The Persistence and Resurgence of Medical Pluralism

For Paul Starr, medicine is the dream of reason partially come true, and the recognition and acceptance of this view by most Americans is what has largely determined the development of our health care system. Starr's efforts to advance this vision led him to neglect the extent to which medical pluralism survived and thrived in America.

In the first chapter of The Social Transformation of American Medicine (1982) (hereafter TSTAM), Starr describes a time (1760-1850) when doctors had little in the way of status or respect. Physicians' knowledge about disease and their skills as healers were questioned by practitioners of many stripes, including those within their own ranks. In fact, the very need for specialized medical practitioners was doubted by those who saw the home as the natural locus of health care, and family members (informed by popular medical manuals) as the natural and best providers. This cacophony of views was widespread and reflected the diverse set of beliefs held by most of the population, as well as its leaders. The American ethos was to distrust specialized knowledge, particularly knowledge that was "secret" or inaccessible to the average citizen.

What changed all of this, in Starr's view, was the rise and public recognition of scientific rationality. The populace began to recognize that the natural world had a "legitimate complexity" that might not be equally accessible to all. The democratic belief that everyone could know how the natural world really worked no longer seemed accurate or apt to bring about the cure of illness. The growth of education and literacy, along with the nation's rapid urbanization and industrialization, only facilitated the acceptance of this new perspective.

Starr begins by claiming that few "would go so far to prove a point as to trade a modern physician for a traditional healer" (4). Yet, that is precisely what many people, especially the most highly educated, are now doing (Eisenberg et al. 1993, 1998; Astin 1998). In fact, what Starr called "lay healers" and "domestic medicine" are still very much a part of how our nation deals with illness and health. Complementary and alternative medicine (CAM) is the contemporary term that best encompasses Starr's lay healers. Similarly, the term self-care and its attendant information-seeking strategies essentially comprise what Starr called "domestic medicine." A reader could easily come away from TSTAM with the sense that after the turn of the century lay healers and domestic medicine had largely died out in the United States. The accuracy of this description is important in evaluating Starr's broader thesis. What if the old medical cacophony never really died out and is now stronger than it has been over the past many decades? If so, perhaps Starr's fundamental belief that the power and autonomy of American medicine emerged largely through the public's association of doctors with science and rationality is misguided or overdrawn.

CAM and Medical Pluralism in America

There is no standard, accepted definition of CAM. Some (Lowenberg 1989; O'Connor 1995; Goldstein 1999) have sought to characterize CAM by seeking an underlying set of beliefs or values common to most of its specific forms. Still others have employed ad hoc taxonomies. Despite this lack of clarity, even a casual observer of health care in America would be hard-pressed not to recognize the significant role of CAM. The most widely cited national study of CAM utilization estimated that there were 629 million visits to CAM providers in 1997, an increase of about 50 percent in the number of visits over a seven-year period (Eisenberg et al. 1998). These findings are well in line with a number of other national sample studies that have consistently found that 40-45 percent of the adult population has used CAM to deal with a symptom of a health problem within the past twelve months (Harris and Rees 2000; Wooten and Sparber 2001). When those who use CAM to prevent illness or promote overall health are included, it is likely that almost 70 percent of the population has used some form of CAM as an adult (Eisenberg...