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• Pragmatism -- among consumers seeking a cure and among general practitioners seeking clinical results and more patients -- is not a complete explanation for the burgeoning of complementary and alternative medicine (CAM) in Western societies. Instead, this growth is substantially a result of pervasive and rapid social change, alternatively termed 'globalisation' and 'postmodernisation'.
  
• Globalisation and postmodernisation are creating a new social reality, of which a prominent characteristic is the proliferation of consumer choice.
  
• GPs are enmeshed in this social change and subject to the trend to greater choice -- both their patients' and their own. On the one hand, GPs are reacting to social change as "economic pragmatists", responding to consumers' increasing demand for CAM. On the other hand, GPs themselves are acting as agents of social change by acknowledging the limitations of orthodox biomedical treatments and promoting CAM as part of their service delivery.
  
• Lack of scientific validation of CAM has not prevented GPs' use of such therapies. The phrase "clinical legitimacy" can be seen as a trump card that overrides "scientific legitimacy". It is the shibboleth of a postmodern movement among GPs towards healing and the "art" of medicine, as opposed to the "science" of medicine per se.

The GPs I interviewed cited reasons for incorporating CAM into their practices that fall into three broad categories:¹³

Integrated approach: A considered choice to regularly incorporate CAM, in addition to orthodox biomedical therapies.

Ideological conversion: The adoption of CAM as the main treatment practice. GPs who fall into this category also tend to use diagnostic techniques similar to those of alternative practitioners.¹³

The prevalence of the last two categories, at least among the GPs I have interviewed formally and conversed with informally, contradicts the conclusion by Bensoussan, in a Journal editorial,³ that simple pragmatism -- among both patients and doctors -- adequately accounts for the dramatic increase in the use of CAM.

Other writers have coined the term "clinical legitimacy" (see Glossary) to explain the links among consumer demand, pragmatism, and increased GP provision of CAM. That is to say, CAM is effective, particularly in the treatment of chronic conditions, regardless of the lack of scientific explanation or validation. This clinical success, aside from gratifying both patient and doctor, ensures continuing consumer demand, and thereby increases the financial viability of GPs who incorporate CAM, whether directly or through referrals.¹⁴

Data from my research show that GPs acknowledge that, regardless of the deficit of scientific evidence for how or why, CAM does achieve clinical results.

GPs who offer CAM are keenly aware of this demand for "natural" therapy, and clearly do respond partly as pragmatists catering to consumer demand. However, my interviews reveal that GPs are not acting entirely as economic rationalists responding to market forces. GPs who resort to CAM, like their patients, are often ideological in their motivations. Many are genuinely disillusioned with their biomedical training and with the reality of general practice. They are genuinely seeking a more rewarding approach to primary healthcare, for themselves as well as their patients. For example, some GPs recommend CAM even to patients who prefer or expect synthetic drugs -- a practice described by one doctor interviewed as "good medicine", particularly in light of antibiotic overprescribing.¹³

Therefore, while my findings validate the roles of both therapeutic and market pragmatism in the increasing use of CAM by Australian GPs, these same findings suggest that this increase involves factors beyond simple pragmatism. The interview data support the sociological hypothesis that a broad cultural shift is occurring in late capitalist societies such as Australia, the United States, the United Kingdom and Western Europe, and GPs, like consumers, are not immune to this sweeping social change.^15-17 Arguably, GPs who use CAM are not just influenced by this social change, they contribute to it.

• increasing public access to information;

• increasing sensitivity towards traditional cultural practices; and

• increasing openness to traditional medicines, for example traditional Chinese medicine.³

Another aspect of globalisation is concern about the ecological crisis, which has contributed to a "return to nature" within Western societies. Postmodernisation theorists point to this trend -- the return to nature -- as a key determinant in the historical shift from modernity to postmodernity. The return to "natural" medicines is a part of this trend and of globalisation processes generally.¹⁸

In Western societies, the effects of globalisation, along with the postmodernist movement, are creating a new social reality (ie, postmodernity), one that has created a greater awareness and, for some, greater appreciation of other cultures, which historically have used traditional medicines.¹² Postmodernism has attacked the philosophical foundations that underpin the modernist worldview, including the belief that science, particularly medical science, holds the key to a utopian world "free of disease and inequality".¹⁹ All the GPs and alternative practitioners I interviewed advocated more scientific research into CAMs. However, the effects of globalisation processes and postmodernism are contributing to a new, relativistic, postmodernist worldview whereby both doctors and consumers see biomedicine as only one road to health and wellbeing -- not necessarily a dead-end road, but also not a freeway.⁹

Moreover, CAM is being commercialised and aggressively marketed, an outcome predicted by globalisation and postmodernisation theory,^12,18,20 and a far cry from a starry-eyed conversion to "new age" values.³ Benoussan notes that one does not have to adopt postmodern values to use CAM, but rather that we live in an age in which people shop around for healthcare services.³ No doubt this is true, but increased consumer choice -- the ability to shop around -- is itself a postmodern value. A fundamental premise of postmodernisation theory is that globalisation and the commercialisation of traditional culture, including healthcare, increases diversity in the market place and thereby increases consumer options.^10,12,20

Market forces aside, a surprising number of the GPs interviewed were openly critical of their biomedical training and their perceived role in general practice as "technocrats" rather than "healers". As a result, GPs are seeking new avenues of specialisation and professional development. To reiterate, GPs who offer CAM are, like their patients, not only pragmatic but also ideological in their incorporation of CAM. Many of these GPs acknowledge the limitations of biomedical and synthetic pharmaceutical treatments. The lack of scientific evidence for CAM does not appear to have constrained these developments. In fact, my research revealed that GPs often legitimise their use of CAM -- in addition to citing clinical legitimacy -- by citing the history and tradition underlying these treatments.⁹ This return to tradition, history, and roots is a prominent aspect of postmodernisation.^12,18 It is of considerable interest that the Australian Therapeutic Goods Administration has specified two major categories of evidence for complementary therapies: (1) scientific evidence, and (2) evidence based on traditional use of a substance or product.²¹

Despite the obvious weakness of much "postmodernist" literature on CAM, to dismiss postmodern theory outright is limiting and misleading. The following may serve to illustrate the effect of globalisation and postmodernisation upon Western health systems. Remarkably, these comments come from a GP who attended the Alternative Medicines Summit (organised by the Commonwealth Department of Health and Family Services) held in Canberra on 16 October 1996. This summit, the first of its kind, was attended by medical as well as alternative practitioners. In reporting events, the representative for the medical practitioners wrote:

I felt the tone of the day's proceedings was one of "us versus them". Inasmuch as "natural and complementary practitioners" were seen as a distinct alternative to orthodox practitioners, particularly in cases of serious illnesses. Indeed, one speaker during the day indicated that as it was an Alternative Medicines Summit, orthodox doctors present should really be in only an observer capacity. There was no integration going on, rather the attitude was one of them seeking status as practitioners of the "new medicine", and control of their therapies.²²

Note the dramatic contrast to the relationship between orthodox and alternative medical practice in modernity. Orthodox doctors are now concerned about being excluded from the "new medicine" practised by alternative practitioners rather than vice versa. The same doctor went on to conclude:

There is a paradigm shift, occurring in health from within, that reflects a societal evolution, unstoppable by anyone. How to integrate all these practitioners, or even if it is desirable to, is a question that still perplexes me. There seems to be no one universal model, thus it becomes an exercise in lobbying for market share, and seeking, for example, inclusion in Medicare.²²

With all due respect to common sense, simple pragmatism and clinical legitimacy, this type of sea change requires globally informed, forward-looking sophistication in the area of policy. For example, Duckett has noted that Australian health financing arrangements have not kept pace with a population that is embracing natural therapies. He opines that, as a society, "we may be over-investing in services for which there is a Medicare rebate and under-investing in other more effective or cost-effective services".²³ Within the climate of evidence-based medicine, this observation invites the controversial question Based on evidence, who achieves the more cure-effective and cost-effective results: GPs who use exclusively orthodox treatments, GPs who incorporate CAM, or traditionally trained practitioners who use only CAM?. As things stand, any answer invites the truly urgent question Who regulates what, and how?.

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11. Commonwealth Department of Health and Aged Care. Reforming the Australian Health Care System. The Role of Government. Occasional papers: New Series No. 1. Canberra: Publications Production Unit, 1999.
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21. Complementary Medicines Evaluation Committee's guide to levels and kinds of evidence to support claims. Canberra; Commonwealth Department of Health and Aged Care, 2000. Available at <http://www.health.gov.au/tga/docs/pdf/ tgaccevi.pdf>.
22. Integrative Medicine Association. IMA Newsletter, Issue 6, December. 1996.
23. Duckett S. Policy challenges for the Australian Health Care system. Aust Health Review 1999; 22: 130-147.

Reprints will not be available from the author.
Correspondence: Dr H L Eastwood, Department of Social and Preventive Medicine, Herston Medical School, University of Queensland, QLD 4072.
h.eastwoodATspmed.uq.edu.au

©MJA 2000
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