Healing Across Borders: A Summary of Medical Pluralism (KA)
Written By Kajol Aryal
Medicine as we know it today has been derived from a myriad of societal and regional knowledge - merging different traditions and practices. While efforts have been made to recognise the cultural roots, most of “Western” society is unaware of the important contributions to healthcare made by different countries and their practices. Nonetheless, the widespread use of “alternative” medical therapies has risen, often used in conjunction with biomedical practices, which have been mass-popularised in countries such as America. The term medical pluralism was coined for this - meaning the coexistence and use of different medical approaches, treatments and institutions that people can use whilst pursuing better health.¹
How do we define “medical pluralism”?
The concept of medical pluralism developed during the second half of the twentieth century, as studies into “non-western” medical traditions grew and their interplay with “biomedicine” was examined. During the 1950s, studies of anthropology started to focus on “medical systems” to better understand the development and influence of medical practices in other cultures. Due to this, medical systems were classified based on various elements, including: geographical differences, such as local (folk) medicine or regional (such as Unani or ayurvedic) medicine; disease aetiology (whether the illness was “personalistic” - due to humans, or “naturalistic” - due to the weather or the humours); as well as written texts and traditions.¹
However, differentiating practices into independent systems was soon acknowledged as reductionist because it oversimplified the complexities of medical knowledge, how different practices are intertwined and how they have influenced each other. Additionally, the use of the word “tradition” was recognised as unsuitable because it creates the view that a medical practice has remained rooted and unchanged since ancient times, when in actuality they are fluid and dynamic, evolving to meet the demands and knowledge of the time. Therefore, the recognition of the interplay between different medical practices across various cultures led to the evolution of the term “medical pluralism,” which was popularised from the late 70s onwards. From this, “medical syncretism” and “medical diversity” as concepts also blossomed, believed by some anthropologists to be more suitable terms than medical pluralism.¹ Medical syncretism is a more focused definition of the broader term “medical pluralism”. It refers to the activities conducted by healers who blend different treatment strategies and explanatory models to better help their patients.²
Is medical pluralism beneficial?
Medical pluralism has become more relevant now than ever as globalisation has encouraged the spread of information, medical practices and alternative pharmaceuticals across international borders.³ Through understanding how people deal with their illnesses, studies noted that many utilise multiple sources such as biomedical drugs, home remedies, familial or community support, and other holistic therapies to improve their health. This demonstrates how medical pluralism is already present in much of society.
Indeed this is the case in Japan, with a medically pluralistic healthcare system that has been utilised for decades. The use of different practices in treatment can have multiple benefits and applications across various fields. From a socio-political context, it provides an essential foundation for developing a concept that breaks away from the reductionist argument between “biomedicine versus ethnomedicine” or the “West vs the rest.”¹ From a medical context, the interdisciplinary use of multiple medical practices can lead to more inclusive, patient-centred care as the patient is at the forefront of the decision-making and type of care they receive.
Moreover, the World Health Organisation (WHO) has encouraged the integration of other medical practices as a way to bridge gaps in healthcare provisions and facilitate more culturally sensitive healing practices. For instance, in psychiatric and mental health practices, certain African, Asian and Native American communities encourage more beneficial healing methods that acknowledge racial and cultural issues and are more tailored to the community’s’ needs. Additionally, wider knowledge of the different medical systems and practices can aid our research and education. It could potentially encourage the development of certain life-saving treatments, as exemplified by Tu Youyou’s discovery of Arteminisin for malaria through Chinese herbal medicine.
Medical pluralism in practice
Societal Integration of Medical Pluralism: Japan
The use of “traditional” medical therapies alongside biomedicine is already a common practice in Japan and has been for the past four to five decades. Physicians in Japan can prescribe therapies from Kampo medicine, with around 148 officially approved Kampo formulas and medicines, which are mainly utilised in primary care. As a holistic medical system rooted in Chinese herbal medicine, Kampo has been adapted and integrated for use in Japan’s healthcare system. The term “Kampo” translates to “method from the Han period (206 BC to 220 AD) of ancient China,” exemplifying its origins. Its formulas are included in medical guidelines for conditions such as hypertension, back pain and chronic pain, with some hospitals even utilising Kampo in their clinical pathways, in conjunction with biomedical therapies.⁷
The basic foundation of both primary care and Kampo medicine utilises the biopsychosocial approach, focusing on the whole person, which can enhance patient trust, the patient-clinician relationship and the patient’s understanding of their illness. This in turn aids their self-healing journey, facilitating better care. Kampo medicine has been under review in recent years, to test its efficacy and safety.Therefore, it is utilised only when necessary and is handled under the same regulations as those used to standardise “Western” medical products. Furthermore, as a safeguard, Kampo physicians act as “gatekeepers” who provide preventative measures and Kampo formulas when it is beneficial but also ensure to provide a “biomedical” diagnosis and connect patients to specialists for their conditions when appropriate. This shows how Kampo medicine has been thoroughly integrated into Japan’s healthcare system, being robustly researched and used holistically for the benefit of patients.
Community-based Psychiatric Care: Native American Communities
Native American communities in the States have the lowest life expectancy among ethnic minority groups as well as the highest overall suicide rate, especially among young people (aged 10-24).⁴ Suicide in these communities was mainly attributed to social and community disruption due tothe deep-seated impacts of colonialism and socioeconomic inequalities.⁵ Generational trauma because of historic mistreatment, oppression and displacement from their lands led to the loss of or disconnection to culture in Native American communities.Furthermore, without core cultural teachings, children experienced a lack of future orientation and established identity.⁶
Therefore, in the US, rates of depression and suicide have reduced by building culturally responsive suicide prevention programmes and involving members of the communities in their establishment. One such initiative in Arizona, developed for the White Mountain Apache peoples by members of their community alongside John Hopkins’ Bloomberg American Health Initiative, saw a 38% decrease in suicide deaths and a 53% decrease in suicide attempts across all ages.⁴ One reason for this is that reconnecting young people to their culture helps strengthen their understanding of their identity. In turn, they can establish stronger relationships with other members of their community, engendering a better sense of belonging and creating more pathways for well-being.
Furthermore, positive emotions felt through physical experiences of one’s culture, like through dancing, singing and being with other people, can influence and even reprogram neurological pathways - a phenomenon known as neuroplasticity. In effect, collective physical movement has the opposite influence of depression and stress on these neurological pathways, aiding in the mitigation of mental health disorders.⁶
Overall, ensuring that healthcare provisions have avenues for Native Americans to reconnect with their culture or utilise their teachings in healthcare provision has been greatly beneficial and is a clear example of the relevance of medical pluralism.
Can medical pluralism aid research?
Another example of the relevance of medical pluralism is when Nobel Prize Winner Tu Youyou and her colleagues consulted ancient Chinese medical and herbal texts to aid their research of anti-malarial treatments. Tu Youyou came across a reference to “sweet wormwood” which had been used to treat malaria in China in 400 AD. Using this information, they found that by extracting an active compound in wormwood, called artemisinin, it could battle malarial parasites.⁸ Now, the WHO has recommended artemisinin combination therapy as the first line of defence against malaria.⁹
Therefore, the combination of cultural medical therapies with conventional biomedicine can aid with research, treatment, medical education and understanding of illness. Utilising and comprehending medical pluralism helps us better tailor healthcare provisions to individual and community-based needs as we can build more trust and patient-centred care. Moreover, there are already efforts being made at varying levels to make healthcare practices more integrated and inclusive, which can be built upon to create a more pluralistic medical system.
What are the potential drawbacks of medical pluralism?
Whilst medical pluralism and the integration of medical practices can provide a broad range of therapeutic options, certain drawbacks are important to acknowledge. The main argument is a lack of robust scientific evidence for certain herbs or practices, potential side effects, and interactions with other treatments. This is the primary reason why CAM (complementary and alternative medicine) is limited under the NHS. CAM has been recognised by the UK government as the use of therapies outside mainstream healthcare. This involves the use of therapies such as homoeopathy, acupuncture, chiropractic and herbal medicines¹⁰, but the availability of the service varies depending on the patient’s condition and the evidence around the practices. There is a danger of patients relying too much on CAM therapies and having unrealistic expectations of what their doctor can provide for them. This could lead to patients delaying certain treatments or diagnoses of a condition, which could result in potentially severe complications.¹¹
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Whilst medical pluralism and the integration of medical practices can provide a broad range of therapeutic options, certain drawbacks are important to acknowledge. The main argument is a lack of robust scientific evidence for certain herbs or practices and potential side effects. This is the primary reason why CAM (complementary and alternative medicine) is limited under the NHS. The UK government has recognised CAM as the use of therapies outside mainstream healthcare. This involves the use of therapies such as homoeopathy, acupuncture, chiropractic and herbal medicines.¹¹
NICE has recommended alternative therapies for a limited number of practices: the Alexander technique for Parkinson’s disease, as it helps to improve posture and movement; ginger and acupressure for morning sickness; and manual therapy for lower back pain.¹⁰ As CAM is greatly limited on the NHS, doctors will not usually recommend it unless the patient is seeking out a specific therapy and needs guidance on it. Therefore, alternative therapies are usually provided outside the NHS, which patients seek out themselves. For instance, the Alexander technique is learnt through private lessons with teachers of the practice.
Additionally, although chiropractic has been well-evidenced and proven to be useful for improving lower back pain, it is not widely available on the NHS because it’s not prioritised as a branch that requires NHS funding, especially at a time when funding and resources are already tight. Therefore, most who seek chiropractic pay for it privately at chiropractic clinics.¹² Only in a few rare cases, such as when a patient has had chronic musculoskeletal pain for an extended period, may a GP refer patients to chiropractic. This decision is also made depending on whether chiropractic is available on the NHS in their local region or if it’s in a specific integrated care pathway that the patient will use.¹³ Therefore, whilst alternative therapies are recognised in the UK, they are not usually provided or covered by the NHS, due to a lack of robust scientific evidence, concerns about effectiveness and lack of funding for alternative therapies. However, patients can still receive advice about CAM from their GP if they are considering using it, especially because certain alternative therapies could interact with other medications that the patient is using for a pre-existing condition.¹⁰
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Additionally, it has been argued that medical pluralism can sometimes mask the unequal power relations between different medical systems by understating the dominance of biomedicine in medical practices, theory and knowledge. Furthermore, utilising cultural medical practices without fully understanding the context they are used in or without knowingthe history behind certain practices and herbal medicines could be damaging. It could be seen as repeating colonialistic measures like misappropriating or stealing cultural practices.¹ Therefore, it is critical that through integration, a practice or herbal medication is not only reduced to its use but that there is an acknowledgement of its greater context and that credit is given to the culture it is from.
Conclusion
When considering traditional or herbal medicine, there is often the argument of a lack of evidence or therapies not being completely safe to use. However, most therapies available from other cultural practices are only used after the appropriate evidence has been gathered. Additionally, our medical knowledge today is already, to some extent, the product of the coalescence of medical texts, knowledge and information from various cultures. Through medical pluralism, we are highlighting the roots of the discoveries by rightfully attributing practices to where credit is due and typifying the social and psychological aspects of therapies to facilitate holistic medical care. As our world becomes ever more interconnected, an understanding of this topic will become evermore relevant, but whether awareness will increase is up for debate. At the least we need to give more recognition to the contributions of other cultures and countries to the development of “Western” medicine.
Medical pluralism offers a diverse approach to healthcare, blending conventional medicine with other “alternative” practices. Whilst this integration can enhance patient care, it also raises important questions about effectiveness, accessibility and cultural recognition.
Your perspective matters - what do you think? Do you believe our society is already medically pluralistic or that further integration of cultural practices needs to occur? Do you feel “medical pluralism” is an appropriate term and that it is even beneficial? And do you feel that enough credit and recognition is given to the contribution of other cultures and countries to healthcare?
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