .0001) and herbal medicine (24.4% vs. 35.8%, P=.005) (Ben-Arye, et al. 2009d). Analysis of the use of herbal remedies from a cross-cultural perspective (Ben-Arye, et al. 2009b) exemplifies ethnic differences between different sub-groups within the population. We found differences in the use of such remedies between Arabs and Jews, and within each social and religious subgroup. Among the Jewish respondents, non-nativeborn Ashkenazi Jews reported the lowest rate of herbal use (19%) as compared with Israeli-born Jews (27.5% P= .0391), non-native born Sephardic Jews (32.9% P= .0123) and immigrants from the former USSR after 1990 (38% P= .0077). Significantly, fewer Jews reported the use of herbal remedies (28.2%) than each of the three Arab subgroups: Muslims (33.4% P=0.044), Christians (36.1% P= .0209) and Druze (45.2% P= .0229). A similar pattern emerged with regard to consultation with herbalists: a sub-analysis of such consultations among the Jewish and Arab populations showed that Druze reported a higher rate of consultation with herbal practitioners (67.9%) than Muslims (43.2%, P=0.0175), Christians (41.6%, P=0.0138) and Jews (17%, P= .0001). Jews consulted herbal practitioners significantly less frequently than Muslims (P= .0001) and Christians (P= .0001). The differences in consultation with herbalists within the Jewish study group were not statistically significant (Ben-Arye, et al. 2009b) (Graph no. 3).

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More Jewish than Arab respondents reported using diet therapy, including nutritional supplements (43.6% vs. 34.3%, P= .0390); energy healing; mind–body practices; chiropractics; and homeopathy (Ben-Arye, et al. 2009a) (Graph no. 4). More Jewish than Arab women reported consultation with homeopaths (15.7% vs. 3.0%; P < .001) and chiropractors (12.2% vs. 3.2%; P < .001) (Ben-Arye, et al. 2009c). Jewish patients with diabetes consulted more frequently than Arabs with homeopaths (9.2% vs. 1%; P= .018) and chiropractors (15.4% vs. 5.2%, borderline significance P= .05) (Ben-Arye, et al. 2009e). Immigrants reported less frequent use of touch and movement therapy compared to non-immigrants (21% vs. 44%, p= .006), but more frequent use of herbal remedies (38% vs. 23%, NS) (Ben-Arye, et al. 2007b). Fewer women than men reported consultations with herbal practitioners (31.4% vs. 40.3%; P = .003) and chiropractors (6.7% vs. 10.6%; P = 0.028) over the previous year, but more women than men consulted with practitioners of mind-body practices (13.8% vs. 8.1%; P= .005) and homeopathy (8.0% vs. 4.7%; P= .045) (Ben-Arye, et al. 2009c).

3. Attitudes Towards TCAM Integration Inclusion of TCAM services in the Israeli health service was largely supported by Arab respondents (96.2%) as well as by Jews (95.0%) and by — 212 —

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women (96.6%) as well as by men (94.4%) (P= NS). Somewhat more non-immigrants than immigrants (97% vs. 91%, p= .01) and more nonBedouin Muslims than Bedouins (98.2% vs. 91.9%, P< .0001) favored the integration of TCAM into primary care. Far fewer Bedouin than non-Bedouin Muslims were willing to participate in payment for TCAM services (46% vs. 86.7%, P< .0001), while small differences were founded between Arab and Jewish participants (73.9% and 74.8%), and between women and men (75.9% and 72.0%) (Ben-Arye, et al. 2007a, b; 2009a, c, d). In general, participants attributed an important role to their family physician regarding TCAM integration in the primary care clinic. An overwhelming percentage (over 90%) expected their family physician to have knowledge of TCAM and to be receptive to it. All the differences between the participant groups were found to be small, even when significant. Family physicians were expected to initiate referral to TCAM in a hypothetical scenario in which TCAM was integrated within primary healthcare clinics. A majority of Jewish and Arab participants (83%) preferred such an arrangement (Ben-Arye, et al. 2009a, c, d). Participants were asked to describe the characteristics of a practitioner offering TCAM treatment in a hypothetical integrative family medicine clinic. An impressive difference was found between Arab and Jewish participants; far more Arab than Jewish participants supported the idea of non-physician practitioners providing TCAM care rather than physicians (70.2% vs. 34.9%, P< .0001). This idea was also supported by more Arab than Jewish women (70.4% vs. 35.0%; P< .001), whereas more Jewish than Arab women favored TCAM provision by physicians, including their personal family doctors (26.0% vs. 17.2%; P< .001). More immigrants than non-immigrants favored the provision of TCAM treatments by an appropriately trained family physician (27% vs. 14%, P= .001). More Bedouin than non-Bedouin respondents favored provision of TCAM treatments by an MD-CAM practitioner or their family physician (20.1% vs. 12.1%, P< .0001) (Ben-Arye, et al. 2007a,b; 2009a, b, c, d). Respondents were asked what type of TCAM practitioner they would like to join the clinic’s team. More Arab respondents than Jews, more Arab women than Jewish women, and more Arab than Jewish diabetes patients favored the addition of a herbalist to the primary care team (31.6% vs. 19.6%, P< .0001; 33.1% vs. 19.2%; P< 0.001; 34% vs. 21.6%; p= 0.008) rather than a practitioner in the modalities of movement/manual — 213 —

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healing, Chinese medicine, homeopathy, or chiropractics (Ben-Arye, et al. 2009a, c, e). Druze respondents supported the inclusion of an herbal practitioner on the clinic’s team more than Christians (50% vs. 36.7%, P= .013), Christians more than Muslims (36.7% vs. 29.7%, P= .0046), and Muslims more than Jews (29.7% vs. 19.5%, P= .0001). Among the Jewish subgroups, more immigrants from the former USSR favored adding an herbal practitioner to the clinic’s team (38.7%) than Israeli-born respondents (16.7%, P= .0001), non-native Ashkenazi (17.7%, P= .0001) and Sephardic (19.3%, P= .0004) Jews (Ben-Arye, et al. 2009b). Comparison of the rates of participants who reported consultation with herbal practitioners and folk-traditional healers to the rates of those who supported the idea of adding such practitioners to the primary care team reveals an interesting point. There is a large difference between folk-traditional medicine and herbal medicine. Among women respondents, for example: 40.7% of the Arab women reported consultation with an herbalist and 33.1% favored addition of an herbalist to the primary care team; while 25.7% reported consultation with a folk-traditional healer and only 4.8% wished to add such a healer to the primary care team. It appears that Arab respondents considered it far more appropriate to add an herbal practitioner to the clinic’s team than a traditional healer (Graph no. 5).

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Discussion Practitioners and laypeople have conceptualized and practiced alternative therapies in developed countries throughout the twentieth century, including the mid-century decades when the hegemony of bio-medicine was at its peak. The survival of alternative medicine was not merely a matter of individual choice or professional competition, but was fundamentally also a matter of politics (Johnston, 2004). Over the past two decades, TCAM therapies have played an increasingly prominent role in many developed countries. This review indicates a similar pattern in northern Israel. A significant section of the studied populations reported using both conventional medicine and TCAM. Variations in the type of modalities used and of attitudes toward integration appear to be related not merely to gender, economic and educational variables (Shmueli and Shuval, 2004; Shmueli, Igudin and Shuval, 2010), nor only to cultural variables (Ben-Arye, et al. 2009a), but also to social and political power imbalances, marginalization and strategies of inclusion and exclusion. As in other developed countries, bio-medical knowledge enjoys a hegemonic authority in Israel, while CAM and folk-traditional medicine are perceived as non-orthodox forms of medical knowledge and practice. The term “CAM” is sometimes used merely as another name for traditional medicine (WHO, 2010), as it is usually based on some imported and adopted traditional-folk medicine; they essentially share many characteristics, including a holistic attitude, spiritual concepts and practices, mind-body treatments and sometimes the use of health rituals; both are health care services that are excluded from or marginal to the dominant medical system. Yet, our review suggests that Israeli non-orthodox medicine is extremely heterogeneous. The main variation in rates of usage among respondents from diverse cultural population groups was linked to the specific preferred modality. Israeli ethnic minority groups (mainly Arabs) as well as immigrants appear to make greater use of indigenous herbal and folk-traditional medicine and to consult more frequently with herbalists and folk-traditional healers than do Israeli-born Jews, who favor CAM treatments that are more frequently used in developed nations and might be more expensive such as diet therapy (including nutritional supplements), homeopathy, chiropractics, energy healing and mind–body practices. The analysis of usage of herbal remedies and consultation with herbalists from a cross-cultural perspective exemplifies the gradient — 215 —

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of ethnic differences, ranging from the most Euro-American culturally oriented population group to the indigenous Mediterranean cultural groups. Non-native-born Ashkenazi Jews reported the lowest rate of herbal remedy use, followed by Israeli-born Jews, non-native born Sephardic Jews, Muslims, Christians up to the Druze, who reported the highest usage rates. Geographical-historical locality is thus related to use of herbal remedies. Israel’s position at the meeting point of three continents has generated a considerable botanical diversity of approximately 2700 plant species, of which 150 (5.5%) are endemic to the area (Mendelssohn and Yom-Tov, 1999). Use of herbal remedies is currently evident in the Eastern Mediterranean (Azaizeh, et al. 2006; Lev and Amar, 2000), and is documented in the Bible and in various other Arab and Jewish historical sources (Lev, 2002; Lev and Amar, 2007). Furthermore, the research highlights attitudes toward TCAM integration. Most of the population groups support the inclusion of TCAM in the Israeli health service, and expressed their readiness to participate in payment for these services. Respondents attribute an important role to the family physician, and most expected their family physician to have knowledge of TCAM and to be receptive toward it. Family practitioners were also expected by the majority of participants to initiate referral to TCAM in a hypothetical scenario in which TCAM is integrated within primary medical care rather than accessed through self-referral. The main variable that differentiates attitudes toward TCAM integration among respondents from diverse cultural population groups is the particular type of TCAM practitioner they prefer. A far higher proportion of respondents from ethnic minority groups (mainly Arabs), as compared to Jews, prefer non-physician practitioners providing TCAM care rather than physicians, and would like to see an herbalist on the clinic’s team. Jews tend to prefer touch and movement therapists, chiropractors, homeopaths and Chinese medicine practitioners. An exceptional group is the Bedouin. Far fewer Bedouin participants reported overall TCAM use and consultation with practitioners, including less frequent use of folk/traditional medicine, dietary supplements and herbal medicine. More of them favored provision of TCAM treatments by an MD-CAM practitioner or their family physician and far fewer were willing to participate in payment for TCAM services. This finding could be explained by hypothesizing underreporting of TCAM — 216 —

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use by Bedouin respondents. If we are to accept the validity of the results, however, the Bedouins of northern Israel appear to be an exceptional ethnic group, using less TCAM than others. This phenomenon can be explained as a result of poverty and by the delayed modernization of this society in northern Israel, which only 40 years ago was still a nomadic and semi-nomadic population (Ben-Arye, et al. 2009d). At present, Bedouin society is undergoing rapid urbanization. This process may induce higher esteem for scientific medicine and reduced esteem for traditional and herbal medicine as a result of rapid exposure to modernization. Because of their presumed higher esteem for modern medicine, Bedouins may expect their family physician actively to integrate TCAM with conventional care in the clinic (Ben-Arye, et al. 2009d). Our findings suggest that medical pluralism in Israel is closely connected to cultural pluralism and to the social power structures. CAM treatments that are more commonly used in developed nations are more prevalent among the Israeli Jewish majority (e.g., diet therapy, nutritional supplements, homeopathy, chiropractics, Chinese medicine including acupuncture, energy healing and mind–body practices). These modalities have also penetrated healthcare organizations, undergoing professionalization and institutionalization processes (Cohen, 2009; see also chapters 2 and 5) and earning a degree of public legitimization. Stemming from their popularity and economic importance, the success of these treatment modalities has been attributed primarily to their domestication by the dominant culture of biomedicine (Fadlon, 2004). Folk-traditional medicine, on the other hand, and especially traditional healers, frequently consulted by those belonging to the Arab and immigrant minorities, is not offered by healthcare organizations; moreover, most of the users themselves do not perceive traditional healing to be a suitable addition to regular healthcare clinics. We suggest that this attitude could be the result of a dual marginality: in other words, a combination of the low political status of minorities and the low status of local traditional knowledge in a modern developed country. Modern bio-medicine is linked to science and evidence-based knowledge, while what we categorize as traditional medicine is generally perceived to be based only on belief.

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Conclusions 1. The cultural pluralism that characterizes northern Israel is expressed in health care pluralism; 2. Patients’ preferred patterns of TCAM use shaped their attitudes toward TCAM integration; 3. These preferred patterns are socially and culturally dependent; 4. Medical pluralism is associated with cultural pluralism and power structures; 5. Practical implications: TCAM integration models should consider the social-cultural diversity among the patient population; 6. Research implications: the study of TCAM integration into healthcare services should examine power-knowledge relations in the local cultural and political contexts.



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CHAPTER 13

THEORETICAL CONCLUSIONS: BOUNDARIES AND BRIDGES

Post-Modernism and CAM The theoretical point of departure of this book proposes that the cultural ambience of “post-modern” or “late modern” societies provides a supportive cultural context for the development of CAM. This idea is based on a parallel chronological growth of the two phenomena: the period labeled “post modern” or “late modern” began in the 1980s, the era which also saw the beginnings of the growth of CAM in many Western societies. Post-modernism is characterized by a number of qualities which distinguish it from the earlier “modern” era (Bauman, 1995; Best and Kellner, 1997; Eastwood, 2000; Giddens, 1991; Lyotard, 1979). On the macro level, its dominant characteristics are rapid economic development, globalization, increased democratization, pluralism and reduction in the power of central governments (Smith, 2000). More relevant to the issues considered in this book are a set of characteristics which include a profusion of choices, an erosion in authority, and many alleged “truths” which do not have consensual legitimacy but are viewed as shifting social constructs (Rorty, 1989; Turner, 1995). These occur against a background of change or disintegration of long-established boundaries in a process which has resulted in an erosion of social cohesion, rejection of long-held values and norms, weakening of the influence of traditional figures of authority, and individual seeking of new experiences. At the same time, there is a growth in tolerance of differences and ambiguity, as well as increased skills in living in a context of conflicting values (Lyotard, 1979). We did not propose to examine the validity of these contentions or to scrutinize their prevalence in Israel. What we have done is focus our research on a complex social context, replete with numerous crisscrossing boundaries. Within this context, we have examined strategies utilized to handle the dilemmas which arise. These strategies are compatible with and dependent on specific cultural contexts. Analysis of the empirical data permits a number of conclusions regarding the association of CAM — 221 —

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with selected post-modern phenomena. At the same time, the presence of selected elements of post-modernism does not attest to the relevance of all of its alleged characteristics. Although the hegemony of bio-medicine in Israel remains strong, the development of CAM and its growing acceptance indicate that biomedicine is not perceived by wide segments of the population as the exclusive authority in the field of health care. Substantial numbers of CAM providers and users accept the legitimacy and knowledge of other experts—along with or instead of bio-medicine. The same is true of many bio-medical practitioners themselves. This is not an entirely new phenomenon; the hegemony of the medical profession, however powerful and dominant, has not been entirely successful in establishing a full monopoly of health care. However, since the 1980s it has been increasingly challenged by segments of the population who unhesitatingly utilize other experts for their health care. This can be viewed not only as an acceptance of the multiplicity of truths, but as a factor contributing to an overall erosion in attempts to establish the exclusive authority of bio-medicine. The growing presence of CAM and the increase in its specialties provides evidence for the polycentric structure of knowledge and expertise. Homeopathy—while not a new phenomenon—is a prime example, and there are others. Our research highlights the frequency and ease with which boundaries are crossed or re-contoured. This is another characteristic of post-modern societies. The progressive mainstreaming of CAM indicates that professionals and laypersons are increasingly skilled in managing a context of conflicting values. Our principal focus has been on micro rather than on macro processes of post-modernism; we have not dealt with economic development, globalization or democratization. Neither have we sought to establish causality; what we have found is an associative relationship between the growth of CAM and a number of specific qualities of post-modernism. The findings do not support the notion that these “post modern” qualities are a sine qua non for the development of CAM, but rather that they have supported its growth. Boundaries and CAM The dual processes expressed by “boundaries” and “bridges” provide parallel themes for the book. The theoretical literature on boundaries — 222 —

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has provided important insights regarding processes of separation in which numerous boundaries interact with each other. It is evident that the many boundaries that prevail in the bio-CAM contexts studied are not congruent and may not be related to each other. We have found that boundaries are not all alike; they differ in terms of relative permeability, salience, durability and visibility. They also differ in how they are defended, imposed, bridged or dissolved. In this context, actors develop modes of negotiating passage as well as techniques of adapting themselves to changing boundary contours (Alba, 2005; Pachucki, et al. 2007). Thus, the title of our book—Boundaries and Bridges. Processes of integrating CAM and bio-medicine in Israel have been strongly medicalized. On the macro level, this is expressed formally in the well-guarded formal boundary separating bio-medicine and CAM in the jurisdictional arena by the Doctors’ Ordinance. The provision in this Ordinance that CAM practitioners can work within bio-medical organizations under medical supervision made possible the co-optation process, which determined the overall structure of the public CAM clinics. The most critical boundary change seen in the course of this process was effected by certain of the bio-medical organizations themselves—the three sick funds and the hospitals which established the CAM clinics. In changing the previously sealed organizational boundary and re-contouring it to include CAM, the sick funds and the hospitals’ outpatient units endowed CAM with a certain legitimacy stemming from their association with the highly respected bio-medical care system. Within the context of this important boundary change, they were careful to make clear the simultaneous inclusion and separateness of CAM with respect to bio-medicine. While located inside these bio-medical organizations, CAM is not accorded equal status to its bio-medical host. The senior bio-medical officer (ro’fe me’mayen) controls the organizational boundary by examining the credentials of CAM practitioners before selecting the ones accepted to work in the clinics. This selection also determines which forms of CAM will be offered to clinic patients. Furthermore, the bio-medical screening of patients at the point of entry determines who will be accepted for CAM treatment (chapter 5). Medicalization is further seen in the use of the term “complementary” to describe these clinics and make evident their secondary status relative to their bio-medical neighbors. CAM practitioners working in these settings have been marginalized, and their conditions of employ— 223 —

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ment are inferior to those of bio-medical personnel (chapter 5). Most recently, the increasing use of the label “integrative” serves to soften this invidious distinction on the symbolic level. We have also seen how integrative physicians working in family practice settings in the regular (non-CAM) sick fund system have been limited by formal organizational boundaries from full integration of CAM into their day to day practice (chapter 10). The dominant policy of medicalization is further expressed in the intensity with which core boundaries of bio-medicine are guarded. Thus, we have observed the closure of specific hospital arenas which are off-bounds to CAM practitioners—despite the tolerance or partial acceptance of CAM in other areas of bedside care in hospital practice. The research has shown how these boundaries have changed over time— opening up areas that were formerly hermetically closed. More and more traditionally-closed areas of practice may be cautiously changing the contours of their accessible territory (chapters 5, 6). Despite trends toward greater tolerance and open-mindedness, a powerful core of rejection remains at the heart of the bio-medical establishment in Israel, and acceptance of CAM remains conditional. A notable exception is the Israel Society for Integrative Medicine, which is an integral part of the prestigious Israel Medical Association. The small number of devoted and active members of this society, established in 2002, play an important role in promoting and strengthening the integrative processes already at work. We have noted the role of its members in promoting CAM in the hospitals and in some community settings (chapter 5). Furthermore, along with the powerful processes of medicalization, we have pointed to important processes of CAMification. These operate at the micro level along informal pathways. Rather than formal confrontations over boundary crossings, social networks and particularistic relationships are utilized to gain entry into health care settings ostensibly closed to CAM. Many of the integrative practitioners are imbued with a keen desire to disseminate the essential beliefs of CAM in the bio-medical community. Among the central CAM tenets thought lacking in much of current bio-medical practice and worthy of dissemination are holism, integration of body and mind, improved interpersonal interaction with patients, assisting patients to heal themselves, greater emphasis on prevention, a healthy lifestyle and the use of less invasive procedures. This — 224 —

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effort represents an attempt to diffuse the cognitive boundary between CAM and bio-medicine—but not necessarily eliminate it. In our case studies, this view was most evident among the midwives who showed considerable missionary zeal, as did many of the CAM-family practitioners (chapters 9 and 10). Although most of the practitioners interviewed had already made a critical, career-defining decision by deciding to traverse the boundary separating bio-medicine and CAM, it became clear in the course of the research that negotiation of this robust and well guarded boundary is not a one-time event; it occurs repeatedly in different contexts and, in some cases, on a daily basis in the course of clinical practice. For example: we have observed the process of boundary negotiation utilized when CAM practitioners regularly enter hospitals—the bastion of biomedicine—to provide bed-side care for hospitalized patients; it is also evident when physician-homeopaths and family practitioners who also practice CAM first encounter a patient and decide on the appropriate mode of treatment (chapters 5, 7). Principal Strategies for Re-Contouring Boundaries The research has shown that bio-medical practitioners who utilize CAM confront a variety of boundaries in the course of their professional work. Among the most salient are those separating evidence-based medicine from health practices based on other forms of legitimation. Other important boundaries encountered are spatial, epistemological, cognitive, juridical, social and organizational. Individual practitioners utilize a variety of strategies in re-contouring and crossing these boundaries. 1. Pragmatism vs. Evidence-Based Medicine One of the most impermeable boundaries separating bio-medicine from CAM is the former’s basic criterion for legitimacy: evidence based research. Despite considerable on-going research, this criterion is not met by a high proportion of CAM practices. The findings show that the dilemma posed by this apparent problem does not trouble the CAM practitioners; almost all of them were entirely comfortable in responding to this challenge. Their mode of handling this boundary is to adopt an alternative criterion for legitimacy: “clinical pragmatism.” From their point of view, the litmus test for legitimacy is not controlled experimental research, but rather the clinical effectiveness of a given mode of — 225 —

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treatment; “it works!” was the universal response of the CAM physicians. In assuming this stance, they re-defined one of the critical boundaries of bio-medical legitimacy by establishing “the patient’s welfare” as the critical condition for legitimacy. The finding is striking in its prevalence among virtually all of the CAM practitioners in the study. 2. Translation of CAM concepts into bio-medical rhetoric and symbolism Recognizing the symbolic power of bio-medical rhetoric in gaining legitimacy, some CAM practitioners avoided the use of CAM-related terminology and chose to utilize bio-medical vocabulary to describe CAM processes. Wardwell (1994) has noted that nurses lean on their bio-medical background to “scientize” their practice of CAM. One of the physician-homeopaths described a central concept of homeopathy—the “Energy Medicine” paradigm—in terms of theories relating to biological fields and electromagnetic waves or theories. This is an attempt to draw a connection between human energy systems and new insights in modern physics (Rubik, 2002; Schwartz and Russek, 1997). By this mechanism, many of the CAM practitioners sought to make evident their bio-medical identity and their acceptance of its cultural assumptions. Such rhetoric is a form of boundary work which evokes the cognitive foundations of bio-medicine—importing them over the boundary into a CAM setting in an effort to gain legitimacy (chapters 7, 8). A form of isomorphism occurs when bio-CAM practitioners utilize external symbols to emphasize their bio-medical identity. This is seen in their dress code, use of a stethoscope and other unmistakable symbols of bio-medical identity. Of the two identities available to them, many of the CAM physicians chose to emphasize the bio-medical option as a source of prestige and legitimacy. Although they had undoubtedly crossed a major boundary, they were careful to make known their ongoing identity with the bio-medical side of the boundary (DiMaggio and Powell, 1983) (chapter 5). 3. Spatial Differentiation of Practice One way of controlling boundaries is by separating the locus of practice of CAM and bio-medicine. This makes it possible to utilize different epistemological paradigms without discomfort. Such differentiation provides for epistemological duality—a comfortable form of “dual citizenship.” — 226 —

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An example is provided by the nurses discussed in chapter 8, who maintained a private CAM practice at some distance from their hospital work and did not perceive themselves as violating the axioms of biomedicine. Indeed, they repeatedly evoked their bio-medical credentials as providing cognitive legitimation to choose what they view as appropriate techniques for treatment; several see themselves as expanding the boundaries of bio-medicine by the addition of methods which improve the patient’s quality of life and reduce suffering. 4. Informal by-passing of Formal Boundaries The phenomenological approach utilized in our research highlights the role of micro processes that become evident when individuals describe their experiences and express their feelings from their own perspectives (Denzin and Lincoln, 2000; Gubrion and Holstein, 2002). The findings make clear that the formal structure of institutions and legally imposed regulations describe only part of the context of real-life as experienced on an everyday basis. Indeed, these formal requirements are powerful in themselves and establish an overall structural bio-medical presence—but the social reality, when examined closely, shows considerable deviation from that structure. The experiential setting shows that many regulations are by-passed or ignored in the context of dayto-day behavior. The book is replete with examples of this phenomenon. We will recall only two here: Mizrachi (chapter 6) shows how knowledge and professional conduct are refracted through daily practice, with boundaries shaped and reshaped by local, immediate forces. The formal jurisdictional definitions of the roles of bio-medical and CAM practitioners were not carried out to the letter, and close observation showed frequent deviations from the norms prescribed. For example: the entry of CAM practitioners into the wards and their interaction with bio-medical doctors was defined as “research” in order to impart legitimacy. In chapter 5, another example of the informal over-riding the formal is seen in the clinics run by the sick funds, where official bio-medical control is imposed briefly at the time of the patient’s first visit but is hardly felt once patients reach a CAM practitioner. The latter is quite autonomous to practice according to the norms of his/her CAM specialty. Bio-medical control is present but barely visible except at long intervals.

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5. Boundary Denial: “One Medicine” An important boundary-crossing mechanism is denial of the existence of a boundary separating bio-medicine and CAM. The contention that there is only one medicine and it includes all methods that cure or relieve patients of pain and illness may be viewed as an effort toward integrating CAM and bio-medicine under one conceptual and practical roof. From this point of view, the existing epistemological and cognitive boundaries are irrelevant: all theories, methods, cures and techniques that contribute to patients’ well-being are legitimate and should be utilized when needed (chapters 7, 8, 9). 6. Criticism of bio-medicine: a form of boundary work There was widespread criticism of bio-medical practice by most of the individuals interviewed, regardless of their field of practice. None of it touched on the validity or usefulness of the hard core of science and technology, which is the heart of medical practice. The criticism focused principally on the mode of practice and specific lacunae in the bio-physician’s role. Such criticism seeks to re-contour the cognitive boundary of contemporary medicine and can be viewed as a form of CAMification— an effort to introduce elements of CAM into bio-medical practice. It is claimed that this will improve health care by addressing the weaknesses and failures of contemporary bio-medical practice. Examples abound: the midwives referred to the over-medicalization of childbirth; almost all noted the over-use of technology and the excessive use of medications and invasive procedures. Many CAM practitioners described biomedicine as reductionist while CAM is holistic. CAM is sensitive to the patient’s emotional needs, while bio medical physicians have little interest in or understanding of patients’ feelings. Listening to the patient in an attempt to discern her/his needs requires more time than is allotted to the encounter in the sick fund clinics, especially when many biophysicians spend much of the patient’s visit reading computer-based records and adding their own data to it. 7. Social interaction Bio-medical-CAM practitioners have at least two professional identities—a situation that can lead to some discomfort. The research shows that the social-professional context determines which will be highlighted. In most cases, the high-status bio-medical identity is emphasized, — 228 —

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but in others, the CAM identity. Interaction with like-minded colleagues serves to provide social support in ambiguous contexts. Giddens (1991) has noted that such contacts provide ontological confidence. The research shows that family doctors who practice CAM make a point of maintaining active contacts with their bio-medical colleagues—by means of conferences, consultations and informal friendships. Among physicians who practice homeopathy, it is notable that many prefer professional and social contacts with other homeopaths or other CAM practitioners. Taken as a whole, CAM practitioners feel more comfortable with CAM than with bio-medical colleagues; in interaction with the latter they often sense themselves to be “strangers” (Simmel, 1971). Conclusion In drawing together the theoretical findings we have pointed to two social processes that structure our theoretical thinking with regard to the co-existence of CAM and bio-medicine in Israel: separation and joining. These are expressed in the title of the book, where we refer to boundaries and bridges. The research demonstrates that these processes—which are in some sense antithetical—are active simultaneously. Thus, there are boundaries which separate, but at the same time bridges have been formed that lead to joining. Some boundaries remain impermeable, while others have become more passable, have been re-contoured, or techniques have been developed to bypass them. It would seem that on the macro level, the boundaries that separate CAM and bio-medicine provide an imprinting effect on the overall structure of the relationships. Thus, we have referred to powerful processes of medicalization in the overall structuring of CAM and bio-medicine in Israel. The principal bio-medical institutions responded to the growth of CAM in Israel by re-contouring one of the critical organizational boundaries of the health care institutions to admit CAM practitioners; on the macro level this was seen in the establishment of CAM clinics by all but one of the sick funds and in one third of the hospitals. On the micro-level, bio-medical practitioners who utilized CAM developed a variety of effective strategies for crossing the many boundaries they opass on a day-to-day basis. This has made possible dual citizenship in two worlds and enabled them to carry out their professional roles in both. — 229 —

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CHAPTER 14

MEDICALIZATION AND CAMIFICATION

Our book has ranged over a wide array of topics concerning the meeting ground of CAM and bio-medicine in Israel. These have included a discussion of theoretical issues, an historical analysis, descriptive narratives and surveys of several types of patients. A major part of the book is dedicated to a set of case studies of bio-medical practitioners who have studied and practice various forms of CAM in a variety of clinical settings: community and hospital physicians, nurses, midwives, family practitioners. In addition to all of these, we have examined the views of decision makers who are involved in health care policy. What can we conclude about the diversity of modes and structures in which bio-medicine and CAM are joined in Israel? In this final chapter, we will draw the research findings together to consider how CAM and bio-medicine co-exist in Israel. Both macro and micro processes will be considered. Thus, we will focus on the cultural and political context in which the principal actors and institutions provide health care and on the relationships among them. These have been contextualized in the micro processes observed when bio-medical professionals add CAM to their repertoire of skills. In depth study of these contexts has enabled us to reach a greater understanding of the social context in which CAM and bio-medicine co-exist. The Origins of Co-Existence Until the late 1980s, CAM was a sporadic and barely-noted phenomenon in the health-care scene in Israel. The bio-medical institutions occupied a dominant position expressed in an unchallenged hegemony over health care. The professional medical organizations were strong, and the medical schools taught the highest standards of contemporary bio-medical practice. The health care system—the roots of which were planted well before the establishment of the state of Israel—provided care to all segments of the population, albeit not at an equal level to all. Israel’s small space and centrist governmental structure make possible more control than is feasible in societies with more widespread and — 230 —

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differentiated regional and organization structures, such as autonomous districts or boroughs. It was the increased use of CAM by consumers in the 1980s that brought about the response of the bio-medical institutions to the apparent challenge. Although the rates of CAM use have not reached the level of many other Western countries, the change in consumer behavior signaled a threat to the long-established hegemony of bio-medicine. It was unthinkable for many of the leaders of the elite bio-medical community that consumers would prefer the unproven, un-researched, possibly charlatan practices of unlicensed CAM practitioners to the scientific, evidence-based techniques of contemporary bio-medicine. The historic centrality of a strong and well-established public system of health care and the relatively marginal role of private medical services at the time made the placement of CAM within the public sector an obvious choice. It set the stage for a highly medicalized pattern of coexistence of bio-medicine and CAM. During the 1980s, the hospitals and sick funds were experiencing severe financial difficulties, and were seeking ways to strengthen the economic infrastructure of the health care institutions. Neo-liberal trends were sweeping the economy—reducing the role of government in providing services and encouraging competition among the sick funds and among the hospitals. CAM was not included in the universal set of entitlements provided by the National Health Law; thus, it was hoped that fees for CAM service would contribute to deficits in the budgets of the hard-pressed sick funds and hospitals. It was this instrumental motive rather than any fundamental change in its on-going critical stance regarding CAM that led to the co-optation pattern adopted by the bio-medical institutions. The result was that in 1991 the public hospitals began to establish outpatient CAM clinics under their official auspices, and three of the sick funds created their own networks of community-based clinics dedicated to CAM services. In 2010 one third of the public hospitals had outpatient CAM clinics, and over 80 CAM-dedicated clinics were operated by the sick funds. Thus, most of CAM in Israel (65%) is delivered under the formal auspices of the publicly sponsored, bio-medical health-care system. 35% is provided in private or mixed (public/private) clinics. Some of the latter have agreements with the sick funds to offer reduced fees to persons — 231 —

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carrying supplementary health insurance (Business Data Information COFACE, 2008). The Structure of Co-Existence We will first discuss the large public CAM services and then describe the smaller private sector. 1. The Public Sector In the public sector CAM is practiced in community-based CAM clinics and, to a lesser extent, with hospitalized patients. There are also a small number of integrative physicians who practice in the context of the regular primary care clinics of the bio-medical system. We will consider each of these in turn. There are two types of community clinics dedicated to CAM: those affiliated with hospitals and those affiliated with the sick funds. The first CAM-dedicated clinic, established in 1991 at Assaf Harofe Hospital, established a structural pattern which was subsequently adopted by all of the community CAM clinics. An examination of the basic structure of these clinics in 2010 shows that the initial pattern has persisted in its initial form for over a decade. The structure devised for the CAM clinics reflected three goals of the bio-medical initiators: to gain as much income as possible from patients’ fees; to maintain the hegemony of bio-medicine; and to attract clients by offering a broad array of CAM services. By way of contrast to the regular sick fund clinics in Israel where medical care is dispensed with no fee for service or with a small symbolic charge for specialists, the CAM clinics require patients to pay. Fees are controlled, and persons carrying supplementary health care insurance pay about half of the regular fee. In any case, the costs are not negligible. Like all payments for health care, the fees introduce an element of inequality by making CAM less accessible to lower-income segments of the population. The structure developed is a form of co-optation that attained all of the above goals. It was constrained by the jurisdictional boundary defined in the Doctors’ Ordinance, which provides that only a licensed physician may practice medicine (Doctors’ Ordinance, 1976, 1987; Appendix B). Since the Ordinance also permits qualified persons working under the supervision of a licensed physician to provide health care, this authority — 232 —

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is sufficient to legitimize the work of CAM practitioners in the clinics. It covers practitioners with and without bio-medical credentials. (Glauber, 2001; Grinstein, et al. 2002; Yishai, 1999). This absence of formal regulation may be viewed as an important strategy of control of the judicial-political boundary. In effect, it works to strengthen the monopoly of bio-medicine by limiting access to health care by non-physicians unless they work under bio-medical supervision. The director of each clinic is the principal gatekeeper, a physician who is also qualified in one or more fields of CAM practice. The practitioners employed in the clinics include CAM specialists in many fields: acupuncture, homeopathy, chiropractic, reflexology, Feldenkrais, Reiki, naturopathy, touch and movement modalities, herbal medicine, bio-feedback, Alexander, aromatherapy, alternative nutrition, Paula and others. Only a minority are also licensed in a bio-medical field. The bio-medical screening process establishes an unmistakable boundary defining the domains of bio-medicine and CAM; upon arrival all patients undergo a preliminary screening routine based on their biomedical records. If these are incomplete, the patient is requested to complete them before she/he can be accepted for CAM treatment. The bio-medical gatekeeper serves as a diagnostician and administrator, but generally does not practice as a bio-medical clinician in these settings although he/she may practice in a CAM specialty. The hegemony of bio-medicine defines a hierarchical relationship with CAM. This is seen in the salaries and employment status of the CAM practitioners which is inferior to that of the bio-medical personnel. From the viewpoint of Boon, et al. (2004), this form of practice may be seen as “parallel,” a far cry from fully integrative medicine. Re-asserting the traditional boundary of its hegemony, the biomedical institutions entitled the newly established CAM clinics “complementary,” “pain clinics” or “natural clinics.” The notion of “alternative” was deliberately rejected. This rhetorical labeling strategy— one of the processes termed “boundary work” by Gieryn (1999)— highlights the dominance of bio-medicine and makes an unequivocal statement regarding the secondary role of CAM. At the same time, it has been noted that its acceptance within the biomedical organizational structure endows CAM with an unmistakable legitimacy regarding health care (Davies, 2001). Despite its lacking jurisdictional legitimacy, its sponsorship and inclusion within the — 233 —

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broad boundaries of the prestigious bio-medical family of health care institutions bring it close to mainstream health care in Israel. What is more, patients gain confidence in CAM from its bio-medical sponsor. We have observed that bio-medical control of the CAM clinics is at least partly ritual. While the formal control mechanisms remain, they play a minor role in the context of everyday clinical practice in which CAM is primary and uncontested. From the CAM practitioner’s viewpoint as well as that of the patient, the bio-medical control function is felt only sporadically, although it cannot be entirely discounted. CAM practice is segregated from bio-medicine and there is little integration of skills from the two spheres. There is no evidence to suggest that the CAM practitioners feel a need for greater bio-medical contacts. Neither did we find any meaningful dialogue regarding theoretical or epistemological issues between bio-medical and CAM practitioners. In such a work environment, there exists an opportunity for interaction and consultation among CAM practitioners with different specialties. However, the findings show this to be a relatively rare phenomenon. Like most bio-medical specialists, the CAM practitioners tend to remain within the confines of their own specialty unless specifically approached for a professional opinion. This is a form of isomorphism in which CAM practitioners re-enact the professional behavior of their bio-medical counterparts. The organizational structure of the CAM clinics could explain the low frequency of CAM use in Israel relative to other Western, developed countries. In many Western countries where CAM usage is considerably higher, a large proportion of CAM is provided by primary care physicians in the context of their regular clinical work (Joos, et al., 2009; Rolfe and Hohenstein, 2001; Thomas, et al., 2001). In Israel, the basic structure of these clinics discourages their use for primary health care. The fees are a major deterrent, and the screening process delays access to urgent needs for primary care. The complete segregation of bio-medicine from CAM could also be a deterrent to some patients. Furthermore, the introduction of CAM into family practice in the regular primary care clinics is fraught with organizational complications—as discussed in chapter 10. If CAM were accessible in the context of primary health care, it is reasonable to assume that use would increase considerably. Now to move on to hospitals. Our research shows that since the 1990s, hospital boundaries are increasing permeable to CAM practitioners who — 234 —

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provide care to a growing number of hospitalized patients. When the research was launched in 2000 we found CAM practitioners to be thinly spread in numerous hospitals in different departments: orthopedics, oncology, pediatrics, internal medicine, obstetrics, neonatal intensive care units, gastroenterology, neurology, nutrition and pain clinics. By 2010, CAM activity had grown considerably—especially in the field of oncology—due to the dedicated efforts of a small number of integrative physicians. CAM practitioners enter hospital practice by means of unofficial channels of communication. Rather than working through formal mechanisms of public recruitment, informal networks and personal contacts are the principal modes of negotiating recruitment of practitioners. In recent years, the directors of the hospitals’ outpatient CAM clinics have played a major role in this process. The hospitals prefer to hire physicians or other bio-medically trained persons who have acquired an additional specialization in a CAM field. But such candidates are not always available, and compromises occur in response to consumers’ demand for a wide array of CAM specialties. There are many visible signs indicating the differential status of biomedical and CAM personnel. These include the type of medical work performed and the boundary demarcation of spaces in which CAM is proscribed, e.g. the surgical sphere, emergency room, nuclear medicine and imaging units—life-saving units are all strictly off-bounds to CAM practitioners. An interesting recent exception is the experimental admission of hypnotists, reflexologists and touch therapists to selected pre- and post-surgical facilities. The presence of CAM practitioners inside hospitals, the stronghold of bio- medicine, is viewed by some bio-medical practitioners as threatening to the cognitive core of medicine. Thus, CAM practitioners focus on “care” of patients while “cure” is in the hands of the bio-medical staff. This differentiation signals the lower status of CAM, which does not deal with what is viewed as the core elements of contemporary medicine. Legitimization for the presence of CAM practitioners in a hospital department is gained by utilizing labeling mechanisms that lend authority to their presence but make clear their non-belonging. The labels used to characterize the work of CAM practitioners are the biomedical words “research” and “clinical experiments.” Thus, joint efforts — 235 —

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by a physician and a CAM practitioner to improve the quality of life of patients in an oncology department have been referred to as “clinical experiments” and “research” that sought to demonstrate the efficacy of alternative methods of treatment. This labeling makes clear the non-permanent presence of CAM personnel, who are remunerated by research grants which are bounded in time and therefore not part of the core of regular health care. In the hospitals, departments of oncology and pain clinics have been the most welcoming to CAM practitioners. This is explained by the unambiguous boundary defining their work: it is confined to palliative care focusing on the side effects of bio-medical procedures. Their outsider status vis-á-vis the bio-medical staff is made clear by the fact that many are volunteers or are remunerated by outside funds or endowments established by the families of deceased persons who benefited in the past from CAM treatment. The last category here discussed is integrative care in sick fund clinics. In 2009, there were over 5,000 physicians practicing in the regular primary care clinics run by the four sick funds. These are distributed in all parts of the country and provide universal medical care to all under the provisions of the National Health Law of 1995 (Rosen and Samuel, 2009). As noted, CAM in not included in the list of entitlements under the Law. Among these physicians is a small sprinkling of primary care doctors who are also qualified in one or more CAM fields and who seek to integrate these skills into their practice. Most of them are family practitioners, internists, or pediatricians. Chapter 10 discusses the social processes involved in this effort at CAMification of family practice. None of the four sick funds, which employ these physicians, has addressed the many issues involved in this innovative mode of practice. Insofar as the sick funds are concerned, CAM is officially provided in the special network of clinics dedicated to CAM which they have established. The CAM physicians who work in the regular sick fund clinics have no trouble crossing the many boundaries which crisscross their professional lives. They are unbothered by epistemological or cognitive conflicts, and generally believe in “one medicine.” Many see themselves as pioneers and are keen to utilize the best of their bio-medical and CAM skills for the benefit of their patients. The integrative physicians are engaged in a process of CAMification of — 236 —

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primary care. Like the midwives (chapter 9), they identify strongly with their bio-medical profession while at the same time seeking to introduce CAM into clinical encounters when they believe it can be useful. The research shows that the organizational boundary drawn by the sick funds presents a major obstacle to the implementation of this type of integrative practice. Since, as noted, CAM is not included in the basic list of entitlements provided by law, it cannot be provided in the context of the sick fund clinics without a fee for service. The salaried primary care doctors are not permitted to take fees during their working hours. As mentioned earlier, from the point of view of the sick funds, the demand for CAM is formally dealt with by the network of CAM clinics, and patients should be referred to them. These constraints cause considerable discomfort to the integrative physicians who are constrained in the use of their CAM skills. Most are critical of the quality of care offered in the sick funds’ CAM clinics and of the separatist mode of practice there, which differentiates bio-medicine from CAM so sharply. At the same time, it is awkward for them to refer patients to their own private clinics. Despite their desire to integrate CAM into the public primary care system, some decide that part-time private practice provides the optimal solution. Many have opened private clinics in which they integrate biomedicine and CAM, giving primacy to whichever type of treatment seems optimal for individual patients. In these settings, CAMification is more easily achieved. An additional option is to introduce CAM discreetly into the public primary care clinic by offering patients CAM advice and therapy informally, as best they can. Most amenable to such discreet entry are recommendations regarding alternative diets, relaxation techniques and use of herbal or homeopathic products which can be purchased over the counter. Time-and space-consuming procedures—such as acupuncture or reflexology—are naturally more difficult to introduce. The CAM midwives, discussed in chapter 9, are in a similar position; working in the delivery rooms of hospitals, they introduce CAM procedures discreetly, with the consent of the birthing woman. The environment of the delivery rooms is strongly bio-medical, but the CAM midwives resist the medicalization of childbirth. They seek to reduce the use of epidural while introducing massage and other touch techniques to control the pain of delivery. Their work is subject to bio-medical — 237 —

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scrutiny by other midwives, but they are supported inside the hospital by those obstetricians who promote natural childbirth. This approach of the midwives provides a further example of the CAMification process. 2. The Private Sector The percentage of private participation in the global expenditure on health has been increasing in recent years in Israel. In 2010, it reached 43%, which is higher than in most developed OECD countries (http:// www.oecd.org). This is a source of serious concern in a society committed to an egalitarian policy in health care. The fact that 35% of CAM is provided by the private sector contributes to inequality and is part of the broader trend seen in the on-going reduction in public support of health and welfare programs. It is important to note that CAM is provided privately only in community clinics; generally there is no charge for CAM when it is delivered to hospitalized patients. Part of the private sector delivering CAM services is linked into the public sector by contracts and agreements with the sick funds, which provide reduced fees to patients carrying supplementary health insurance. Many of the CAM practitioners in the private sector also work in the public sector. The lucrative setting of private practice is seductive in a society that is structured around an open market economy. Working privately on a part-time basis, they are able to augment their incomes considerably: it is estimated that fees for CAM treatment in the private sector are two to three times the fees paid in the public CAM clinics. Private practice offers practitioners a less constrained clinical ambience; they have more time to select their diagnostic and treatment options as they see fit. For practitioners who are bio-medically trained, the balance of bio-medical and CAM is not constricted and can be adjusted by the practitioner freely to a patient’s needs (chapter 10). In this context, CAMification is an open option. The CAM-nurses described in chapter 8 provide an example in which a spatial-temporal boundary provides for complete separation between their bio-medical and CAM practice. These nurses practiced bio-medicine in public hospital settings and moved to a private clinic elsewhere to practice CAM. In each of these differentiated settings, the nurses work in an environment that is minimally invaded by values or controls that — 238 —

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challenge the treatment modes they choose to utilize. They do not worry about powerful others scrutinizing their clinical work. At the same time, we have noted an interesting asymmetry in this type of differentiated boundary work. In the context of their private CAM clinic, the nurses are entirely comfortable in importing bio-medical skills over the territorial boundary defining their CAM environment. Thus, they view it as a sine qua non to screen patients by the use of bio-medical tests and records before starting CAM treatment. However, in the context of their hospital work, the nurses adhere strictly to bio-medical procedures. Even when they believe that a CAM technique could relieve a patient’s pain, they are reluctant to use it lest one of the other bio-medical members of the staff observe such deviant behavior. Sometimes they use CAM discreetly—while checking over their shoulder for a critical presence. Some Pending Policy Issues

1. Regulation CAM is here to stay. The public as a whole and patients in particular are entitled to a safe system of CAM care. It is the responsibility of the state to protect the public by ensuring that CAM is practiced in accordance with professional, ethical and practice standards (Nicolai, et al. 2006). A major outstanding issue in Israel—as in many other countries— is the establishment of a system of licensing which makes explicit and enforceable the standards of practice required for the different forms of CAM practice. It cannot be assumed that training for medicine in itself provides the knowledge, skills and judgment needed for CAM practice. Israel can learn from the experience in Europe and in the United States, where guidelines have been developed for the appropriate practice of CAM by bio-medical physicians (Cohen and Kempfer, 2005; Horrigan and Block, 2002; Nicolai, et al. 2006). Licensing for non-medical CAM practitioners is a complex problem which needs to be addressed creatively, taking into consideration the considerable differences among the various CAM specialties and their specific needs. 2. Bio-medical education CAM is taught sporadically in medical schools in Israel; it is not a regular part of the curriculum in schools of nursing, of occupational therapy or — 239 —

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physical therapy. Practitioners in these schools and in other bio-medical training institutions need to be exposed to the basics of CAM therapies. The object is not to train them as CAM practitioners, but to provide a basis for understanding the options available to their patients for referrals. Furthermore, they need to understand the CAM experiences of those of their patients who have already undertaken these types of treatments. Greater understanding of CAM by bio-medical practitioners is likely to increase their open-mindedness so that patients will report to them more freely on their experiences with CAM treatment. Lack of knowledge or awareness of a patient’s de facto use of CAM can be an impediment to appropriate bio-medical care. The research has shown that, in the future, certain CAM treatments may be included in patients’ medical records, and will therefore require more knowledge and understanding of its implications by bio-medical practitioners (Kelner and Wellman, 2003; Oberbaum, et al. 2005). 3. Primary Care In Israel, the sick funds provide universal, accessible primary care at no direct out of pocket cost to patients. Judging by patterns of CAM use in other countries, there might be substantial numbers of people in Israel who would prefer CAM for primary medical care. However, the structure of the sick fund CAM clinics is not geared to the provision of this need. The fee for service is an important barrier with regard to primary care. As a result, people who can afford to pay seek CAM for primary care in the private sector.

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Epilogue

We have seen that, despite the tenuous regulation and control of CAM in Israel, there is a growing population of users and a thriving group of CAM providers. In the absence of governmental regulation or licensing, supervision by a physician provides the only formal quality control. Most of CAM is delivered within the framework of the public medical care system; about a third is delivered in the context of private clinics. CAM is not included in the universal health benefits package and requires payment of a fee for service. In the public sphere, the fees are regulated; nevertheless they make CAM less accessible to lower income segments of the population. Within this context, CAM practitioners enjoy considerable professional autonomy. The history of the medical profession indicates that it has a long tradition of defending its turf against strangers or invaders who have challenged its monopoly by offering alternative paradigms and healing methods. In this tradition, it responded to the growth of CAM in Israel by intensive medicalization of the arenas in which CAM and biomedicine co-exist. Nevertheless our findings lead to the conclusion that in the context of the social climate of post-modern societies prevailing in Israel and in many Western societies, medicalization has been uneven and is not allencompassing. The boundaries of bio-medical institutions have been recontoured to include CAM (Easthope and Adams, 2004); processes of cooptation have been successful, but at the same time have provided CAM with the legitimacy of inclusion within the organizational umbrella of mainstream bio-medical institutions. With regard to health care—as in other areas— there is widespread acceptance and use of different types of knowledge in addition to that of the bio-medical canon. CAM has become more and more acceptable even within parts of the conservative bio-medical community. On the macro level, powerful medicalization has kept overt territorial and epistemological conflict under control. The major actors in the public arena—the sick funds, the Ministry of Health and the Israel Medical Association—have evaded direct confrontation with — 241 —

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the issues of regulation, and appear to accept the existing modus vivendi on the assumption that bio-medical hegemony is intact. The integrative physicians inside the Israel Medical Association are a small, active, innovative group which seeks to advance its views within the medical establishment as well as outside it. They are prime movers in the CAMification of bio-medicine and have made important progress. The quality of the cultural milieu provides a supportive background to their efforts. Not all CAM practitioners in Israel are keen to work collaboratively with bio-medical practitioners. Many seek autonomy and resent medical dominance. Those who are employed by the bio-medical institutions do not enjoy the benefits or status of bio-medical personnel in the same institutions. In an experimental integrated clinic in Sweden, the staff deliberately addressed issues of hierarchy and collaboration among bio-medical and CAM practitioners. The stated goal is to attain “interdisciplinary, non-hierarchical decision-making involving a mix of conventional and complementary medical solutions in individual case management” (Sundberg, et al. 2007, p. 110). This model provides a goal devoutly to be wished in Israel as well as in other countries. The CAM practitioners’ professional organizations in Israel represent a broad array of interests, some of which are common to all of them, but many of which are unique to each occupational group. These groups differ in the size of their membership and in the level of consensus regarding goals and methods of attaining them. This makes collective action difficult. In the foreseeable future, it seems likely that the CAM practitioners’ professional organizations will become increasingly vocal and influential. With regard to the micro level, the findings do not show evidence of epistemological conflict among bio-trained practitioners who have embraced and practice CAM. There is no indication of the kind of “schizophrenic break” referred to by Simmel (1971). The opposite is the case: boundary-crossing is widespread and frequent. It is accomplished with finesse and skill—and with little evidence of discomfort. Clearly, the boundary-crossers are self-selected and are therefore endowed with the necessary skills and motivation to undertake such crossing. Repeated exercise of these skills hones them to a fine point of proficiency. A broad variety of strategies have been developed to manage these social processes. What is more, sanctions against non-conformity to — 242 —

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the mainstream have lost much of their deterrent power. Since there is more tolerance of differences and ambiguity, there is also an increase in the ability to manage conflicting types of knowledge (Bauman, 1995; Lyotard, 1979). It would seem that it is possible to live in an environment of multiple authorities where one is faced with competing truths all claiming legitimacy. In this sense, we may conclude that the processes observed in Israel health care have both local and global implications and can shed useful light on similar processes in other countries.

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Appendix A*

Israel—Summary of Demographic and Health Data

Vital statistics Population 7,233,700 Ethnic groups Jewish 76.4 per cent (of which Israel-born 67.1 per cent, Europe/America-born 22.6 per cent, Africa-born 5.9 per cent, Asia-born 4.2 per cent); Muslim Arab 17 per cent; Christian 3.2 per cent; Druze 1.7 per cent Language Hebrew (official), Arabic used officially for Arab minority, English most commonly used foreign language Age structure 0–14: 27.9 per cent; 15–64: 62.3 per cent; 65+: 9.9 per cent Birth rate 19.77 births/1,000 population (2009) Death rate 5.43 deaths/1,000 population (2009) Infant mortality 4.22 deaths/1,000 live births (2009) Life expectancy 78.62 (m); 82.95 (f) (2009) HIV/AIDS adult prevalence 0.1 per cent (2007) Tobacco use 31.1 per cent (m); 17.9 per cent (f) (2005) Health spending 7.35 per cent of GDP; public 68 per cent; private 32 per cent (2005) GDP growth rate 5.2 per cent (2006); 5.4 per cent (2007); 4.2 per cent (2008) Public debt 78 per cent of GDP (2008) Unemployment 6.1 per cent (2008) Capital Jerusalem Head of state President Shimon Peres (since 2007) Head of government Prime Minister Binjamin Netanyahu (since 2009) Government Unicameral 120-seat Knesset Administrative divisions 6 districts Land area approx 1/11th the size of the UK Context The state of Israel was established in 1948: after world war two the British withdrew from Palestine and the UN partitioned the area into Arab and Jewish states. The Arabs rejected this arrange— 245 —

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ment but were defeated by the Israelis in a series of wars. Israel has many political parties, and all its governments have been coalitions. In 2003, the USA, EU, UN and Russia devised a ‘roadmap’ to settle the conflict by 2005 by setting up a democratic Palestine alongside Israel, but progress was undermined by outbreaks of violence. Israel unilaterally disengaged from the Gaza Strip in 2005, while keeping control over entry points. The election of Hamas in 2006 to head the Palestinian Legislative Council froze relations. Prime Minister Ehud Olmert shelved plans to evacuate most of the West Bank following conflict with Hizballah in Lebanon. Talks resumed after Hamas seized the Gaza Strip and Palestinian president Mahmoud Abbas formed a new government without it. Olmert resigned in 2008 after corruption allegations, and a new coalition government under former Prime Minister Benjamin Netanyahu took office in March 2009. Israel has a technologically advanced market economy, but armed conflict and large-scale immigration throughout its history have posed heavy burdens. Roughly half the government’s external debt is owed to the USA, its major source of economic and military aid. Milestones 1911 Before the state of Israel was established, workers’ associations set up the first ‘health plan’ to provide care and employ immigrant doctors, laying the foundation for much of today’s health care system. 1913 The Hadassah Medical Organisation set up the Tipat Halav system of well-baby clinics. 1918 Hadassah builds hospitals in Jerusalem, Safed and Tiberias. 1948 The State of Israel was established; a Ministry of Health replaced the Department of Health that existed under the British mandate; regional health bureaus and an epidemiological service were formed; the state took over hospitals and set up mother-and-child health care services. 1953 Military hospitals transferred to the Ministry of Health, which becomes the main supplier of hospital services. — 246 —

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1973 Employers compelled to contribute to their workers’ health insurance. 1988 State Commission of Inquiry into the functioning and efficiency of the health care system (the Netanyahu commission) set up against background of workforce and patient dissatisfaction, lengthening waiting lists and growth in black-market medicine. 1990 Netanyahu commission recommends major financial and organizational reforms. 1995 National health insurance introduced. Hospital revenue capped. 1996 Patients’ Rights Law enacted. 1997 Health tax on employers abolished. 1998 Co-payments introduced for doctor visits. 2005 Government begins to transfer ownership of hospitals to health plans. Healthy Israel 2020 initiative on health promotion and disease prevention launched. Health Care Health care is funded predominantly through an earmarked health tax, although co-payments and supplementary health insurance play an increasingly significant role. Major reforms in the mid-1990s have not been completed and continue to work their way through the system. Concerns that Israeli health care is too centralised are widespread. Periodic military conflict and terrorist attacks bring additional strain, especially for hospitals, which have to treat injured soldiers and civilians while continuing to provide routine care under dangerous conditions. Meanwhile, the needs of Israel’s Arab population continue to pose a challenge: they have lower life-expectancy than Israeli Jews, and often face cultural and linguistic barriers to accessing care.

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Funding the system Israel’s health care is funded from an earmarked health tax and from general tax revenue. The health tax is levied at 3.1 per cent on salaries up to half national average earnings and at 4.8 per cent beyond that, up to a ceiling of five times average earnings. Additional revenue from general taxation makes up any shortfall in planned health spending. The government then distributes funds to the four health insurance organizations according to a capitation formula adjusted for age mix. Since 1995 every resident of Israel must register with one of these. Before that, about 5 per cent were uninsured. The four competing but non-profit-making insurance companies and their approximate shares of the market are: • • • •

Clalit—53 per cent Maccabi—24 per cent Meuhedet—13 per cent Leumit—10 per cent

Patients must also make co-payments for drugs and pay a flat-rate fee for their first visit in any quarter to specialist doctors, specialist clinics and diagnostic centres. Groups such as elderly people receiving benefits are exempt, as are patients with certain conditions such as cancer, AIDS and TB. There is also a ceiling per household on co-payments. Patients belonging to three of the four health insurers make no copayments to use primary care. Providing services The four insurance companies cannot refuse applicants on grounds of age or health, and by law must guarantee a range of services that includes: • • • • • • •

medical diagnosis and treatment preventive medicine and health education general, psychiatric and maternity hospital care surgery and transplants preventive dental care for children first aid and transport to a hospital or clinic workplace medical services — 248 —

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• • • • •

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medical treatment for drug abuse and alcoholism medical equipment and appliances obstetrics and fertility treatment treatment of injuries caused by violence paramedic services.

1. Primary care About 60 per cent of primary care is delivered by GPs working as salaried employees of the insurers and the other 40 per cent by independent contractors, though the ratio varies between insurers. GPs work in both group and individual practices. All insurers insist that hospital visits are authorized by a GP or community-based specialist. Israel has 2,000 community-oriented primary care clinics operated by the insurers, the Ministry of Health or the municipalities. In addition, there is a nationwide network of 850 mother-and-child care centres, 460 of which are run directly by the Ministry of Health. Services provided include health education, check-ups to monitor child development, and immunization. 2. Secondary care The Ministry of Health owns and operates about half of Israel’s acute hospital beds, two-thirds of psychiatric hospital beds and under 10 per cent of chronic disease beds. The largest insurer, Clalit, runs another third of the beds, with the rest operated by non-profit- and profitmaking organisations. Israel has 2.1 acute care beds per 1,000 population, just over half the OECD average of 3.9. It has four medical schools, each affiliated to a major university, two schools of dentistry, one of pharmacology and 20 nursing schools. Most specialist ambulatory care has traditionally been provided in community-based settings rather than hospital outpatient departments: only about 10 per cent of visits to specialists take place in hospital. Insurers are keen to shift more care from hospitals to community-based services. 3. Private sector Israelis pay for private health care either with out-of-pocket payments or through voluntary health insurance. Voluntary health insurance can — 249 —

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be bought through commercial insurers or through the four statutory health insurers, which are obliged to provide this to any member who requests it, with the premium depending on age alone and not health status. About 80 per cent of the population has voluntary health insurance from one of the statutory insurers, a proportion that more than doubled in the decade to 2005. Typically this covers visits to private doctors, treatment in private hospitals and complementary medicine. About 30 per cent of the population is covered by commercial voluntary health insurance as well. Commercial insurers are free to set premiums according to health status, to exclude pre-existing conditions and to reject applications. Doctors in primary care and community health services are not restricted in the amount of private work they may undertake, although if they work in the public sector they must have their employer’s permission to practice privately. Hospital doctors may work privately only in private or voluntary hospitals: private practice is illegal in government and Clalit hospitals, although some doctors flout this rule in return for under-the-table payments. Policy Issues Israel’s health care system underwent major reform from the mid1990s, following the recommendations of an inquiry committee. In the past five years the most significant developments have included: • • • • • •

the increasing importance of co-payments continued growth in supplementary voluntary health insurance a shift in the balance of power from hospitals to insurers proposals to launch a fifth health insurance organization to increase competition, perhaps allowing it to make a profit or to affiliate with major medical centers proposals to introduce price competition among the insurers.

Gradually hospitals are gaining more independence. They now have ‘research accounts’ or ‘trust funds’ financed by selling after-hours — 250 —

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services to the insurers, which they themselves can decide how to spend. These funds account for more than 10 per cent of activity in government hospitals. However, giving hospitals greater autonomy remains a policy aspiration. Since the Ministry of Health runs half of the country’s hospital beds while also acting as a regulator, conflicts of interest can arise. Operational management issues are thought to distract the ministry’s policy-makers from planning and quality assurance matters. Policy analysts therefore argue that the Ministry should extricate itself from providing hospital care. Proposals include: • making government hospitals into stand-alone, non-profit-making hospital trusts • transferring all government hospitals to a new National Hospital Authority, distinct from the Ministry • transferring ownership of hospitals to the four insurance organisations. The Ministry of Finance prefers the last option, arguing that this would help to control spending. However, the Ministry of Health believes patients’ interests are best served by hospitals and insurers remaining separate. It has set up a hospital administration unit to prepare hospitals for greater autonomy through improving their operational and financial skills. *Quoted with permission from The King’s Fund, London. Source: Global Emerging Leaders Network, Israel Profile. www.globalemergingleaders.org (2009).

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APPENDIX B

LEGAL ASPECTS OF COMPLEMENTARY MEDICINE Jonathan Davies, LLB, Fellow of the American College of Legal Medicine and Fellow of the Royal Society

The public demand for both mainstream and complementary and cosmetic medicine has expanded so rapidly that it already equals the demand for mainstream medicine.1 However, despite this dramatic growth rate,2 complementary medicine has not achieved the mature professional autonomy of conventional medicine because of the latter’s refusal to recognize it. The prevailing attitude of most biomedical doctors is that complementary medicine, lacking any scientific basis, is trying to encroach on the territory of established medical science and obstruct its progress. American newspapers have printed angry critiques of alternative therapies on the grounds that their theories have not been scientifically investigated and their therapies may do their patients more harm than good.3 In Israel there is as yet no clear definition of complementary or alternative therapy. It is critical to determine whether a therapy is definable as a “medical treatment” within the general meaning of the Patients’ Rights Act, 1996, namely, an activity designed to provide “medical treat1 For a comprehensive survey on the subject see the report of the British House of Lords’ Science and Technology Select Committee, Complementary and Alternative Medicine, 21/11/2002. See the website: www.publications.parliament.uk/pa/id199900/idselect 2 A much-quoted survey of the phenomenon in the USA is David M. Eisenberg et al., Unconventional Medicine in the United States: Prevalence, Costs and Patterns of Use, 328 New England J. Med., 246,246 (1993), from which it appears that more Americans sought the therapies offered by complementary medicine than conventional medicine. In 1998 a follow-up study was published: David M. Eisenberg et al, Trends in Alternative Medicine Use in the U.S., 1990-1997, 280, JAMA 1569, 1575 (1998), which indicated a further significant growth in the demand for alternative medicine. It found that in 1997 42.1% of Americans had sought out at least one of the sixteen alternative therapies on offer, an increase of 33.8% on the figure for 1990. The American public paid 425 million visits to alternative practitioners, paying out $10.3 billion. Over 75 major medical schools had begun teaching alternative-medicine-related courses. Alternative medicine had become a substantial industry, with its own scientific infrastructure, professional literature, performance standards and academic training. 3 Richard Saltus, Medical Journals Rip Alternative Remedies, Boston Globe, Sept. 17, 1998. — 252 —

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ment, including procedures for medical diagnosis, preventive medical care, and psychological or nursing care” or, more specifically, under the National Insurance regulations,4 as treatment for the purposes of “cure, including laboratory tests, physical therapies, examination and treatment by means of X-rays, radium therapy, including treatment by isotopes and similar materials, tests and examinations by professional physicians, psychoanalytic and psychotherapeutic care, hospitalization, medication, convalescence, medical rehabilitation, the provision of orthopedic and therapeutic appliances, including prostheses of various kinds, dentures, hearing aids, spectacles, orthopedic shoes and other personal appliances and accessories approved by a physician”. The above distinction also has importance for the way the law regards complementary medicine as a whole and the issue of professional responsibility in particular. This issue is divisible into four aspects: First, with respect to the recognition of a profession in terms of training and experience requirements, licensing examinations, professional ethics (including advertising restrictions), practitioner health and internal disciplinary procedures.5 Second, with respect to establishing professional standards to cover every area of performance, including guidelines as to collaboration with the members of other professions or the referral of patients to them for consultation or treatment. Third, for determining the Ministry of Health’s responsibility for and oversight over a profession or field of practice, including laying down rules and regulations to govern its ethics (to include appointing a public complaints commissioner) and regularizing communications between its practitioners’ professional association and their client-public. Fourthly, the above distinction also has importance with regard to practitioners’ professional responsibility for injury caused to patients. The practice of complementary medicine entails side-effects and risks. Damage may result from therapeutic massage, from infection consequent upon the insertion of needles, from not warning a patient of potential treatment risks and treating them without having obtained informed consent. As things stand today, no patient injured by a complementary thera4  5

See National Insurance [Provision of Medical Treatment to the Occupationally Injured] Regulations, 1968. See Memorandum on Regularized Health Professions Bill, 2001, which proposed recognizing seven healthcare professions (clinical genetics, nutritional dietetics, chiropraxy, medical laboratory work, podiatry, speech therapy, medical records maintenance). — 253 —

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pist has any legal remedy short of suing for negligence in the courts. In the absence of any supervisory mechanism or any licensing requirement, any person can entitle him/herself a ‘specialist in alternative medicine’ and administer potentially harmful treatment.6 There is a difference between injury caused by regulated medical care and injury caused in the course of alternative therapy, and for this reason every therapy offered the public needs to be clearly defined. There is also a need for legislative regularization of “esthetic medicine”. Since Israel’s Basic Law of Freedom of Occupation allows commercial bodies to employ physicians to perform cosmetic surgery, a plethora of institutes offer a wide variety of medical and cosmetic treatments. These employ doctors who are not always qualified to perform the surgeries offered and advertise their wares in the media—breast augmentations, hair removal, liposuction and other procedures, performed by the latest technologies.7 The Physicians’ Ordinance [New Version] prohibits the practice of medicine without a license but the reality is that the Ordinance’s definition of ‘medical practice’ does not furnish a satisfactory answer to the competence of practitioners in all the many branches of complementary medicine which flourish without any Ministry of Health oversight. The Ministry of Health supervises only bodies established in law. Since complementary medicine is not legally regularized it is not supervised. The current state of affairs in complementary and alternative medicine lacks any regulation. Despite the 1994 Alon Committee report on complementary medicine, despite the State Comptroller’s 2002 and 2004 reports, despite court verdicts that have deplored the situation, 6

See for example, Arnon Avni vs. State of Israel 8241/98 (Miscellaneous Criminal Petitions, Tel Aviv, unpublished): according to the indictment summary, the accused practiced both as realtor and as complementary Shiatsu therapist and committed the alleged offenses on young women he was treating. 7 For example, I found a press announcement which called on any one who had undergone failed plastic surgery to apply by fax to lawyers representing certain of these institutes, whose lawyers offered their services in representing the applicants against the doctors responsible for the failed procedure. The advertisement pronounced that a plastic surgeon was not a specialist in esthetic medicine, citing a 1982 decision of the Israel Medical Association’s Scientific Council that “the training period for plastic surgery requires trainees to carry out one breast reduction, one breast augmentation and two facelifts”. The advert goes on to state that “There are plastic surgery specialists who have never been required to perform nose or eyelid surgery, liposuction, peeling, abdominal firming, hair implant, etc.” The innocent reader will take from the advertisement that they should place no trust in their plastic surgeon and should have any esthetic surgery procedure carried out only in the cosmetic care institute advertised. — 254 —

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to this day the status of alternative and cosmetic practitioners has not been defined in law. In practice the Israel Ministry of Health exercises no licensing or oversight powers. Nor are there criteria or stipulations as to who may publicly declare themselves a therapist or healer. This statutory situation discriminates against the plastic surgeons who operate under restrictions and requisites as to training, licensing, ethics and advertising and favors the complementary practitioners who, being unlicensed, suffer no restriction at all. It is a state of affairs which injures the standing of doctors as a whole and of specialists in particular. The Supreme Court has already pronounced on this state of affairs by ascribing responsibility to the State in its twin roles as regulator and, via the Ministry of Health, the responsible authority for all medical care institutes, even when the state agency has itself no part in delivering the care. In State of Israel vs. John Doe and others (Civil Appeals 8526/96) issued on 23/6/2005, the Supreme Court reviewed the State’s appeal against a Jerusalem District Court judgment (Justice Y. Tzur) which examined the responsibility of the Yona Institute-Medical Center Ltd., for impotency treatment, performed by injecting silicon into the sexual organ. The District Court not only convicted the doctors who ran the institute and the attending doctor of negligence after it found that they were not specialists in the medical treatment administered and that some of them did not even have an Israeli licence to practice medicine. It also imposed 30% of the responsibility for the damage done on the Ministry of Health for having failed in its duty of oversight over the institute, as laid down in the People’s Health [Registration of Clinics] Regulations, 1987. The Supreme Court rejected the State’s appeal, stating that the evidence presented to the lower court included newspaper advertisements which clearly set out the treatments the institute provided. The institute labeled itself “the largest center in Israel for plastic surgery and esthetic treatments”, employing “the best specialists” and “the world’s most advanced medical equipment and appliances”. It further stated that “We take responsibility for your health”. With respect to the State’s duty of oversight over such institutes, the Supreme Court issued a statement that the State’s duty to license gives rise to a duty to oversee the implementation of this licensing and of all that follows from it. Any person injured by the nonfeasance of this duty of oversight may well have cause of action on the grounds of breach — 255 —

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of statutory duty (Torts Ordinance, Article 63) or of negligence (Torts Ordinance, Articles 35-36). There is an urgent need to establish legal regulation on alternative medical professions. The field needs to be regulated by statute, so that it satisfies all requirements as to licensing, staff training and experience, ethical conduct, the maintenance of confidentiality, indemnity insurance, implementation of the Patients’ Rights Act, and disciplinary boards and tribunals. The first steps should be the promulgation of regulations prohibiting private institutes and clinics from employing doctors to perform plastic surgery who do not have the necessary specialist qualifications and to subordinate these institutes to Ministry of Health regulation.

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Index

Abbott, A. 92 Adams, J. 151 Allen, D. 132 Al-Or, Yom Tov 55-58 Altman, Dr. Micha 68 Arbeli-Almozlino, Shoshana 66 Authority: exclusive- 63, 222, -figure 123, 221, -based on knowledge 105, -based on prestige 138, 143, 224, scientific- 43, 97, traditional- 31, 38 Averbuch, Dr. Emma 80 Averbuch-Smetannikov, E. 175 Barabash, Gabi 69 Barzilay, Israel 58 Bauman, Z. 40 Beliefs: -about sources of illness, 19-23, 50, 52-54, 57-59, 67-69, 110-112, 128, 199-200, conflicting- 20, 2325, 40, 41, 61, 62, 115-124, 165, 166 popular 50, 52, 203, 204, 218 Ben-Arie, Dr. Eran 70, 71 Ben-Gurion, David 58, 60 Ben-Porat, Mordechai 64, 67 Berkeley, Nora 60 Bi-Gil, Dr. Gretz 54 Birth: natural- 142, 145, 146, 150-152, 159, home- 141, 143 Boon, H. 25

Boundaries (characteristics): durability of- 223, formal- 97, 104, 106, 107, 223, 224, 227, informal- 98, 104-107, permeability of- 136, 138, salience of- 136, 223, visibility of- 223 Boundaries (types of): authority- 138, 140, crisscrossing- 221, 236, epistemological- 83, 104, 140, 162, 165, 171, 173, 225, 228, 236, juridical 225, geographical- 45, 172, -of identity 162, 164, organizational- 41, 44, 75, 77, 79-81, 83-85, 90, 91, 139, 140, 159, 162, 163, 167, 171, 172, 181, 223, 224, 229, 237, spatial- 225, 238, social- 41, 45, 103, 107, 163, 169, 173, structural- 102, symbolic- 45, 102, 107, temporal- 172, 238, territorial- 85, 131, 136-138, 239 Boundaries: crossing- 41, 48, 125, 127, 136, 138, 139, 155, 170-173, 221, 224, 225, 228, 229, 236, 242, denial of- 228, -theory 28 Boundary work: -as separation 223, 238, -as differentiation 226, -through division of labor 114 — 277 —

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CAM, forms of: acupuncture 22, 32, 47, 52, 53, 61, 62, 65, 78, 80, 87, 88, 93, 96, 99, 130, 160, 164, 165, 168, 194, 200, 203, 217, 233, 237, Alexander 35, 80, 205, 233, anthroposophic 13, Ayurvedic 200, based on Kabbalah 204, biofeedback 22, 78, 80, 96, Chinese medicine 22, 78, 80, 97, 136, 142, 160, 164, 165, 168, 200, 205, 214, 216, 217, chiropractic 22, 32, 35, 53, 62, 65, diet\ nutrition 35, 53, 61, 63, 96, 130, 164, 172, 203, 205, 209, 211, 212, 215-217, 233, 235, 237, 253, Feldenkrais 35, 49, 52, 56-60, 96, 130, 131, 205, 233, guided imagery 88, herbs 175, 203, hypnotism 87, 88, 235, Islamic healing 203, lifestyle 31, 40, 60, 63, 70, 72, 172, 173, 203, 224, magic 52, 158, massage 22, 32, 80, 130, 151, 153, 186, 205, 237, 253, naturopathy 35, 49, 52-56, 59, 69, 71, Paula 22, 35, 80, 142, 233, reflexology 22, 32, 35, 65, 78, 80, 87, 88, 93, 96, 97, 130, 131, 134, 142, 145, 155, 186, 194, 205, 233, 235, 237, Reiki 22, 35, 80, 131, 134, 135, 142, 145, 233, relaxation 172, 205, 237, shiatsu 22, 35, 62, 78, 80, 87, 96, 130, spiritual healing 203,

yoga 87, 130, 134, 153, 205 CAMification 28, 171, 224, 228, 230, 236-239, 241 Care: bedside- 77, 78, 224, quality of- 168, 187, 190, 191, 193, 237, models of- 23, patients’ well-being 105, -vs. cure 46, 89-91, 100-102, 107, 235 Cassidy (1995, p. 20) 24 Citizenship: -dual 137, 226 Clinics: ambulatory- 77, 78, 81, 89, 91, 93, 105, 107, biomedical- 132, CAM- 27, 35, 36, 66, 68, 75-77, 80-83, 85, 86, 88-90, 95, 96, 98, 109, 112, 161, 168, 169, 172, 223, 229, 231-235, 237-240, community- 28, 30, 36, 78, 82, 84-86, 90, 110, 112, 129, 146, 154, 169, 231, 232, 238, integrative- 213, private- 22, 36, 75, 78, 84, 131, 136, 137, 139, 168, 181, 183, 194, 195, 231, 237-240, 256 sick fund18, 30, 34, 36, 51, 75, 77, 78, 81, 86-88, 93, 109, 112, 160, 161, 165, 167-169, 172, 177, 178, 181-183, 186, 193-195, 203, 205, 206, 223, 224, 227-229, 231, 232, 236-238, 240, 241 Cognitive: -boundary 41, 75, 79, 90, 138-140, 162, 166, 171, 225, 228 Cohen, M. 47 Cohen, Ran 69 Collaboration: collaborative

— 278 —

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work, between CAM and biomedicine 24, 95, 203, 241 Community: biomedical 20, 24, 154, 169, 173, 224, 231, 241 membership in 173 Conflict: in practice 115-124 in epistemology 133, 241, 242 confrontation- 38, 40, 133, 224 Confrontation: avoidance of- 133 Consent: informed- 78, 87, 145, 190, 253, obtaining146 Consumer: -demand 17, 31, 34, 69, 82, 90, 231, 235 Contours: changing- 79, 108, 139, 223, 224 Control: over boundaries 34, 41, 43, 44, 50, 223, over CAM 76, 240 Co-optation 76, 161, 223, 231, 232 Costs: -of CAM use 78, subsidizing- 101 Coulter, I. D. 25 Credentials: biomedical- 79, 80, 84, 137, 227, 233 Davies, Yonatan 79 Davis-Floyd, R. 151 Demand: consumer- 17, 34, 90, 235, market- 100, popular161 Diagnosis: bio-medical examination 112, 124, 137, 138, 163, 164, CAM examination 22, 23, 54, 55, 58-59, 111, 113, 163, mis- 163, rituals

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of- 104 DiMaggio, P. 42 Disease: models of-, -vs. illness 98, 99, 101, 102 Division of Labor 190, 114 Doctors’ Ordinance 33, 35, 56, 76, 79, 91, 187, 191, 194, 223, 232, 254 Domestication 170, 217 Douglas, Mary 20 Economic: -development 221, 222 Edelman, Shmuel 68 Effectiveness: evidence for- 9, 25, 87, 179, 180, 186, 189190 Eilon Committee 34, 64-66, 71, 93, 94, 100 Eilon, Menachem 66-68, 95 Elkin, Hillel 66 Empowerment: -of patients 127, 143, -of women 148, 152, 157 Epistemology: biomedical- 99, CAM- 141, 144, 156, contradiction of- 18, epistemological boundaries 83, 104, 140, 162, 165, 171, 173, 225, 228, 236, explanation of disease, 19-22, 83, paradigm 48, 171 Establishment: medical- 17, 20, 25, 32, 36, 44, 49, 60, 69, 85, 91, 147, 161, 241 Evidence: -based medicine 99, 107, 112, 127, 158, 225, objective- 124, subjective- 124 Expertise: experience 22, 26, 32, 65, 78, 98, 101, 104, 106, — 279 —

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109, 116, 117, 123, 130, 141, 143, 144, 147, 148, 152, 154-158, 162, 178, 179, 194, 195, 221, 227, 239, 240, 253 experts 45, 54, 63, 68, 123, 142, 149, 222, knowledge 153, 222, skills 18, 19, 36, 53, 80, 109, 122, 123, 125, 127-129, 131, 132, 140, 141, 159, 172, 185, 188, 221, 230, 234, 236, 237, 239, 242, 252, specialization 82, 86, 87, 95, 96, 99, 131, 172, 235, training 26, 29, 33, 34, 42, 43, 52, 54, 62, 65, 66, 68-70, 76, 95, 97, 103, 105, 109, 112, 116, 124, 128, 130, 132, 133, 137, 138, 141, 144, 160, 162, 173, 176, 181, 187-190, 193-195, 239, 240, 252n2, 253, 254n7, 255, 256 Family doctors 9, 28, 33, 160, 161, 213, 229 Fee for service 168, 232, 237, 240 Feldenkrais, Dr. Moshe 58-62 Feldenkrais method 35, 49, 52, 56-60, 96, 130, 131, 205, 233 Feminism: active- 143, gender 143, 162, 203, 205, 215, ideology 141, 144, 146, 150, 156 Formal: -boundaries 227, law 13, 17, 29, 30, 35, 36, 61-63, 65, 69, 84, 91, 98, 110, 141, 161, 171, 176, 177, 182, 184, 187, 193, 194, 203, 231, 236, 237, 247, 248, 253-255, legal

11, 13, 33n3, 35, 49, 55, 56, 64, 65, 76, 79, 92, 93, 107, 110, 134, 146, 168, 175-177, 181-183, 191, 193, 194, 203, 252, 254, 256, licensing 30, 33-35, 44, 65, 76, 176, 177, 187-189, 191-193, 239, 240, 253-256, -organizations 35, 161, 224, -policy 64, 77, regulations 33, 34, 57, 60, 61, 64, 65, 67, 98, 150, 167, 176, 177, 182, 183, 186, 187, 189, 191-193, 195, 227, 233, 239-241, 253-256, -standards 66, 69, 97, 104, 124, 136, 138, 158, 176, 185, 189-193, 194n1, 195, 230, 239, 252, 253, supervision 35, 75, 76, 82, 87, 95, 105, 124, 141, 176, 189, 191, 223, 232, 233, 240 Funding: public- 182, private-36, 176, 231, 238 Gamus, D. 83 Gatekeeping 97, 98, 104 General Practitioners: family drs 9, 28, 33, 160, 161, 213, 229 Giddens, A. 40, 175, 231 Gieryn, T. F. 95, 139, 235 Glaser, B. G. 146 Greenblatt, David 64 Grounded Theory 109, 144 Grushka, Dr. Theodor 57 Guri, Israel 57 Hacham, Amos 60 Hahnemann, Samuel 112 Hasidoff, Yossef 57

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Health entitlements (sal briut) 15, 30, 36, 161, 171, 176, 186, 231, 236, 237 Healthcare System: history of- 199, -in Israel 203, 204 Hegemony: exclusive authority 63, 222, ideological- 199, marginalization 84, 90, 103, 200, 215, -of biomedicine 34, 47, 53, 66, 71, 108, 143, 215, 222, 231-233, 241 Hierarchy 104, 107, 241 Holism 47, 48, 69, 127, 128, 132, 151, 224, 249 Homeopathy 109-126, classical111, clinical- 13, 111 Hospital: clinics based in- 3536, 75, 77-78, 80, 83-86, 232-234 -delivery rooms 27, 141, 144, 146, 147, 158, 237, inpatient- 35-36, 75, 77, 80-91, 98-99, 145, 146, 158, 234-236, -nurses 136, -rounds 84, -wards 227 Hughes, Everett 142 Identity: boundary of- 162, 164, professional- 128, 164, primary- 169, public- 164, Ideology: feminist- 141, 144, 146, 150, 156, - professional- 141 Illness: -vs. disease 19, 98, 99, 101, 102 Indeterminate Component: -vs. technical component 128, 149, 154 Inferiority 103, power imbalance 200

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Informal: -contacts 235, -social networks 173, 235, -vs. formal 98, 106, 107 Insider: -vs. outsider 83 Institutional: -boundary 102, institutionalization 70, 185, 186, 217, isomorphism 82, 89, 226, 234 Integration: models of- 205, 218 Integrative: Israeli Society for Integrative Medicine 36, 224, 233, -medicine 22, 23, 69, 89, 160, 161, 163, 200, 202, 205, -physicians 165, 171-174, 224, 232, 236, 241, practitioners 161, 169, 224 Interests: conflict of- 182, financial\commercial- 182, 190 Isomorphism 82, 89, 226, 234, mechanisms of- 82, 89, 226 , structural- 82, 234, -through scientization 138, 226 Israel Medical Association 13, 34, 66, 69, 79, 82, 95, 161, 177, 224, 241, 254n7 Israeli Society for Integrative medicine 36, 224, 233 Jurisdictions 114, based on symptoms 97, 98, 101, division of labor 190, 114, professional 92, territory 8991, 145, 224, 252 Kaptchuk, T. J. 25 Katzir, Efraim 59 Keret, Dr. Dani 71 Keshet, Y. 23 Klassen, P. E. 145 — 281 —

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Knowledge: biomedical- 99, 103, 104, 112-116, 124, 132, 139, 215, body of- 41, 45, 48, 110, 119, 126, CAM- 25, 84, 95, 103, 143, 186, -paradigm 23, 198, -true\false 98 Kronus C. L. 43 Languages: biomedical- 54, 115, 136, common- 96, conflicting- 24, 44, 96, 115, 116, 136, 166, homeopathic- 121, scientific- 125, -translation – 121, 125, 136 Law: Doctors’ Ordinance 33, 35, 56, 76, 79, 91, 187, 191, 194, 223, 232, 254, ethical aspects 175-177, 183, 187, 192, 194, 195, 239, 256, Health Insurance Law 29, 176, 182, legal aspects 11, 33n3, 35, 49, 55, 56, 64, 65, 76, 79, 92, 93, 107, 110, 134, 146, 175, 177, 181-183, 187, 189, 191, 193, 194, 203, 227, 250, 252, 254, 256, licensing 30, 33-35, 44, 65, 76, 176, 177, 187-189, 191-193, 239, 240, 253-256, National Health Law 30, 36, 84, 161, 171, 203, 231, 236, suits, 138, 176, 188, supervision 35, 75, 76, 82, 87, 95, 105, 124, 141, 176, 189, 191, 223, 232, 233, 240, restrictions 44, 66, 107, 181, 189, 253, 255 Lay: -knowledge, 31, 104, public- 31, 81, 82, 90, 100, 231 Leckridge, B. 25

Legitimacy: -based on tradition 50, 59, 154, 200, -based on scientific data 35, 36, 47, 81, 83, 87, 112, 125, 223, 225, 226, 241, based on credentials 59, 76, 79-81, 84, 95, 98, 137, 223, 227, criteria for- 35, 39, 40, 52, 54, 70, 71, 81, 83, 90, 96, 118, establishing- 70, 81, institutional- 92 clinical – 47, 125, 225, 226 Lifschitz-Milwidsky, Liat 142 Lipovecki, G. L. (1983) 42 Lyotard, J. 41 Macro: -level 18, 221, 223, 229, 241, -processes 222, 230 Mainstreaming: -of CAM 35, 46, 70, 112, 173-174, 200, 222, 234 Mann, D. 25 Marginalization 84, 90, 103, 200, 215 Market: capitalist- 29, -economy 238, 246, health-care- 42, 45, -pressures 90 Medicalization 47, 71, 223, 224, 228-230, 241, -of birth 147, 150, 157, 228, 237, of society 241, rejection of- 147, 150, 157 Medication: Chinese Herbs 160, conventional- 114, 122, dosage 114, 118, 122, homemade 205, homeopathic122, 123, OTC- 172, 201, 237, supplements 87, 205, 209, 211, 212, 215-217

— 282 —

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Menczel, Efraim 65, 66 Methodology: interviews 26, 27, 77-81, 85, 89, 93, 104, 109, 112-117, 119, 120, 122, 124, 125, 130, 131, 137, 138, 144, 146, 150, 152, 162, 164, 166, 168-170, 177181, 183-190, 194, 196, 225, qualitative 26, 109, 130, 144, 162, 177, questionnaires 205, 206 Michaeli, Dan 65 Micro: -level 18, 224, 229, 242 -processes 18, 222, 227, 230 Midwives: 25-27, 88, 127, 141159, 225, 228, 230, 237, 238 Miller, F. G. 25 Mind-Body 19, 151, 212, 215 Ministry of Health 12, 29, 30, 34, 52-56, 60-67, 69-72, 86, 93, 97, 100, 105, 129n1, 177, 195, 241, 246, 249, 251, 253-255 Mizrachi, Avshalom 65, 67, 229 Modan, Baruch 62 Models: bio-medical-, 19-20, 24, 42, 45, 47, 97, 104 -of care 23, Monopoly (healthcare) 19, 34, 42, 134, 222, 233, 241, hegemony 9, 20, 34, 45, 47, 53, 64, 66, 71, 107, 108, 143, 199, 215, 222, 230-233, 241 Montgomery, S. L. 23 National Health Insurance Law 29, 176, 182, health entitlements 182 National Health Law 30, 36, 84,

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161, 171, 203, 231, 236 Negotiation: -over boundaries 69, 225 Netanyahu, Benjamin 248, 249 Netzach, Mordechai 55 Norms 19, 129-132, 141, 142, 152, 166, 167, 221, 227 Nurses 25-27, 46, 78, 82, 103, 127-141, 145, 149, 153, 159, 226, 227, 230, 238, 239 Objective; -vs. Subjective 124, 179 Olmert, Ehud 66, 248 Oncology 13, 80, 81, 86-88, 235, 236 Ontological: -confidence 229 Organizational: -boundaries 41, 44, 75, 77, 79-81, 83-85, 90, 91, 139, 140, 159, 162163, 167, 171, 172, 181, 223, 224, 229, 237 Organizations: Israel Medical Association 13, 34, 66, 69, 79, 83, 95, 161, 177, 224, 241, 254, Israel Society for Integrative Medicine 36, 224 Outsiders: -vs. insiders 83, strangers 41, 174, 229, 241 Pain: chronic- 58, suffering 19, 50, 85, 132, 133, 137, 209, 227 Panton, Dr. Zvi 62 Paradigm: bio-medical 19, 47, changing 45, 70, 81, 84, 108, 119, 129, 142, 223, 224 Paramedical: allied health professionals 138, 139, midwives 25-27, 88, 127, — 283 —

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141-159, 225, 228, 230, 237, 238, nurses 25-27, 46, 78, 82, 103, 127-141, 145, 149, 153, 159, 226, 227, 230, 238, 239, occupational therapists 139, pharmacists 42, 194, physiotherapists 25, 46, 61, 80, 103, 139 Patient-caretaker relations: intimacy 170, -with biomedical practitioners 101n2, -with CAM practitioners 46, 77, 78, 80, 81, 84-86, 89, 90, 93, 103, 170, 205, 235 Payment: fee-for-service 84, 161, 168, 232, 237, 240, freeof-charge 181, 195, gratis 168, 172, public funds 182, supplementary healthcare insurance 30, 36, 84, 161, 167, 232, 238, 247, 251 Physicians (biomedical): -vs CAM practitioners 24, 25, 35, 46, 76, 81, 102, 139, 173, 187, 188, 193, 203 family- 184, 204, 205, 213, -homeopaths 109, 112-116, 119, 124, 125, 194n1, 225, 226, integrative- 165, 171174, 224, 232, 236, 241 Pintov, Dr. Shai 68, 70, 83 Pluralism: cultural- 199, 202, 217, 218, - health\medical126, 199, 200, 204, 206, 218 Policy: -makers 18, 26, 75, 175, 177, 178, 181, 182, 186, 188, 191, 193, 195, Population: Arab 28, 29, 32n2,

50, 51, 202-204, 206, 209, 211-217, 245, 247, Bedouin 28, 202, 204, 209, 211, 213, 216, 217, Christian 29, 51, 202, 204, 211, 214, 216, Druze 29, 202, 204, 211, 214, 216, 245, Jews 28, 29, 50-53, 202, 204, 206, 209, 211-216, 247, migrants 28, 29, 52, 202, 204, 209-215, minorities 200, 201, 217, men 109, 209, 212, 213, Muslims 202, 204, 211, 213, 214, 216, Palestinians 202, rural- 52, 205, 206, urban203, 205, women- 28, 32, 88, 109, 141, 143, 146-148, 150, 152, 153, 155-158, 203, 204, 209, 212-214, 254 Post modern 38-41, 46-48, 110, 173, 221-222, 241, late modern – 38, 92, 221 Power: hegemony, 39, 42, 44, 217, 226 hierarchy of- 105, 131, 136, 139, 164, 174, imbalance of- 200, 215, -knowledge- 39, 199, 201-202 Practice: day-to-day- 18, 115, 125, 129, principles of- 110, 111 Pragmatism: a-theoretical 116 Prevalence of use: CAM across counties, 31-CAM in Israel – 31-33 -over time 17, 44, 68, 75, 146, 224 Prevention 22, 127, 173 Private Practice 28, 82, 167, 168, 171, 172, 183, 184,

— 284 —

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237, 238, 250 Profession: professionalization 43, 66, 217, professional identity 128, professional orientation 48, 128, 149, 154, sociology of- 38 Ravid, Moti 67 Records: medical- 76, 87, 89, 112, 168, 192, 233, 239, 240, 253n5, patients’- 87, 89, 138, 240 Referral: to traditional- 203, 213 216, -to CAM 25, 32, 46, 112, 168, -to private CAM 168, 183, 237, self- 183, 216 Rejection: denigration 101, exclusion 21, 84, 94, 103, 107, 201, 215, negation 101, 102 Religion: Christian 51, Kabbalah 204, Islamic Medicine 203, Jews 202, Muslims 203 Safety 148, 175, harm 65, 100, 105, 114, 175, 180-182, 189191, 252, risk 24, 67, 105, 113, 132, 139, 147, 150, 153, 176, 183, 192, 253, suit 138, 176, 182, 188 Schiff, Dr. Elad 70, 71 Scientific: -authority 43, 97, -methods 93, 99, 112, -outlook 39, 109, scientization- 138, 226 Screening: -physician 76, -processes 76, 112, 233, 234, -ritual 77, 91, rofe memayen 91, 161, selection (of pa-

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tients) 181 Sick Funds: -clinics 36, 88, 161, 172, 181, 194, 195, 228, 232, 236, 237, Clalit 13, 30, 36, 51, 86, 204n1, 205, 206, 248250, Leumit 30, 36, 161, 248, Maccabi 14, 30, 36, 194, 248, Meuhedet 248 Simmel G. 40, 41, 45, 109, 173, 174, 229, 242 Skills: clinical- 80, 129, 131, 132, 141, 159, 172, 236, 237, 239, experience 22, 26, 32, 65, 78, 98, 101, 104, 106, 109, 116, 117, 123, 130, 141, 143, 144, 147, 148, 152, 154-158, 162, 178, 179, 194, 195, 221, 227, 239, 240, 253, knowledge 25, 84, 95, 99, 103, 104, 112-116, 124, 132, 139, 143, 186, training 26, 29, 33, 34, 42, 43, 52, 54, 62, 65, 66, 68-70, 76, 95, 97, 103, 105, 109, 112, 116, 124, 128, 130, 132, 133, 137, 138, 141, 144, 160, 162, 173, 176, 181, 187-190, 193-195, 239, 240, 252n2, 253, 254n7, 255, 256 Social developments: democratization 221, 222, economic developments 222, globalization 31, 199, 221, 222, late modernity 38n1, 92, 221, post-modernism 39, 70, 222 Social: -agents 103, 104, -boundary 103, 163, 169, 173, -class 52, -interactions — 285 —

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130, 135, 228, -networks 173, 224, -processes 10, 18, 24, 26, 30, 37, 200, 236, 242 Socialization: formal- 127, in medical school 128 Space: -of the clinic 75, 102, spatial boundaries 225, 238, symbolic- 103 Specialization 82, 86, 87, 95, 96, 99, 131, 172, 235 Spirituality: faith healing 203, kabbalah 204, mysticism 204, spiritual healing 203 Status: high- 77, 84, professional- 43, 127, epistemological- 98n1, 107 Strategy: of integration, 87 of marginalization, 233, of control 34, 40, 233 Straus, A. L. 146 Subjective: -vs. objective 124, 179 Supervision: -of quality of care 191, -of training, 33, 105, 176, 189 -of treatment 35, 75, 76, 82, 87, 95, 105, 124, 176, 191, 223, 232-233 Symbolic: artifacts 39, -boundary 45, 102, 107 -marginalization 45, 84, 102, 103, 107 Technical Component: -vs. indeterminate component 128, 149, 154 Technology: high- 31, 50, 129, 132, 142, 150, 151, 157, 228 Terminology: biomedical- 99, CAM- 98, 226 Theberge, N. 43

Time: allocation of- 32, 82, 100, 102, 168, 180-182, 185, 190, 195, 228 , temporal boundary 172, 238 Tovey, P. 151 Traditional: -beliefs 154, -healers 50, 52, 200, 214, 217, folk 44, 200, 201, 203, 205, 206, 209, 211, 214-217, TCAM 199, 201, 202, 204209, 212, 213, 215-218 Training: biomedical- 26, 116, 124, 137, 160, 240, CAM-95, 194, 195, credentials 59, 76, 79-81, 84, 90, 95, 98, 137, 223, 227, 233, education 56, 81, 103, 127, 128, 133, 166, 185, 188, 192, 194, 204, 215, 239, 248, 249, supervising of- 33, 105, 176, 189 Truth: hegemony of- 39-40, 101, 104, 119, 221, multiplicity of- 39-40, 101, 104, 119, 221-222, 242 Utilization: patterns of- 30-33 Values: ethics 67, 169, 177, 183, 187, 253, 255, feminism 141, 143, 157, holism 47, 48, 69, 127, 128, 132, 151, 224, 249, ideology 54, 141, 143, 144, 146, 149, 150, 156, 158, norms 19, 129-132, 141, 142, 152, 166, 167, 221, 227, post-modernism 39, 70, 222, tolerance 42, 125, 126, 221, 224, 242 Ward, Dr. Brian 194 Willis, E. 26

— 286 —

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Work setting: bedside 77, 78, 224, biomedical 35, 101n2, 132, 161, 252, delivery room 27, 141, 144-147, 156, 158, 159, 237, family practice\GP 109, 249, 160, 162, 171, 234, 236, hospital 27-30, 35, 36, 43, 51, 66-68, 70, 75, 77, 78, 80-82, 84-91, 93, 95, 96, 98, 99, 101-109, 112, 129, 131133, 136, 137, 139, 141, 142, 144-146, 149, 150, 152, 154, 158, 166, 194, 200, 203, 223225, 227, 229-232, 234-239, 247-252, 253, ward 142 Workplace 79, 106, 249, -assimilation 106, multiplicity of- 131, status in- 79

— 287 —

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— 289 —

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