Contesting the Rules of Medicine:

Homeopathy’s Battle for Legitimacy
By Erin Steuter

This essay examines the political, economic and ideological elements at work in a battle over authoritative knowledge in the field of biomedicine. The orthodox medical establishment is facing a challenge to its historical position of dominance from an array of alternative therapies. As one of the leading forms of alternative medicine, homeopathy is seeking legitimacy but faces significant opposition from the scientific and medical community. The Canadian public and other social organizations are lobbying for medical pluralism and more access to alternatives. In this essay the author examines this contest and evaluates the nature of the ideological debate between homeopathy and the medical establishment historically and in the contemporary period.

Science is an inherently political arena. Contrary to the notion advanced by some members of the scientific community that science is an apolitical, factual enterprise, humanist scholars of science recognize the socially constructed nature of scientific enterprise. They point to the elaborate interplay of economic, institutional and ideological factors that establishes what is sanctioned as scientific knowledge in our society versus what will be relegated to the status of folklore, mysticism or quackery. In contemporary Canadian society legitimate scientific knowledge falls within a fairly narrow range.

In so far as there is a modern orthodoxy that has usurped the place traditionally held by religion, it is science. The institutions that we entrust with knowledge production are scientific, and the technologies we use to solve problems are scientific. The alliance of Western medicine with modern science - which we call biomedicine - is so intimate that it is almost inconceivable to imagine a successful heretical challenge to biomedicine without a concurrent crisis in science as a whole. (Wolpe 1133)

The structures of science narrowly define what lies within the range of accepted opinion. The boundaries of the hegemony are securely policed by the scientists and policy-makers who are the official gatekeepers of knowledge. For a scientific break-through to be acknowledged as such, it must be legitimated. This involves the affirmation of various social institutions and actors. Yet despite the rhetoric about "eureka" moments, in fact, new initiatives in the field of science and medicine are treated with great scepticism. Many of the most cherished of today's scientific principles and medical practices were treated as heresies when they were first introduced, while countless innovations have never succeeded in overturning established practice.

When a new approach is developed it faces a battle for legitimacy. Groups engaged in a competition over dominant knowledge systems use a number of means to gain advantage over their opponents, including political lobbying, mobilization of resources and ideological legitimization (Zald and McCarthy). Ideology can be defined as a set of ideas that shapes our understanding about what is natural, rational, and legitimate (van Dijk; Eagleton; Steuter). Ideologies are used by social groups to justify their own positions and to marginalize and discredit their rivals.

For any particular domain several knowledge systems exist, some of which, by consensus, come to carry more weight than others, either because they explain the state of the world better for the purposes at hand (efficacy) or because they are associated with a stronger power base (structural superiority), and usually both. In many situations, equally-legitimate, parallel knowledge systems exist and people move easily between them, using them sequentially or in parallel fashion for particular purposes. But frequently one kind of knowledge gains ascendency and legitimacy. A consequence of the legitimation of one kind of knowing as authoritative is the devaluation, often the dismissal, of all other kinds of knowing. (Jordan 56)

The medical field provides an example of a remarkable historical transformation of authoritative knowledge. From the mid-nineteenth century until the beginning of the twentieth century, North America had a pluralistic medical system. Medical knowledge held by homeopaths, folk healers of various kinds, midwives and other empirically based practitioners was considered authoritative by different parts of the population. A series of events led to the establishment of allopathic professional knowledge as the dominant form.1 The transformation quickly delegitimized all other kinds of healing knowledge and put the newly defined medical profession in a position of cultural authority, economic power and political influence (Starr; Coulter; Warner). Yet, in recent years, changing powers and the changing social standing of the medical profession no longer confer the same prestige as they did in the past 75 years (Warner). This has given rise to the development of a variety of alternatives to mainstream medicine whose practitioners vie for public approval and social legitimation (Crellin et al.).

In Canada today we are witnessing "a renegotiation of the social contract of healing" and "the re-emergence of alternative modes of thought and practice about health and illness" (Pescosalido and Kronenfeld 16). The orthodox medical establishment is again facing a challenge to its established position of dominance from an array of alternative therapies. Fifty per cent of Canadians use some form of alternative medicine and spend approximately $1.8 billion a year on it ("Canadians Pour Billions" 16). In the United States, visits to alternative medicine practitioners now exceed total visits to standard physicians. Americans are spending more than $20 billion a year on alternative therapies and treatments (Eisenberg et al. 1569). Alternative medicine consists of a number of types of therapies, including chiropractic, acupuncture, massage therapy, herbalism and homeopathy. Homeopathy is a form of treatment that uses extremely diluted preparations of natural substances. It is the fastest growing of these alternative medicines. This year, it is expected that homeopathy will account for 15 per cent of all medicine sold in Canada (Kreidie 14).

Homeopathy has a strong tradition in Europe.2 In North America, however, homeopathy has been subject to considerable criticism from the medical establishment, which claims it is an unsubstantiated and unscientific form of treatment. Homeopaths counter that their treatment gets results and that only the medical profession's deeply ingrained suspicion towards the unorthodox prevents it from acknowledging homeopathy's claims of veracity. The state, which has historically reinforced the hegemony of the existing medical system, is now being challenged by rising health care costs, increased dissatisfaction with the delays and inadequacies of the health care system, pressure to privatize medicine and lobbying from groups seeking support for alternative and complementary medicine.

In this essay I examine the battle for legitimacy between the proponents of alternative medicine and the existing medical establishment. They are competing against each other for the support of the public and government regulators (Wolpe; Gillett; Stambolovic; Baer). The medical establishment is commonly viewed as an elite governing group, backed by tradition, which protects a profession's special knowledge. The establishment has also acquired the power, including political power, that allows it to maintain exclusivity and standards. I argue that this creates political struggles over what is to be viewed as scientific in the medical area. Biomedicine favours its own particular views and tends to disparage the views of alternatives. Medicine has attained cultural and social authority and seeks to exclude alternatives and prevent competition. The alternative perspective argues with a critique of orthodox medical practices and a plea in favour of medical pluralism. Homeopathy's battle for legitimacy provides a good case study of the interaction of science and politics in Canada.

Historical Aspects
This is not the first time homeopathy has been engaged in a battle for legitimacy. Homeopathy was brought to the United States in 1825 from Germany. Its successes during cholera epidemics made homeopathy a popular alternative to conventional medicine. Its minimalist approach contrasted favourably with the purging, bleeding and leeching techniques of allopathic medical practitioners of the time.

At the beginning of the twentieth century, there were 22 homeopathic medical colleges in the United States, and one out of five doctors used homeopathy (Coulter 131). There were 195 homeopathic hospitals across North America, and dozens of homeopaths practised in Canada. For example, Canada's first female doctor, Emily Stowe (1831-1903), was an eminent homeopathic physician. Unsuccessful at gaining admission to medical school in Canada, Stowe applied to the New York Medical College for Women, Homeopathic, from which she graduated in 1867. Dr. Stowe was the founder of Women's College Hospital in Toronto, Ontario (Ania). Most Canadian provinces had homeopathic doctors; many of them were members of the local medical society and were covered by provincial medical legislation, which recognized homeopathic physicians as legitimate practitioners (Connor).

Scholars of American history of medicine have revealed that conventional physicians viewed homeopaths as competitors and formed the American Medical Association (AMA) in 1847 partly as an attempt to exclude and subdue these rivals. In articles in professional journals and newspapers, allopathic doctors criticized homoeopathy and accused those practitioners of "quackery" and of taking credit for the placebo effect. The AMA sought to undermine homoeopathy by expelling all those except allopathic practitioners from membership in medical societies. Members of the AMA were not permitted to consult with homoeopaths or have any professional relations with them. These actions, and the ascendancy of a mechanical model of the body and of disease, pushed homeopathy into the background. By 1910 only 15 colleges remained. By the late 1940s, no courses in homeopathy were taught in the United States (Coulter 450).

While American doctors openly attacked unorthodox therapies, Canadian physicians continued to rely on external control of medical practice. They did not attempt to organize public support for their opposition to "irregular" practice. Instead, they appealed to the government to restrict the activities of irregular therapists (Clow). The rivalry between medical approaches was less extreme in Canada, and historians such as Connor stress the relative tolerance and integrationist approach of homeopaths and allopathic practitioners in the Victorian period. But the Canadian Medical Association (CMA) did expel several homeopaths from the association, and many regular physicians were forced to repudiate publicly their association and consultation with homeopaths.3 The restrictive licensing practices of the provincial College of Physicians and Surgeons meant that homeopaths were practising "under siege conditions" (Connor, "A Sort of Felo-de-Se" 520). Homeopathy survived for longer in Canada than in the United States because the partition between irregular and regular medicine was "more permeable in Canada." Anglo-Canadian medical practitioners tended to "value professional credentials and demeanor more than specific therapeutic practices" (Connor, "Homeopathy" 111). Nevertheless, Canada's homeopathic hospitals reverted to allopathic methods, and homeopathic practitioners went out of business by the middle of the twentieth century.

Historical research into this contest shows that, despite considerable public support of homeopathy's success in healing patients, conventional medicine gained a monopoly on the health care system in part because it was successful in an ideological campaign that valorized scientific medical practice and discredited the homeopathic alternative (Coulter; Warner; Rogers). One way conventional medical practitioners gained public legitimacy and support in the United States was through their use of masculine language to portray their form of medicine as "heroic." Homeopathy could not sustain support in the context of a patriarchal society when it was characterized as a feminized form of treatment that was "gentle," "weak" and "passive" and that was embraced by and practised by many women (Connor, "Homeopathy"; Taylor; Jansen).

Homeopathy and other competing alternative therapies were driven into obscurity for more than half a century, and the dominance of the orthodox medical system became nearly absolute.

Contemporary Revival
Since the 1970s, homeopathy has been on the rise in North America, and in the past 10 years it has developed a strong following among patients and lay supporters who are acting as advocates on its behalf. Dozens of private homeopathy schools have recently opened, including several in Canada, and thousands of homeopaths are establishing private practices in North America. According to the National Center for Homeopathy, in the United States there are currently 22 institutes offering educational programs in homeopathy that are approved or are under review for approval by the Council on Homeopathic Education (CHE), and five in Canada (www.homeopathic.org/edudir.htm). The National Center for Homeopathy lists more than 120 member homeopathic practitioners in Canada and 10 times as many in the United States (www.homeopathic.org/Sechintr.htm). Contemporary homeopathic practitioners focus on creating a parallel professional community by establishing schools and associations. They eschew entry into the existing medical establishment (Connor, "Homeopathy"; Gort and Coburn). Homeopathy is an unregulated profession in Canada, which means that anyone can legally practise this therapy. Regulated health care practitioners (medical doctors, veterinarians, naturopaths) must practice homeopathy in accordance with their own scope of practise, standards of practice and code of ethics. In recent years, homeopaths have joined together in an effort to develop standards for the profession; the standards include allowing the use of the titles Homeopathic Doctor, Doctor of Homeopathy or Homeopath. In 1999 the Ontario Homeopathic Association filed an application for regulation of homeopathic medicine in the province of Ontario under the Health Professions Act of Ontario. Connor notes that "the professional and institutional obstacles they have to overcome remain substantial" ("Homeopathy" 131).

Many factors contribute to the increased public demand for homeopathy and other forms of alternative medicine. Researchers note that an increasingly well-informed public is becoming disappointed with the failure of scientific medicine to live up to its promises and to fulfil popular expectations. Also significant may be the frequency of iatrogenic disease (illness caused by medical treatment), the suffering caused by some diagnostic procedures, and the apparent inability of allopathic science to cure various common and chronic diseases (Patel; McGregor and Peay; Kelner and Wellman). Homeopathy focuses on a holistic form of healing that is concerned with the treatment of the whole person, and this focus is becoming increasingly valued by contemporary health consumers. Where allopathic medicine focuses on the alleviation of symptoms caused by illness, homeopaths argue that they seek to follow the symptoms to discover the underlying cause of the condition and prescribe remedies that will aid in the body's ability to heal itself. Homeopaths have had particular success in treating chronic health complaints such as backaches, depression and fatigue, which have proven resistant to many allopathic treatments.

Users of homeopathy most commonly seek help for chronic health problems and rely on the complementary approach as an adjunct to conventional medical care. According to an article in Maclean's magazine, a recent University of Toronto study said that education, income and social status are key factors when it comes to choosing modes of therapy. The article said the study compared patients of family physicians with those of alternative practitioners and found that alternative care users are more likely to have higher household incomes and education, to be female and to consider spirituality an important factor in their lives. Maclean's quoted one woman cited in the study: "People who are of a higher social class are used to having some control over their lives. Choosing where you go for various health problems is one more example of control" (Elash 70).

One stated benefit of homeopathy is the degree of attention given to the patient by the practitioner. Homeopaths are philosophically committed to spending significant time with patients so the practitioner has time to ask dozens of questions to determine the underlying cause.

It felt wonderful. It felt like I was actually going to be given medication that was only for me, rather than medication that was designed for the generic word "hay fever." It's a throwback to having an actual physician who knows about you. (Chillot 111)

Medical doctors spend an average of seven to 10 minutes with each patient. According to a recent study of doctors in the United States and Canada, the average physician listens to patients for 23 seconds before interrupting them. That result was considered an improvement - earlier research found doctors listening for 18 seconds (Papp and Wallace).

Yet despite reports from patients and laboratory confirmations, homeopathy is still deeply distrusted by the medical establishment.4 We are currently witnessing a revival of the ideological battle that once successfully marginalized homeopathy. Today, scientific critique is the dominant rhetoric at work; the debate revolves around the basic principles of how homeopathy works.

The Issues of Contention
Homeopathy was established in Germany in the 1800s by a doctor named Samuel Hahnemann (1755-1843) who developed homeopathic remedies from botanical and mineral sources. Although there are variations in the types of approaches used by practitioners of homeopathy, the core principle stems from the Law of Similars, which states that "likes should be cured by likes." A substance that in large amounts could cause a disorder within the body will, in small amounts, cure that same disorder. An example of this is seen in the case of a bee sting, which causes pain and swelling, and in some people can lead to anaphylaxis. Yet in a homeopathic preparation, a minute dose of bee venom (apis) is used to ease swelling and pain. Homeopathy is known as a "gentle" form of medicine because homeopathic substances are highly diluted from the original strength of the herb or mineral.

Homeopathic remedies are prepared by repeatedly diluting an active ingredient until it virtually disappears from the solution used in treatment. In the pharmacology of homeopathy, the remedies are considered to be more powerful because of this dilution process and can work more effectively to boost the body's own healing abilities.5 Advocates of homeopathy believe that the smaller the amount of curative, the greater its power to cure. Yet many scientists and health officials say that homeopathic remedies are diluted to a level below Avogadro's number, so that no molecular traces of the original substances are left in the final solution.6

Western medicine takes the position that an alternative form of treatment is unscientific if it lacks a plausible mechanism of action based on our current understanding of the fundamental laws of science. Western medicine does not consider that those laws may be subject to evaluation. Homeopaths claim their tradition does not deny conventional pharmacology and physics, but rather extends our understanding of both. Homeopathic researcher Dr. Bill Gray argues that recent biophysical research, based on modern quantum electrodynamics and the development of advanced techniques of measurement, has demonstrated that water prepared by homeopathic methods has "regions of coherence and resonance which are capable of replicating clusters and transmitting information." The very molecular and electromagnetic structures of coherent water "render the paradox of Avogadro's number irrelevant" (73).

Many scientists believe homeopathy violates natural laws, and thus any effect must be a placebo effect - the power of a patient's beliefs to influence treatment results. Scientific support for homeopathy is increasing, however. In a meta-analysis of 186 studies of homeopathy, researchers reported in the medical journal The Lancet that patients taking homeopathic remedies were 2.45 times more likely to experience a positive therapeutic effect than would be produced by a placebo effect alone (Linde et al). Homeopaths discount the placebo argument and point to homeopathy's effectiveness in infants and animals who are unaffected by expectations of the treatment.7

Many doctors and scientists have provided a vociferous critique of homeopathy. For example, "Resorting to the idea of molecular memory to explain homeopathy's 'effectiveness' confirms that we are indeed in the wonderful world of magic and make-believe when it comes to understanding homeopathy" (Cote 13) Such statements represent the views of much of the scientific community towards homeopathy.8 A recent article in the Medical Post described a report that found that academic reviewers were more likely to recommend publication of an article on conventional medicine than an otherwise identical article on alternative therapies. The Medical Post quoted the authors of the report: "technically good unconventional papers may be at a disadvantage in the peer review process" (Birchard). This view is reinforced in the media coverage of homeopathy. A recent review of representations of homeopathy in the mainstream media in the United States and Canada shows that homeopathy is commonly presented as a form of junk science (Steuter, "Pedaling Skepticism"). Such representation serves to delegitimize homeopathy.

Supporters of homeopathy respond to criticism with their own rhetoric. They state that the concepts of homeopathy have been traditionally mistrusted and that there is a great deal of prejudicial intolerance fuelled by fear and the control of medicine for profit. Homeopaths argue that the medical profession does not rapidly embrace change; they point to the historical opposition to new ideas, including practices that eventually become an accepted part of medicine. An example is the belief that germs cause disease; the notion was resisted by many nineteenth century doctors. Some comments from supporters follow below: "Doctors, in general, are inculcated with an attitude of arrogance when they are trained. If some new idea comes along, it is automatically rejected and the person who brings it is considered a quack" (Ross 48). And "This resistance is about maintaining the power of the medical profession. A small number of doctors who run the profession are trying to restrict choice in health care, and they are not interested in the fact that so many people are getting well and we are saving so much money" (Fox 40).

Supporters and opponents of homeopathy seek to present their view of the situation to the public and health practitioners. The battle for legitimacy, however, involves achieving recognition and acceptance from government regulators.

Current Regulatory Climate
In Canada, in virtually every province, medical licensing authorities are investigating doctors who offer alternative health care and, in some cases, threatening to revoke their licenses. The story of Jozef Krop has become well known. Krop, an Ontario medical doctor, was investigated for more than 10 years by the Ontario College of Physicians and Surgeons because he used unorthodox diagnoses, such as food and chemical sensitivity, hair analysis and vitamin therapy. There were no patient complaints against Krop, but he was charged with using "unproven" and "unscientific" techniques and was found guilty of professional misconduct in 1999. After a close examination of the proceedings against Krop, the Canadian Complementary Medicine Association endorsed Krop's practices and offered its complete support for his defense against the College of Physicians and Surgeons of Ontario (www.ocmadoctors.ca/support_letter.htm). Krop quickly became a symbol for supporters of alternative medicine, who call his trial a "witchhunt" (Tusznski 55). His appeal was heard and denied by the Ontario Provincial Court in December 2001.

Krop is not alone. Dr. Guylaine Lanctot gave up her medical license after being investigated by the disciplinary committee of the Quebec College of Physicians and Surgeons. Lanctot did not practise alternative medicine. She was charged with disseminating "wrong and misleading information" in her book The Medical Mafia, which criticizes many of the basic beliefs of conventional medicine, for example that vaccination programs encourage "the moral and financial dependence of Third World countries on the industrialized nations" (127). Dr. Josee Rancourt was disciplined for writing the foreword to a book about a natural cancer therapy and was forced by the medical licensing board in Quebec to disassociate herself from a naturopathic clinic offering alternative cancer therapy (Rona). At least 15 Canadian doctors are facing disciplinary action by provincial Colleges of Physicians and Surgeons at least partly as a result of practising various forms of unconventional medicine, such as environmental and nutritional medicine. This is despite the fact that the Canadian Income Tax Act provides tax relief for expenses due to chemical sensitivity, and the Canada Mortgage and Housing Corporation supports special housing for people with illnesses arising from environmental sensitivities.

Many alternative medicines have been taken off the market as a result of new legislation controls and suppliers of natural foods and supplements have had their goods examined by Canada Customs (Crellin et al.). Nutritional consultants ask patients to sign waivers confirming they are not there for purposes of entrapment. Homeopaths report some difficulty obtaining remedies in a climate of increased suspicion and surveillance (personal interviews).

Human Resources Canada is studying the alternative and complementary health industry, and the Natural Health Products Directorate, a division of Health Canada, is finalizing new regulations to control the manufacture and distribution of natural health products, including homeopathic products. In 1999 Liberal Health Minister Allan Rock announced that seven million dollars has been allocated to establish the Natural Health Products Directorate, which is intended to "provide consumers with the assurance of safety while enhancing consumer access and choice to a full range of natural health products" (Health Canada). The Natural Health Products Directorate will be responsible for all regulatory functions within the life-cycle of natural health products, including but not limited to pre-market assessment for product licensing, licensing of establishments, post-approval monitoring and compliance and implementation of the Standing Committee's recommendations.

The Canadian government's announced investigation into both the natural products industry and the fledgling nutraceutical industry has been greeted with a mixture of enthusiasm and concern.9 The country's health food trade association is supportive, while consumer health advocates claim the new policies will ultimately damage the industry rather than help it. They say the policy will be especially detrimental to the many small businesses that make up the natural products industry. The Health Action Network, a consumer health organization representing natural medicine in Canada, says the industry and government collaborated to change Canada's regulatory framework so pharmaceutical giants could take advantage of a multibillion-dollar industry:10

When major companies such as Bayer, Warner-Lambert, Whitehall-Robbins, Pharmaton and Smith, Kline, Beecham announce that they are entering the natural health products market, you know the stakes are high and they do not play to lose. These corporations do not compete in a free enterprise market, for they heavily influence governments all over the world to make industry decisions, by way of international governments such as NAFTA, GATT and Codex Alimentarius. (Priesnitz).

Critics have expressed concern over the government's initiative. NDP Health Critic Judy Wasylycia-Leis said the Natural Health Products Directorate is a "smokescreen" for the eventual takeover of the herbal medicine market by big pharmaceutical companies: "The drug industry is waiting to put its tentacles into the herbal markets" (Hendley). The Alliance Party and the Fraser Institute also oppose the Natural Health Products Directorate. The Alliance platform calls for "the greatest freedom possible to Canadians in their choice of natural health products" (Hendley). Martin Zelder, a health policy analyst with the Fraser Institute, said: "Alternative medicine, in our view, isn't any different from any service or product. People should have choices, without undue interference from the state. People should get what they pay for and have legal recourse if they're harmed. In this way, alternative medicine isn't different from anything else" (Hendley).

Other Sectors of Support
Historically, the Canadian government has reinforced the monopoly of the orthodox medical establishment by using a narrow definition of medicine in the Medical Act, by making certain drugs available only through prescription by a physician and by restricting the role of public health institutions (Coburn). Now the system is under scrutiny, and supporters of alternative and complementary medicine are using the opportunity to raise questions about the legitimacy of the monopoly approach to health care. Medical pluralism in Canada is being discussed at all levels of health care policy, planning and practice. The Canadian government is under pressure from a variety of stakeholders. Many scientists and licensing authorities are calling for alternative medicine to prove itself using western scientific standards of authentication.

Advocates of the existing medical system are threatened by the government's investment into developing alternative medicine centres.11 Large pharmaceutical companies are ready to add natural health products to their inventories. Many professional groups are expressing an openness to exploring the benefits of homeopathy and other forms of alternative medicine. Support for alternative medicine is coming from a variety of groups. Among Canada's 16 faculties of medicine, 13 report that they are incorporating some form of alternative medicine into the curricula. The most commonly discussed treatments were acupuncture, homeopathy, herbal medicine, chiropractic, naturopathy and traditional Chinese medicine (Middleton 7).

Pharmacists are also expressing support for alternative medicine. They say their customers are looking for alternatives to traditional medicine. One pharmacist spoke to journalist Amanda Kreidie, who quoted him as saying, "[pharmacists] are always looking for ways to enhance their business and the surest way of doing that is by stocking the products customers want" (14). Customer interest is not the only factor influencing pharmacists. Homeopathic remedies have a markup that is 10 per cent more than most conventional drugs.

The insurance industry has taken an interest in alternative medicine. After years of suspicion and hostility, some health insurers are discovering that nontraditional medicine can be cost-effective. One American HMO executive said, "three visits to a chiropractor are a lot less expensive than an MRI or back surgery" (Cowley 56). Many private health insurance companies in Canada are covering homeopathic treatment as well as other forms of alternative and complementary medicine. Demand for these services comes from the public and also from employees' union lobbyists. Chiropractic services were specifically lobbied for by workers and union leaders.

Over the years a number of private insurance companies came to include chiropractic benefits - physician controlled plans did not. The influence of the labour movement and labour unions is evident in the frequent resolutions and pressure by labour unions to have their plans include chiropractic benefits. This support was a continuation of the long-standing efforts by labour unions, and by ordinary working men and women, to have chiropractic recognized as part of the health care system and to have access to the services of chiropractors. (Coburn and Biggs 1042)

The snowballing interest in alternative health care presents a quandary for physicians. The medical profession seems threatened by the homeopathic alternative. Many doctors seeking to maximize health care options for their patients are will, however. Sixty-five per cent of Canadian physicians perceived a demand for alternative medicine from their patients (Verhoef and Sutherlan). A small percentage of physicians emphasize holistic medicine in their practices and offer services such as acupuncture and nutritional counselling. Of Canadian doctors, 16 per cent practise some form of alternative medicine; 54 per cent refer patients to alternative practitioners; 56 per cent believe that alternative medicine contains ideas and methods from which regular medicine can benefit; 73 per cent believe a general practitioner should have some knowledge of the most important alternative treatments (Crellin et al.). Most acknowledge that patients may feel better if they try such alternatives, but they warn patients not to abandon conventional treatment.

We are witnessing the growth of populist "health consumer" movements groups that organize to express their belief in the right for individuals to choose their own care. The movement is one expression of the importance attached to respect for autonomy and rights of patients and a move towards health care pluralism in an increasingly multicultural Canadian society (Crellin et al.). Canadians have shown an increased interest in homeopathy and other forms of alternative medicine, and they are spending millions of dollars outside the state-supported health care system to use these forms of treatment. Many people argue that this is a form of privatized medicine. Many individuals and organizations say government funding of alternative health care would provide better quality health care and ultimately save money by replacing expensive and invasive treatments with the cost-effective and preventive approach of the alternative practitioners.

Costs of Legitimacy
The quest for legitimacy involves both formal and informal elements. Homeopathy has seen a groundswell of demand from patients in the past 10 years. Many of these patients are vocal and are willing to support alternative medicine financially. As well, there are more homeopathic educational institutions, practitioners, initiatives towards self-regulation and internal standardization of the profession. There is also more interest on the part of other members of the health care industry - pharmacists, insurance providers and conventional physicians. Yet homeopathy has been stymied in its attempts to get public funds for homeopathic education, access to hospitals and to public diagnostic facilities, or medical insurance coverage.

In its quest for legitimacy, homeopathy may have to face some difficult decisions. Wolpe notes that "orthodoxies can force conformity through co-optation, isolation, subjugation, absorption or suppression" (1144). Studies show that other alternative forms of medicine have had to make sacrifices as they enter the mainstream; some have had to abandon elements of their outlook or conform to more scientific modes of treatment. Baer notes that biomedicine may easily be able to co-opt the techniques of specific heterodox medical systems such as acupuncture while "discarding their theoretical or metaphysical premises" (1110). Coburn and Biggs demonstrate the ways in which chiropractic has modified many of its core beliefs and has taken on a more "medicalized" approach to gain acceptance by the existing medical community.

Practitioners and patients of homeopathy have a number of concerns about the future of the profession in Canada. Regulatory bodies are currently investigating the state of natural health products; practitioners are concerned that homeopathic remedies will be evaluated using mainstream scientific procedures. It may not be possible to prove the remedies contain identifiable amounts of botanical or mineral elements because of the extreme dilution principle of homeopathy. As well, some essential homeopathic remedies derived from substances that would be poisonous in large amounts, such as arsenic or strychnine, could be banned. Practitioners are concerned that homeopathic colleges will have to adopt curricula based on mainstream medical education, although the mainstream approach to health and disease is contrary to the core principles of the homeopathic approach.

There is concern the regulatory process might subject homeopathic remedies to costly dispensing fees, which would make the remedies less affordable. Another concern is the quality of homeopathic remedies, which require extremely careful preparation to be effective. Homeopathic pharmacists follow rigorous production procedures to ensure that remedies are diluted in the proper manner and are not contaminated by other pharmaceutical ingredients. Some of these same homeopathic pharmaceutical companies are also a subject of concern, because there has been a trend to produce "combination remedies" meant for over-the-counter sales to people who have not consulted a homeopath for guidance in the selection of the appropriate treatment. The combination of various remedies together runs counter to classical homeopathic practice, but the sale of combination remedies for headaches or flu and cold symptoms has been very lucrative. The popularity of the over-the-counter combination remedies may well be changing the practice of homeopathy.

As we have seen, health care consumers do not have equal access to the alternative medical treatments that compete with orthodox medicine. Alternative medicine is subject to attacks from the scientific and medical community, and practitioners are subject to regulatory agencies that are not acting on the basis of patient complaints. Regulatory organizations persistently exclude non-orthodox alternatives, and recent policies may only serve to enable the takeover of alternative medicine by powerful pharmaceutical companies who may fundamentally alter the nature of the treatment.

Supporters of homeopathy have achieved a significant measure of legitimacy for homeopathy, but there are further levels of legitimacy. Some supporters want homeopathy to become a generally respected, self-regulated profession covered by the majority of private health insurance programs. Others seek full acceptance and coverage by the Canadian medicare system. To gain such acceptance, homeopathy must undergo investigation into its science and its economic viability. This level of legitimation would entail costs and consequences. As we have seen, others who have sought this path to acceptance have had to make significant compromises to achieve the recognition of the mainstream health community.

The authority of any particular knowledge system, and the power relations supporting it and benefitting from it, are often perceived as natural, rational and legitimate. I have argued that they should be seen as socially constructed, relative and often coercive:
The constitution of authoritative knowledge is an ongoing social process that both builds and reflects power relationships within a community of practice. It does this in such a way that all participants come to see the current social order as a natural order, that is, the way things are. The devaluation of non-authoritative knowledge systems is a general mechanism by which hierarchical knowledge structures are generated and displayed. (Jordan 57)

The mainstream medical system has made its monopoly appear legitimate. The economic resources it consumes also appear legitimate. The medical practitioner is central to the health care system - not the patient, or the nurse. The allopaths have thus created a dependence. Society believes it needs medical doctors and is prepared to pay handsomely for them. Supporters of allopathic medicine say all people in all places would be better off under this form of medicine. In its struggle with homoeopathy, the orthodox medical establishment refers to homeopathy as an "irregular" or "unconventional" system of medicine. General knowledge of the historical role of alternative medicine in North America is limited; the public does not know about the decline of alternative medicine and the rise of allopathy. This dehistoricization is an important element in the establishment of the hegemony of the medical system.

The power of the mainstream medical establishment has been eroded over the past 20 years for a variety of ideological and material reasons. The cost of allopathic medicine continues to grow far faster than the economy, which leads to various forms of rationing, which undermines claims about the adequacy of the system. Doctors are part of the social elite and have lost the public trust. Ministries of health are increasingly staffed by non-physician corporate rationalizers. The medical profession does not have the easy access to the bureaucracies it once had, even though medical ideology and the medical model still dominate (Gort and Coburn). Women are awakening to their subordinate position in society, and recognize their historical exclusion from allopathy and the negative effect of conventional medical treatment on women. As people have lost faith in technology, so they have lost faith in technological medicine. Contemporary medicine is not living up to its claims. Many patients are beset by chronic health problems that defy cure through standard means.

New and more powerful antibiotics are utilized in an effort to restore health, but we seem to be running on an ever-quickening treadmill. The consequence of declining power is increasing interest in alternative forms of medicine and the pursuit of legitimacy by their supporters and practitioners. Will the current crisis in orthodox medicine result in a new medical pluralism? Will the medical profession rally and reassert its social and cultural authority over what is scientific and legitimate in the world of medicine? These questions will continue to be of interest to scholars of science and politics in Canada.

1. Allopathy is the term used to describe the standard medical model used in western medicine. It is denned as "the treatment of disease using medicines whose effects are different from those of the disease being treated. The medicines have no relationship to the disease" (Yasgur 19).

2. Members of the British Royal Family, including Prince Charles and the late Queen Mother (who was an active patron of the British Homeopathic Association) have been enthusiastic users of homeopathy, and in France and Germany it enjoys a popularity equal to that of conventional medicine ("Healers or Quacks?").

3. It is important to note that the power of the Canadian Medical Association was not entirely parallel to that of the AMA. Connor states that in the latter half of the nineteenth century, membership in the CMA was voluntary and there were few privileges associated with being a member. Thus the CMA did not act as the voice of Canadian medicine.

4. See Linde et al. This state-of-the-art meta-analysis reviewed 186 studies, 89 of which fit predefined criteria. They did not count and compare the number of trials that showed efficacy of treatment. Instead the researchers pooled the data from the various studies and assessed them. The assessment showed that patients taking homeopathic medicines were 2.45 times more likely to experience a positive therapeutic effect than those patients taking a placebo. Another analysis was done by J. Kleijnen, P. Knipschild and G. ter Riet. This is the most widely cited meta-analysis of clinical research prior to 1991. The researchers reviewed 107 studies of homeopathic medicines, 81 of which (77 per cent) showed positive effect. Of the best 22 studies, 15 showed efficacy. The researchers concluded: "The evidence presented in this review would probably be sufficient for establishing homeopathy as a regular treatment for certain indications.... The amount of positive evidence even among the best studies came as a surprise to us."

5. Homeopathic remedies have varying strengths; the strengths are indicated by the number of times they are diluted. An example is extract of belladonna, derived from a highly poisonous plant also known as deadly nightshade. Conventional physicians prescribe drops of tincture of belladonna for a variety of gastrointestinal problems, but homeopaths use belladonna in much smaller amounts. The dosage homeopathic physicians commonly use for problems such as croup in children or bronchitis in adults is known as "30C"; the "C" stands for a one-in-one-hundred dilution. That means one drop of belladonna extract is dissolved in 99 drops of a water and alcohol solution; then one drop of the new solution is further diluted by 99 drops of water and alcohol; and so on, 30 times. After 30 dilutions, the concentration of belladonna would be expressed scientifically as 1/1060.

6. Avogadro's number (6.0^sup 23^ x 10^sup 23^) refers to the number of molecules contained in one mole of a substance. It is approximately equivalent to the 24x level of dilution. Potencies greater than 24x will not contain one molecule of the original starting substance. The principle was named for physicist Amadeo Avogadro (1776-856). According to the traditional laws of chemistry, a remedy that has been prepared at a 10^sup 24^ dilution - that is, a homeopathic dosage of 24C - would be theoretically diluted just past the point where a dose contains a single molecule of the original substance. At greater dilutions (often used in homeopathy) contemporary science contends that none of the original substance is left in the water solution (Yasgur, A Dictionary of Homeopathic Medical Terminology, 1992: 27).

7. D. Reilly, M. Taylor, C. McSherry, "Is Homeopathy a Placebo Response? Controlled Trial of Homeopathic Potency with Pollen in Hayfever as Model," Lancet, (18 October 1986): 881-86. The double-blind study compared a high dilution homeopathic preparation of grass pollens against a placebo in 144 patients with active hay fever. The study method considered pollen counts, aggravation in symptoms, and use of antihistamines. It concluded that patients using homeopathy showed greater improvement in symptoms than those on placebo, and that this difference was reflected in a significantly reduced need for antihistamines among those in the homeopathically treated group. The results demonstrate that homeopathic potencies show effects distinct from that of the placebo.

8. A significant event in this debate took place in the pages of the British scientific journal Nature in June of 1988. Nature published a report of a French research team headed by Dr Jacques Benveniste. The team supported the claims of homeopaths that highly diluted remedies work because they contain information left behind by substances no longer detectable in the water. As a condition of publication, the research was confirmed in other laboratories, and Nature's reviewers were unable to find a flaw that would invalidate the results. The editors of Nature took the unusual step of publishing an editorial reservation beneath the article, saying there was no physical basis for the results reported by Benveniste. In July the journal dispatched three observers to investigate the research first-hand: Nature editor John Maddox, fraud hunter Walter Stewart of the National Institutes of Health, and magician James "the Amazing" Randi, famous for debunking claims of telepathic powers and other paranormal phenomena. After five days of observing the experiments, the Nature team concluded that Dr Benveniste's claims were not to be believed and that the laboratory "fostered and then cherished a delusion." They charged that the experiments were poorly designed, that unsatisfactory measurements were discounted and that the experimenter's bias had probably influenced the interpretation of results. In response, Benveniste called the investigation "a mockery of scientific inquiry" and compared it with the Salem witch hunts. He also pointed out that none of the debunkers was trained in immunology. He questioned their competence to judge an immunological experiment. For a fascinating analysis of the Benveniste affair, see Wolpe.

9. Nutraceuticals and functional foods are products that provide demonstrated physiological benefits or that reduce the risk of chronic disease beyond their basic nutritional role. A functional food is similar in appearance to a conventional food. A nutraceutical is produced from foods but marketed in the form of pills, powders, potions or in other physical forms not generally associated with foods. Functional foods currently consumed in Canada include oat bran, green tea, soy milk and yogurt containing live bacterial cultures. Concentrated broccoli tablets are nutraceuticals.

10. A recent article in the Journal of the American Medical Association noted that several of the large pharmaceutical companies have been buying companies that produce herbal products as investments (Crellin, et al.).

11. The Federal Government's proposed investment of $100 million into an alternative medicine centre at McMaster University in Hamilton has given rise to criticism by some vocal opponents who have dubbed the project "Quack U."


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