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The growing legitimation of complementary medicine in Australia: successes and dilemmas.

In the late nineteenth century on the eve of the formation of Australia as a nation-state, the medical system in this emerging country could be best described as pluralistic in the sense that while regular or allopathic medicine constituted the predominant medical system, it was not clearly the dominant one. Regular physicians faced competition from a wide array of alternative practitioners. As regular medicine increasingly assumed the guise of being scientific, it evolved into biomedicine and developed a link with corporate and state interests in early twentieth century in Australia, just as was the case in other capitalist developed societies. Relying upon state support, biomedicine in Australia achieved dominance over alternative medical systems, such as homeopathy, herbal medicine, osteopathy, chiropractic, and naturopathy. Alternative medical systems, however, often do not accept biomedical dominance and often seek to draw upon both support from satisfied patients as well as strategic elites in furthering their legitimation. Various social forces, particularly the development of the holistic health movement, served to challenge biomedical dominance in Australia, like elsewhere, beginning in the early 1970s. Since the 1980s certain heterodox medical systems, particularly chiropractic, osteopathy, acupuncture and Chinese medicine, naturopathy, and Western herbalism, have achieved considerable recognition from the Australian government, either at the federal level or the state level. Indeed, the Australian government appears to have gone further than any other Anglophone country in terms of providing public funding for complementary medicine (CM) education.

Presented at the NHAA 6th International Conference on Phytotherapeutics, Canberra September 2007

A brief history of alternative medicine in Australia

By the late nineteenth century, Australia had come to provide a refuge for various types of alternative practitioners. These included phrenologists, herbalists, hydropaths, lay midwives, spiritual healers and purveyors of home remedies and patent medicines (Martyr 2002). While most alternative practitioners held a low status, especially if they were registered medical practitioners, homeopaths enjoyed a relatively high status in nineteenth century Australia and were represented by the Homoeopathic Medical Society of Victoria. Whereas the 1921 census listed 3959 "regular" medical practitioners, it listed 412 "irregular" practitioners (Martyr 2002). Although homeopaths were not admitted into regular medical societies, they managed for a period of time to operate hospitals in Sydney, Melbourne and Hobart.

In contrast to various other countries, the development of osteopathy has been intertwined with that of chiropractic in Australia. Osteopaths in Victoria managed to achieve inclusion under the 1922 Massage Registration Act. Various private colleges offered courses in osteopathy along with ones on exercise, herbal medicine, nutrition and massage therapy and often taught osteopathy and chiropractic together (O'Neill 1994). Hawkins and O'Neill (1990) report that as of 1990 'no more than 60 overseas trained osteopaths have ever practised in Australia'. Locally trained osteopaths obtained their training either through apprenticeships or instruction at various schools, some of which taught only osteopathy and others which offered diplomas in both chiropractic and osteopathy and yet others which taught an array of natural therapies, including manipulation (Hawkins 1990). In time the locally trained osteopaths became more numerous than the overseas trained osteopaths and were far more likely to combine osteopathy and chiropractic along with other natural therapies (Hawkins 1990).

Some osteopaths transformed themselves into chiropractors with the creation of the United Chiropractors' Association in 1961 (Hawkins 1990). Willis (1989) delineates four periods in the development of Australian chiropractic: (1) the establishment period (1918-1953) in which a group of chiropractors emerged in Victoria from the practice of osteopaths trained in the UK and US trained chiropractors and the establishment of various chiropractic associations; (2) the period of expansion (1954-1961) which witnessed a considerable increase in the number of chiropractors trained both in Australia and overseas; (3) the period of agitation (1961-1973) which resulted in the passage of the Western Australian Chiropractors' Act in 1964 and the inclusion of chiropractic under private health insurance plans; and (4) the period of legitimation that began a Federal Parliamentary committee report in 1977 which recommended registration for both chiropractors and osteopaths, although not herbalists, naturopaths or homeopaths.

Australian naturopathy appears to have drawn from both British and American naturopathy and became intricately intertwined with both osteopathy and chiropractic. Ward (1975) reported that naturopaths in Victoria relied upon osteopathy, chiropractic, homeopathy, electrotherapy, hydrotherapy, diet, herbal medicine, iridology and 'celloids' that were described by Jacka as 'a specialised system of colloidal mineral salts specially prepared by Blackmore Laboratories'. Early naturopaths in Australia obtained their training either through apprenticeships, self education and/or overseas training. Many naturopathic or natural therapies associations and colleges were established during the 1960s and 1970s and added to those which had been created earlier (Evans 2000, Martyr 2002).

The emergence of the Australian dominative medical system

As regular medicine increasingly assumed the guise of being scientific, it evolved into biomedicine in the early part of the twentieth century and increasingly achieved dominance over heterodox practitioners. Like the United States, Britain and other capitalist industrial societies, the germ theory which downplayed the role political economic and social structural determinants of disease by focusing on biological determinants appealed to the Australian capitalist class and its political allies situated in the state apparatus. As Willis (1989) points out, various 'business interests, both national and international, were involved in promoting the paradigm of scientific medicine in Victoria'. In contrast to medical legislation passed prior to 1880, which did little to restrict the practices of heterodox practitioners in Australia, medical legislation passed first in 1908 and then in 1933 ensured the dominance of regular medicine or biomedicine over rival medical systems.

Willis (1989) asserts that Australian biomedicine employed four methods in its efforts to exert dominance over its competitors: (1) subordination that ensured that some health workers such as nurses and midwives were placed under the direct authority of biomedical physicians; (2) limitation that legally restricted the occupational domain of certain health workers, particularly dentists, optometrists, podiatrists and physiotherapists through biomedical representation on registration boards; (3) exclusion by denying legitimacy to heterodox practitioners such as chiropractors, osteopaths, naturopaths, herbalists, homeopaths, and acupuncturists by excluding them from registration, state supported education and research, and nationalised health coverage; and (4) incorporation of certain medical procedures such as child delivery, spinal manipulation and more recently acupuncture, into the scope of biomedical practice.

The holistic health movement in Australia

The holistic health movement began to emerge as a medical revitalisation movement on the US West Coast, especially the San Francisco Bay area, in the early 1970s, but quickly spread to other parts of the United States and other countries, especially Anglophone ones (namely Canada, Britain, Australia and New Zealand), but also Western European countries (Baer 2004). It began as a popular movement that in various ways challenged the bureaucratic, high tech and iatrogenic aspects of biomedicine. It drew upon the hippie or counter cultural movement, the human potential movement, Eastern metaphysics, the environmental movement, and the feminist movement. The holistic health movement was by no means a monolithic phenomenon and varied considerably from society to society. It encompassed numerous alternative medical systems such as homeopathy, herbalism, naturopathy and bodywork, with divergent philosophical perspectives. Although it appeared to have its strongest expression in Western societies, it also drew heavily from various Eastern healing systems such as Chinese medicine and Ayurveda. To a large extent the holistic health movement overlapped with the New Age movement that also became very popular particularly in Western societies. Like the holistic health movement, New Ageism focuses upon a balance in the interaction of mind, body and spirit in its attempts to achieve experiential health and well being.

While the route of diffusion of the holistic health movement from North America to Australia has yet to be delineated in detail, Martyr (2002) observes that:

'The social revolution of the 1960s in the United States generated a variety of related interconnected movements in Australia, including rural resettlement, communal living, permaculture, natural healing, environmentalism, new age, nuclear disarmament, alternative religions, alternative schooling, personal development and arts and crafts. Some of these revived older ideas among the alternative religions were spiritualism, the teachings of Swedenborg and theosophy; among the natural healing therapies were herbalism and homeopathy.'

During the late 1960s and early 1970s, the 'new style flower children' began to join the 'old style straight-backed nature cure adherents' as practitioners of natural medicine (Evans 2000). Numerous new private naturopathic, natural therapeutic, and Chinese medicine and acupuncture colleges were established during the 1970s and 1980s. A considerable amount of overlap developed between naturopathy and Western herbalism beginning in the late 1960s (Hunter 1991). According to Martyr (2002), 'Western herbalism in Australia has in one sense diminished, in that it is now more likely to be incorporated into a broader natural therapies practice'.

The National Herbalists Association of Australia (NHAA) includes many naturopaths within its ranks and has several state chapters. Chinese medicine also grew in popularity during the 1980s because of the influx of traditional Chinese medicine practitioners from Taiwan, Hong Kong, China and Vietnam and the development of easier access to raw Chinese herbs. Despite the fact that homeopathy has by and large become 'subsumed under the umbrella of natural therapies' in Australia, there is a number of distinct homeopathic bodies in the country (Clavarino 1995). Homoeopathic education has in large been incorporated into the curricula of the broader natural therapies schools. Massage therapy also underwent a revival during 1970s within the context of the holistic health movement.

Government inquiries into complementary medicine and the drive for statutory registration on the part of complementary practitioners

The interest of the Australian states in complementary medicine has been expressed in terms of committees of inquiry about its nature and scope, the granting of statutory registration to certain complementary medical systems, support of complementary medicine training programs in public tertiary institutions, and the granting of research funds for testing the efficacy of various complementary medicines and procedures. Various state inquiry committees examined complementary medicine but it was the federally mandated Webb report that recommended statutory registration for chiropractors and osteopaths but not for naturopaths and homeopaths (Committee of Inquiry 1997). Subsequently chiropractic and osteopathy achieved statutory registration in all Australian political jurisdictions. The only other professionalised heterodox medical system to have achieved statutory registration has been Chinese medicine in the state of Victoria in 2000.

Statutory registration has been a matter that has eluded naturopaths and other natural therapists in Australia. Natural therapists enjoyed statutory registration for several years in the sparsely populated Northern Territory beginning in 1985 when the legislative assembly passed the Allied Health and Professional Practitioners Act. The naturopathic section of the Act was based on the curriculum of the Southern School of Naturopathy and granted registration only to members of the Australian National Therapists Association (ANTA) (Jacka 1998). However efforts to implement statutory registration for natural therapists in both the New South Wales and Victoria around the same time failed.

The federal government had adopted a policy of mutual recognition of statutory registration that 'meant that there was to be uniformity between states and it was no longer acceptable to have registration for a profession in one state and not in another'. This policy coupled with an objection from the Australian Traditional Medicine Society (ATMS) that its members were not eligible for statutory registration resulted in the Northern Territory Legislative Territory withdrawing this privilege for natural therapists in general (Evans 2004). As this incident suggests, a major factor that has prevented many complementary practitioners, particularly natural therapists but also practitioners of traditional Chinese medicine outside of Victoria, to obtain statutory registration in the various jurisdictions of Australia is that they are divided into numerous associations.

Schools of complementary medicine and government funding for complementary education and research

Numerous programs offering qualifications in various natural therapies, including naturopathy, Western herbal medicine, Traditional Chinese Medicine, homoeopathy, massage therapy and aromatherapy exist in both private colleges and, since the mid 1990s, in public tertiary institutions in Australia. Private natural therapy schools in 1960s and 1970s often included chiropractic, osteopathy and Chinese medicine along with naturopathy and homoeopathy in their programs of study (Hunter 2002). With the establishment of chiropractic and osteopathic training programs at public universities beginning in the early 1980s, the natural therapy colleges dropped instruction in chiropractic and osteopathy. Hunter (2002) reports that an estimated 400 to 500 students graduate annually from private complementary medicine colleges each year.

Australia has a tremendously large number of private colleges of complementary medicine. The oldest of these is the Southern School of Natural Therapies (SSNT) in Melbourne which started as the Victorian Branch College of the Australian National Naturopathic Association. The largest of the private complementary medicine colleges is the Australian College of Natural Medicine with branches in Brisbane, the Gold Coast, Melbourne City, Box Hill and Perth. The second largest complementary medical school is the Nature Care College of Naturopathic and Traditional Medicine (est. 1973) located in North Sydney. Some Australian complementary medicine colleges have had a long history of long distance education and a few offer classes entirely in this manner (Harris 2002).

Many complementary medicine colleges offer rather limited programs of study in specific therapeutic modalities. My perusal of the internet revealed 26 natural therapies or complementary medicine colleges, four acupuncture/Chinese medicine colleges, two herbal medicine colleges, three homeopathic colleges, 12 massage/bodywork colleges, two reflexology and 6 miscellaneous colleges, but this count probably does not exhaust the listing of private complementary medicine colleges in Australia.

The Australian government has recognised complementary medicine training programs in the following four ways: (1) by creating degree programs in various complementary medical systems in public universities; (2) by creating partnerships with private complementary medicine schools that lead to degrees in addition to advanced diplomas; (3) by offering Advanced Diplomas in various complementary medicines, particularly naturopathy, at TAFEs or public vocational institutions; and (4) by authorising some private colleges to offer degrees in certain complementary medicine systems. Table 1 below depicts public universities with degree programs in various complementary medicine systems. Three TAFE colleges also offer Advanced Diplomas in various complementary medical systems, all including naturopathy.

Victoria University had a degree program in naturopathy and the University of Newcastle had a degree program in herbal medicine, but these programs recently became defunct. Latrobe University had a joint program in nursing and naturopathy in which students obtained their naturopathic training at the Southern School of Natural Therapies. This program ceased admitting students a few years ago and the last of its students are presently completing their training at SSNT.

Various public universities offer partnership extension programs enabling complementary medicine practitioners with advanced diplomas to earn degrees. These are Charles Sturt University which offers the Bachelor of Health Sciences Complementary Medicine: Southern Cross University which offers the Bachelor of Natural Therapies; the University of New England which offers the Bachelor of Health Science in Naturopathy, Traditional Chinese Medicine or Homeopathic Medicine; the University of Newcastle which offers the Bachelor of Natural Therapies; and the University of Western Sydney which offers the Post Graduate Diploma in Naturopathy. Publicly funded training programs in complementary medicine appear to pose a financial threat to the private schools of complementary medicine and may be a factor prompting the latter to upgrade their requirements. Powell (2003), a consultant to the Australian College of Natural Medicine, argues that public universities may eventually drive the private colleges out of the complementary medicine business.

The Australian government provides some support for research on complementary medicines, particularly efficacy studies that occur at three complementary research centres. The Australian Centre for Complementary Medicine has two sites--the University of Queensland Office at the Mater Health Services Building in Brisbane and the New South Wales Office at Southern Cross University in Lismore. It conducts clinical efficacy trials and social research on complementary medicine groups and offers both masters and PhD programs. The Herbal Medicines Research and Education Centre (est. 1997) based at the University of Sydney conducts efficacy studies on herbal and other complementary medicines and offers a Masters of Herbal Medicine. Complementary Medicine Research situated at the University of Western Sydney conducts clinical efficacy studies and public health and social health research on complementary medicine.

Reasons that the Australian government is interested in complementary medicine

As in other developed societies, the corporate class and the state in Australia have since the 1970s come to express concern about rising health costs. Factors that contribute to rising health costs in Australia, particularly prior to the 1990s, have included: (1) an increase in the utilisation of health services; (2) an ageing population; (3) the growth in capital intensive biotechnology; (4) mismanagement in health care delivery; (5) a capital intensive provider driven health care system; and (6) an increase in pharmaceutical expenditures (Hancock 2002). Najman (2003) reports:

'Between 1984 and 1994, the average number of Medicare services per person increased from 7.2 to 10.2. This increase has steadily continued until 2001, when there were eleven Medicare services per capita per year for the Australian population. These services are divided in the following way: five unreferred services to general practitioners, emergency and related services; slightly over three pathology services per person per year; and one specialist service per person per year.'

Between 1990 and 2000, health care costs rose from 7.5% to 8.5% of the Australian GDP (Najman 2003).

In order to address rising health costs, the Australian government has relied upon several strategies: (1) covert rationing that entails limiting public health funds for particular patients or services, such as withdrawal of Viagra on the Pharmaceutical Benefits Scheme; (2) the allocation of patients awaiting surgery to a priority level; (3) increased co-payments for physician visits necessitated by practices such as physicians refusing to bulk bill because they feel that Medicare does not compensate them adequately for services rendered; and (4) the 'establishment of an independent regulator for the private health insurance industry with responsibility for overseeing premium setting, solvency rules and takeovers' (Dodger 2000).

However the growing support in various ways for complementary medicine exhibited by the Australian government may constitute another covert strategy for curtailing rising health costs. Indeed one perspective on the growing popularity of alternative or complementary medicine in developed countries is summarised by Siahpush (1999) as follows:

'The enormous amount of money that flows out of the capitalist class (e.g. in the form of workers' compensation) and the State (e.g. in the form of national health coverage) into the hands of health professionals and hospitals is a hindrance for capital accumulation. Many corporate sectors now opt for less expensive, less technological and more holistic modes of healing. Consequently individuals are encouraged to take the responsibility for their health into their own hands and opt for nontechnological and inexpensive therapies.'

Given that complementary medical systems such as naturopathy, homeopathy and Chinese medicine often emphasise individual responsibility for health, they are compatible with the strong interest among government health administrators, health policy makers and academics in preventive medicine and health promotion. Since the 1970s both Labor and Coalition governments have encouraged citizens to obtain private health insurance and have sought to make them more than self reliant and responsible (Krieken 2000, White 2002).

Under the Labor governments of the 1980s and 1990s, as Kapferer (1996) observes, deregulation, privatisation and 'freedom of choice' became 'benchmarks of quality in fields as diverse as health, education and the welfare of the elderly or infirm'. These policies were justified on the grounds that they would make Australia more competitive in the global economy and have been even more forcibly been promoted by the Liberal National Coalition which has governed since 1996. According to Wiseman (1998) 'the Howard Government's first budget in 1996 demonstrated a determination to reduce dramatically Commonwealth involvement in social and community services, ranging across health and dental services, home and community care, migrant support programs, child care, labour market programs and university facilities and fees'. Nevertheless the Coalition has not been able to dismantle Medicare because of its popularity with the vast majority of the Australian electorate. According to Gardner and Barraclough (2002):

'Previous overt hostility towards Medicare on the part of the Liberal National Coalition has mellowed into a grudging acceptance of the scheme as a continuing institution with wide popular--and hence electoral--support. In the 2001 Budget, the scope of Medicare was actually enlarged for the first time since its inception by allocating funds to subsidise visits to psychologists.'

Eastwood (2002) maintains that the Australian government's openness to complementary medicine 'emphasises consumer choice and empowerment by promoting increasing knowledge, product safety and proven efficacy through government regulation of industry'. The Australian government has estimated that over 60% of Australians utilise complementary medicine and spend some $2 billion (Australian) on complementary medicine, with about two-thirds of this expenditure going to complementary medicines per se and the remaining third to complementary practitioners (Eastwood 2002). Eastwood maintains that the government regards complementary health care as preventive medicine that particularly addresses chronic and lifestyle diseases as a means for cutting health care costs. The government's support for complementary medicine is an integral part of its neo-liberal effort to divest itself of as much health care expenditure as the Australian public will tolerate. Mark Donohoe (2003) also views complementary medicine as a possible cost cutting measure. He argues:

'In the past decade complementary and alternative medicine (CAM) has begun to take centre stage in the arena of health maintenance and prevention for increasingly informed, educated, wealthy and predominantly female health consumers, and offers the prospects of significant health benefits at a fraction of the cost of orthodox medical care. This provides an unusual opportunity; namely to improve health outcomes while breaking the cycle of escalation of public health care expenditures.'

Periodically the issue of whether the government should reimburse complementary practitioners for their services arises. A Medicare Benefits Review committee chaired by Deputy Robyn Layton of the Administrative Appeals Tribunal recommended in its report to the Minister for Health in June 1985 that chiropractic and home birth midwifery be included under Medicare coverage and that 'some chiropractors should be publicly funded to work on a salaried or sessional basis in public hospitals and community health centres' (Willis 1991). The Ministry of Health however rejected these recommendations. While the Australian government has been funding various complementary medicine training programs in public universities, undoubtedly because of the low technology approaches of these medical systems, the operating costs for these training programs must be considerably less than those for biomedical schools. While general practitioners can receive Medicare rebates for administering acupuncture, the only complementary practitioners who qualify for Medicare rebates are chiropractors and osteopaths, albeit on a very limited basis. Since 2005 the Enhanced Primary program, with referral from a general practitioner, permits five visits to a chiropractor or osteopath per annum.

Conclusion

While indeed complementary practitioners, particularly chiropractors and osteopaths, have improved their legitimacy considerably within the context of the Australian dominative medical system, this development has not seriously eroded biomedical domination. As Willis (1988) observes, 'practitioners of complementary care modalities have so far been unsuccessful in gaining access to the hospital system, either public or private'. Support by the Australian state of complementary medicine functions a subtle strategy for privatising health care. Unfortunately this means that generally only people with disposable incomes or with partial coverage under private health plans are the beneficiaries of complementary medicine. While many complementary practitioners, although certainly not all, favour statutory registration, this will not guarantee making complementary medicine available to a wider clientele. Ultimately achieving an authentically holistic, pluralistic, integrative medical system in Australia will require a major social transformation of the larger society.

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Hans A Baer PhD (Anthropology) School of Social and Environmental Enquiry, Studies and Centre for Health and Society University of Melbourne, 221 Bouverie Street, Carlton 3010 VIC hbaer@unimelb.edu.au
Table 1
Public Universities with Degrees (either Bachelors or Masters
or both) in CM systems:

 Chinese
University Chiropractic Osteopathy Medicine

RMIT X X X
Macquarie X
Southern Cross
Western Sydney X X
Uni of Technology Sydney X
Sydney
Victoria Uni of Technology X X X

 Herbal
University Naturopathy Medicine

RMIT
Macquarie
Southern Cross X
Western Sydney X
Uni of Technology Sydney
Sydney X
Victoria Uni of Technology
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Publication:Australian Journal of Medical Herbalism
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Date:Mar 22, 2008
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