|Year : 2017 | Volume
| Issue : 2 | Page : 118-122
Medical pluralism in Europe and India: Concept, historical background, perspectives
Institute for the History of Medicine, Robert Bosch Stiftung, Stuttgart, Germany
|Date of Web Publication||8-Jun-2017|
Institut fur Geschichte der Medizin der Robert Bosch Stiftung, Straussweg 17, D 70184 Stuttgart
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dinges M. Medical pluralism in Europe and India: Concept, historical background, perspectives. Indian J Res Homoeopathy 2017;11:118-22
|How to cite this URL:|
Dinges M. Medical pluralism in Europe and India: Concept, historical background, perspectives. Indian J Res Homoeopathy [serial online] 2017 [cited 2017 Sep 25];11:118-22. Available from: http://www.ijrh.org/text.asp?2017/11/2/118/207667
| Discontent and Medical Pluralism|| |
Charles Miller Leslie, the medical anthropologist who first applied the concept of medical pluralism in global comparison, made a crucial statement about the reason why medical pluralism exists: “The structural reasons that medical pluralism is a prominent feature of medical care throughout the world are that biomedicine, like Ayurveda and every other therapeutics, fails to help many patients. Every system generates discontent with its limitations and a search for alternative therapies.”
Leslie underlines the central significance of patient satisfaction or dissatisfaction with the medical care they receive as an important driving force for the development of pluralistic structures in healthcare. I would like to base my considerations today on this premise. Discontent is without doubt one of the most relevant explanations for the renaissance of alternative medicine since the early 1980s. This revival was initially particularly prominent in the so-called industrialised western world, but also in Brazil, followed from the 1990s onwards by the countries of the former Eastern Bloc. The extent to which the demand for alternative medical approaches has been rising can be seen in France and Germany, to name but two examples, where it has tripled since the 1980s – that is, within one generation. By now (2013), almost 60% of the population in these two countries uses homoeopathic medicines on a regular basis. In recent years, the very small (0.7%) market for homoeopathic (and anthroposophic) medicines in Europe has grown slightly (25%) faster than the overall pharmaceutical market. 6.5 % instead of 5.2% from 2010-2013. The data is similar for India where the growth rate for homeopathic medicines is twice as high in the current decade as that of the pharmaceutical market in general. Domestic homeopathy market 2010 (expected): Rs 26 billion (=2600 crore), growth 25-30% per year against 13-15 per cent of pharmaceuticals industry”, Savvy marketing sees surge in alternative therapies.,. Data about the market for 2014 and 2016/17; concerning patients for 2006, stems from The Associated Chambers of Commerce and Industry of India (ASSOCHAM) report which states during 2006-07, an estimated 4-5 crore patients resorted to homoeopathic treatments and this is likely to grow to 10 crore in the next two-three years”, though homoeopathic treatments last longer than allopathic medication, an increasing number of people prefer the former since they do not have to worry about side effects, it said, Homoeopathy grow at 25-30% over the next 3 years – Assocham report. Earlier data on patients exist only about Delhi: “The number of patients taking homeopathic medicines has increased from around 800,000 patients in 1997 to 1,362,174 patients in 2006: 70% in ten years”. According to the report, the country has around 10 crore homeopathy consumers, which is expected to cross 16 crore by 2017. One hopes that this growth rate may be further accelerated using mail order pharmacies because homoeopathic products are available in thirty times fewer shops than ayurvedic products [Table 1].
| Patient Dissatisfaction|| |
In the decade starting in 1997, patient demand in New Delhi rose by 70% in absolute terms; according to the estimates of the chamber of commerce, the number of users in all of India has doubled to 100 million in the decade starting in 2006. As the population is growing very fast at the same time, this means an increase within the overall population of probably 50% altogether in 20 years. It can be assumed that this increase was greater in the cities than in rural areas [Table 2].
In Germany, the dissatisfaction with cosmopolitan medicine  can be linked to the 5-min medicine which no longer allowed physicians to devote more than a minimum of time to each patient, a fact that is criticised slightly more often by women., This goes together with the ready prescription of drugs; patients, on the other hand, expect regular prescriptions; in addition, there were experiences of adverse side effects, not least due to unconsidered and uninvestigated interactions with other drugs. These points are made increasingly by patients about medical, particularly paediatric; practice and paediatricians are really taking note of them. Another point of criticism was that many surgeries strive for profit maximisation by employing a high level of diagnostic testing. While in India the length of individual consultations is not criticised, the decision in favour of homoeopathic medicines is strongly driven there by the wish to avoid undesired side effects. Another factor could be the “charm” these medicines have, which might derive from the “relationship set up between…the power and prestige of western technology and traditional wisdom and nostalgic values associated with a simpler purer past.”
Around the globe, women are – by the way – much more discontented with cosmopolitan medicine than men if their clearly higher demand for homoeopathic treatment can be interpreted in this way. They often make up 70 or more per cent of homoeopathy users, while the proportion of men is 30% or less. Women appear to expect more communication during treatment while men are content with less exchange. It is also known, however, that this is associated with mutual, gender-specific (and not always accurate) expectations on the part of the treaters and the treated. Members of medical professions are, as patients, particularly dissatisfied with cosmopolitan medicine as is apparent from the fact that a disproportionately high percentage of this population seeks treatment from homoeopathic practitioners.
While such precise investigations into the professional orientation of patients are not available for India, it is clear that – like in Brazil – women patients are even more highly over represented there. Maybe, the more traditional ideals of strong masculinity in these countries contribute to the fact that a medical approach that refers to itself as “gentle” is used less by men – and therefore overall.
On the other hand, India has figures reflecting the extent of discontent that makes it possible to draw conclusions about the desired future development. In 2001, the percentage of citizens there wishing to consult homoeopathic practitioners (12.1%) was twice as high as the percentage of those who actually did consult them (6.3%). At the time when the survey was conducted, there were simply not enough practitioners around to meet the existing need. The estimated 100 million users of 2016 would, however, only correspond to 7.7% of homoeopathy users. This signalises on the one hand homoeopathy's future potential for growth within India's medical pluralism, but on the other hand, it also shows how important it is that the necessary supply is available, since the patient options are otherwise considerably restricted. I will return to this point. However, first, I would like to cast a brief glance at the relative importance of the two medical approaches in India and Germany, based on a few figures [Table 3]. Data on homeopathic physicians in Germany: 5912 active homeopaths (of 7038) (with additional qualification), another 13,899 active naturopaths (with additional qualification), of a total of 371,302 active physicians (of 485,818); 120,733 resident doctors with practice, of which are general practitioners or without further speciality 40,000.
Unfortunately, one cannot find data in all categories for both countries. Another remarkable difference between Germany and India is the number of homoeopaths as compared to the overall number of physicians. This proportion may well be ten times higher in India than in Germany, but the difference is probably much lower when it comes to general practitioners (GPs). In Germany, around two thirds of physicians in private practice are specialists. Their proportion may be similar among allopaths in India, but is likely to be lower. At present slightly more than half of the prospective physicians in India are deciding in favour of specialist medical training, a fact that is discussed as problematic. I would therefore assume that 50 per cent at the most are specialist physicians. There is also no access to coherent information on the number of physicians in private practice as opposed to hospital physicians. In Germany, the number of hospital physicians has for some years been higher than that of physicians in private practice. The number of those who are not working as physicians is also unknown. Most of them are allopaths. There is consequently a multitude of factors that reduce the number of mainstream physicians and therefore drive up the number of homeopaths in relation.
In Germany, homoeopaths make up almost 15% of all GPs. In India, this percentage may be twice or three times as high. It needs to be considered, however, that the per capita density of physicians in India is around five to six times lower than in Germany. In addition, there are many non-medical practitioners there who offer homoeopathic treatment. It can therefore be assumed that the availability of complementary healthcare is generally lower in India although the proportion of homoeopaths is greater. This is particularly true for the population in rural areas and in the slums.,,
In the second decade of the new millennium, cosmopolitan medicine has – for the first time – been provided by the majority of physicians in India. What is most noticeable, apart from the high number of homoeopaths, is the even higher number of ayurvedic physicians in India [Table 4].
The number of homoeopaths has grown considerably in the last seven years, however. While there were still twice as many ayurvedic physicians in 2007, there are now only one and a half times as many. Exact data for India in 2014 are: Allopaths: 938,861 (provisional data 2014 – another ca. 15.000 until the end of the year expected) AYUSH: 736,538, of these are homeopaths 279, 518=37.95%, Ayurveda 399, 400=54.23%, Unani 47,683=6.47%, Naturopathy 1764=0.24 %. The relative decrease of all Ayurveda, Yoga & Naturopathy, Unani, Siddha & Homoeopathy (AYUSH) procedures on offer compared to mainstream medicine is almost entirely due to Ayurveda, while the homoeopaths were even able to increase their market share by almost 10%. The [Table 3] also reveals how fast the situation in India can potentially change [Table 3].,
| Dissatisfaction of Physicians|| |
The importance of the patient demand has always been particularly important for homoeopathy, because even in Hahnemann's lifetime, homoeopathy was viewed critically by many medical experts. However, I will not dwell on the dissatisfaction of patients. The strong rejection from the physicians has always had a negative influence on the supply. This has sometimes manifested in the exclusion from medical associations (above all in the United States). In Germany, the problem was solved by providing controlled inclusion in the physicians' associations: Homoeopathy was accepted as a medical specialisation in several stages between 1928 and 1956, by introducing particular training regulations. The condition for gaining an additional qualification as a homoeopath has always been a full medical training. This means that a budding physician in Germany always needs to have specific reasons for studying homoeopathy.
For the student generation of the 1980s, it was normal to look for alternatives. Maybe, the feared prospect of an oversupply of physicians at the time also played a part in doctors choosing to gain an additional qualification as a means of improving their chances on the medical market. Later on, in a physician's career, discontent with the results achieved by cosmopolitan medicine, the doctor–patient relationship or the therapeutic setting may have been contributing factors. Whatever the situation, practitioners in Germany needed to have explicit motivations for wanting to become homoeopaths.
This is different today and there are reasons speaking against such a decision: Students no longer have the time during their medical training to develop an interest in alternatives. The question of prestige may play a more important part. Prestige is earned with specialisation or merit, and the chances to gain prestige are higher for radiologists, orthodontists or surgeons. Narrative-based medicine is less prestigious in comparison. It needs to be considered, however, that primary care physicians are very satisfied with their patient contacts; their discontent focuses on their administrative workload and they seem less preoccupied with the income question. Nevertheless, the proportion of primary care doctors among physicians in general has been going down for decades. Hospital physicians were on the whole much more dissatisfied. This means that there would be good reasons for choosing to become a primary care physician, but it is more difficult to decide in favour of homoeopathy.
India, in contrast, has parallel medical training structures: allopaths, ayurvedic physicians and homoeopaths each have independent schools, where students enrol as soon as they have completed their levels (end of school examinations). All of the medical schools, around 200 of which are homoeopathy training, are formally equivalent.
But the places in these schools are allocated according to grades: better grades are required for the allopathic medical schools. Presumebly this means that students will favour cosmopolitan medicine if they have the necessary grades. Those who do not may choose to go to a homoeopathic medical school. The AYUSH medical schools, in other words, are of lower status than the schools of cosmopolitan medicine; the fact that homoeopaths and ayurvedic practitioners as well as all other alternative practitioners have their own medical registers makes no difference to this situation. Such markers of formally achieved equality must therefore not be overestimated.
It is also apparent from the support granted by governments for research that cosmopolitan medicine clearly holds a superior position, receiving as it does around 97% of state funding.
The great prestige of cosmopolitan medicine with its capital-intensive methods also points to the importance of a cultural pattern: In most societies, the ability to consume much is indicative of high status. This logic applies to physicians as much as to patients who use consumption to reassure themselves of their own worth. High expenses for diagnostic testing using sophisticated X-ray and magnetic resonance imaging technologies result in higher physicians' incomes and status satisfaction for (many) patients. A consumer society can therefore promote the acceptance of cosmopolitan medicine by helping consumers build their identity on using or buying expensive healthcare. Styling oneself as a follower of a less sophisticated medical system is not recognised at all in such an environment. And yet, the equally growing fears about the effect of food and medicines on their body may nevertheless induce people to decide in favour of an alternative or complementary medicine that has fewer side effects.
| Dissatisfaction of Other Agents|| |
Another agent is playing an important part in the further development of medical pluralism. This agent may – or should – have an interest in a more cost-effective use of resources. I am talking about the health insurers. In a system like the one in Germany where everyone is obliged to obtain insurance, the insurers collect contributions from almost all citizens and could therefore have a major influence on the provision of healthcare. At a time when health insurers have to vie for patients, they have discovered the reimbursement of complementary medical treatment as an advertising strategy. At some time, they even funded medical trials in Germany. The best Dutch and Swiss studies into the importance of additional qualifications for GPs in complementary medicine were also carried out on behalf of the health insurers. Both studies showed that patient satisfaction rose while the insurers' expenses went down. These were crucial arguments in the Swiss debate on the amendment of the constitution that would guarantee the patients' right to choose complementary medical healthcare. It is therefore possible that health insurance companies in states with social welfare systems may become promoters of medical pluralism. This applies only, however, if limiting expenses is what they are really aspiring to. At about 80%, the proportion of private expenses spent directly on healthcare services in India is much higher than in Germany. This means that the importance of health insurers as agents in health politics is even more difficult to assess there.
And finally, we could ask why the politicians in Germany do not do more to endorse medical pluralism, seeing that they keep talking about “cost reduction.” The example shows that the possibility of raising political awareness of this demand has been limited. There are numerous lobbyists who promote the unrestricted expansion of the health market. However, the opposite argument is also relevant: The Swiss example shows the potential for change, and Switzerland does not need to remain a unique case.
| Conclusion|| |
In the light of these developments towards a more comprehensive medical pluralism, the goals of the sceptics who are campaigning against homoeopathy – in Germany, the United Kingdom, India and Australia – become more comprehensible. Their main arguments are well known: (1) Homoeopathy is ineffective. (2) It is ineffective because it is “not scientific.” What the campaign aims at is to spread uncertainty among the public. Its primary target is the patients. Since the campaign is only successful with people who have no experience of homoeopathy, this can be narrowed down to potential new patients. The aim is therefore to limit the growing interest of patients in homoeopathy. In my view, the campaign also aims at creating uncertainty among medical students and young physicians. If they are permanently confronted with a negative image of homoeopathy, they will be less likely to decide in favour of embarking on the corresponding additional training. They might, after all, also earn less because of the inferior public image of complementary medicine. Seeing that it has become more difficult to convince the patients, it is now a matter of defending and strengthening the stronghold of cosmopolitan medicine through the healthcare that is made available.
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[Table 1], [Table 2], [Table 3], [Table 4]