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THE JOURNAL OF SOCIAL POLICY STUDIES_
ЖУРНАЛ
ИССЛЕДОВАНИЙ СОЦИАЛЬНОЙ
ПОЛИТИКИ • ••
Radik Sadykov
HOMEOPATHY WITHIN RUSSIA HEALTHCARE: THE CHALLENGES OF PROFESSIONALIZATION
This article discusses the results of research into the professional status and professionalization of homeopathy in Russia. The theoretical framework is based on interactions between concepts such as social closure, autonomy and professionalization. This framework helps analyse some of the parameters of status among professional homeopaths, namely the economic, power-related and socio-cultural aspects. This analysis is based on qualitative and quantitative data obtained from semi-structured interviews with homeopaths (N=22) and a survey conducted by the author at the Annual Moscow Conference of Homeopathy (N=149), as well as information gained in the course of the secondary data analysis. The survey was used, in part, to clarify and add to the questions that had arisen in the interviews. In order to define the level of individual autonomy among homeopaths we developed quantitative indicators. The data demonstrates that the economic status of Russian homeopathy specialists is relatively low, that professional associations play a limited role in the self-regulation of the group, and that the mechanisms of social closure are weak. All this hinders the professionalization of homeopaths. Nonetheless, homeopaths find a sufficiently high level of individual autonomy as homeopathic practice is not strictly standardised. Today homeopaths as a group face the choice between two professionalization strategies. One is the standardisation of homeopathy, which, although permitting better integration within conventional medicine, threatens ordinary homeopathy practices with a loss of autonomy. The other professionalization strategy rejects standardisation and integration, instead focusing on the preservation of the unique identity and autonomy of the practice. The choice of strategies
Radik A. Sadykov - Candidate of Sciences (PhD) in Sociology. Research Fellow, Centre for Social Entrepreneurship and Social Innovation Studies, National Research University Higher School of Economics, Moscow, Russian Federation. E-mail: [email protected]
© The Journal of Social Policy Studies. Volume 14. № 4
is a dilemma for homeopaths as each option possesses its own advantages and restrictions.
Keywords: Homeopathy, complementary and alternative medicine, profession, professionalization, Russian healthcare
Homeopathy is a type of alternative medicine based on two basic tenets: the principle of 'like is cured like,' which contradicts the biomedical principle of treatment by 'unlike' medicine, and the use of dilutions ('potencies'). Over the last decades, homeopathy has won over a mass of new advocates, not only among doctors but also among patients. While homeopathy did not enjoy any official recognition in the Soviet period and was even subjected to criticism by the state, it appears it had enough support to survive and still play a role in medicine (Yurchenko 2004: 126). With the end of the Soviet era, homeopathy gradually emerged from the underground in the mid-1990's, gaining official state recognition as a method of treatment (Edict of the Ministry of Public Health and Medical Industry 1995), and holding a stable position on the market for medical products and services (Pesonina et al. 2004). Nevertheless, its status in Russia remains fairly marginal; homeopaths are largely confined to working in private-sector healthcare, they do not receive enough state funding to improve their treatment methods and, according to interviews with homeopaths, they are often ostracised by 'conventional' doctors. The peripheral position occupied by homeopaths in the Russian healthcare system is by no means unique; this is a tendency that can be observed in many developed countries (Degele 2005; Almeida 2012). On the other hand, the institutionalisation of homeopathy in Russia is marked by factors specific to this case. To give an example, in Russia classical homeopathy1 only became widely available as late as the 1990's. The uncompromising position of the Soviet Ministry of Health to homeopathy demanded that homeopaths who wanted to continue practicing had to adapt their treatment methods in such a way that would deviate considerably from classical homeopathy and include a conventional focus that was unsuitable from the outset (H7, H102). As will be shown below, those in favour of adhering to the original principles of homeopathy stand in strong opposition to those apparently deviating from this stance.
Over the last ten years, research has demonstrated that, despite the wide array of alternative medicine treatment on offer in practical medical care, overall it appears alternative medicine still suffers a marginal status (Mansurov, Yurcneko 2011; Iarskaia-Smirnova, Romanov 2008; Yurchenko 2004). Partly this can be explained by the limited possibilities for practitioners of alternative medicine to act in a collective manner, as their professional associations do not
1 Classical homeopathy is a strictly conservative practice within homeopathy
2 Henceforth 'H' is designated as an abbreviation for 'homeopaths.'
have sufficient resources for self-regulation. Regulations in the Russian healthcare system are also a problem; although aspects of market development are visible, the system retains many patterns of the Soviet era such as the prevalence of public health service, the exceptional regulative role of the Ministry of Health, and the prevalence of paternalism and centralisation in various relationship levels throughout the system (Tarasenko, Chirikova 2014).
Theoretical framework:
professionalization, social closure and autonomy
The theoretical framework employed in this research is very much in accordance with the Anglo-Saxon tradition of studying professions (Freidson 1994; Larson 1977; Saks 2012). In addition, it treats concepts such as social closure, autonomy and professionalization as interconnected. The term 'social closure' is usually understood as the process whereby social groups draw boundaries to limit access of the group's resources and opportunities to outsiders, ensuring that they are only available to a narrow circle and maximizing their economic benefits (Parkin 2000: 146). Adherents of this theory within the sociology of professions focused on attempts to maintain a legitimate monopoly on the market of professional services, supported through means of social closure. It is for this reason that formal rules are established for those seeking to enter this circle, which are often in the form of qualifications, licences and certificates. To perform the function of social closure in the most efficient manner the group creates professional associations.
Groups, including professions, develop not only formal but also informal and symbolic closure mechanisms. If the formal mechanisms of closure are poorly developed or absent, the members of the group tend to develop symbolic mechanisms of closure, such as elaborating ways to justify their practice, often by employing specific images and elaborating a group discourse. The concept of social closure is associated with that of autonomy. Central to social closure is the idea that must professions be allowed enough autonomy to establish and refine barriers to entering their profession. Thus, it is autonomous professionals who maintain control over both the content and context of professional work.
Organisational sociology and the sociology of professions demonstrate the multidimensional character inherent in the notion of professional autonomy (Hall 1968; Harrison, Dowswell 2002; Randall, Williams 2009). Generally, one differentiates individual from group autonomy (Hall 1968). The idea of individual autonomy or autonomy in the workplace refers to the ability of a professional to determine and to evaluate their own practices without having to report to others (Harrison, Dowswell 2002: 54). In turn, the group autonomy or self-regulation can be seen as the extent to which professions as a whole define formal demands for the realisation of professional activities, ensure their observation and impose sanctions on those who violate them.
The latter dimension of autonomy prima facie is relevant to the activity of professional associations. The classical interpretation of professional associations is that they form their own image of their profession as a whole, as a group of equals with their own identification, interests, and professional projects, striving to protect this unity along with the status privileges of the professionals. Professional associations have the potential to expand the possibilities for improved interaction between the individual members of the professional community. They can also help integrate bases of specialised knowledge and help improve the image of the profession in the public sphere. Associations should therefore be able to enhance prospects for cohesion between various members of the professional community (Ananias, Lightfoot 2012; Welsh et al. 2004).
The study of autonomy is a significant element of modern research into a variety of professions, although its study is complicated by the sheer variety of ways autonomy manifests itself in actual practice. Social closure and autonomy allow the profession to move towards increased professionalization. The latter implies the process of accumulating various types of resources, mainly economic, power-related (autonomy and self-regulation) and socio-cultural (the integrity of the group based on common identity). Within the scope of this analysis it appears impossible to conduct a detailed study of such measures; therefore we address only some of their parameters. This will be sufficient for a preliminary assessment of status among Russian homeopaths.
Methods
The results presented in this article are based on an analysis of quantitative and qualitative data. Twenty-two semi-structured interviews were conducted to identify the specific traits of Russian homeopathy and the social context of their activities. The use of a survey allowed us to obtain some parameters of professional status from a large number of respondents. To begin with, we carried out thirteen individual semi-structured interviews with homeopaths in the summer of 2013. We also analysed the transcripts of nine interviews with homeopaths, which were obtained from the archives of the research project 'The dynamics of the Social and Professional Status of Specialists in Traditional Medicine in Russia', which was carried out in four Russian cities: Moscow, Syktyvkar, Saratov and Saratov Region over 2005 to 2007. We consider this data to be relevant to our analysis in that we used similar question modules.
Furthermore, in the winter of 2013, a survey of 149 homeopaths from twenty-five regions of the Russian Federation was carried out. The survey was carried out via standardised face-to-face interviews. In order to define the level of individual autonomy among homeopaths we developed quantitative indicators. These were presented in a questionnaire to be assessed from 1 to 5 depending on the degree of agreement with each opinion.
Results and discussion
Economic position
The earnings of homeopaths are, on average, slightly worse than comparative figures for all medical workers with higher education (Rosstat 2013). We cannot view this as a definitive, general conclusion as our results were not based on representative sampling of the whole population. According to the results of our questionnaire survey in 2013, the average monthly wage of the homeopath-doctors we questioned was 46,830 roubles (€680.9)1 in Moscow and 30,933 roubles (€449.8) in the other regions, all of which is less than the average monthly wage of medical personnel with higher education2, which is 56,793 roubles (€828.8) in Moscow and 31,745 roubles (€461.6) in Russia's other regions (Rosstat 2013).
This data demonstrates that the average monthly salary of the polled homeopaths turned out to be lower than corresponding positions of general medical staff. Of course, the latter group is comprised of people with different qualifications and experience levels that could make the above comparison problematic. On the other hand, as Sergey Shishkin and his colleagues have shown, professional qualifications do not have a decisive influence on salary differentiation among medical staff. It is, rather, age and experience that hold greater sway, although the increase in average salary for those with more experience amounts to a 6-10 % increase in salary (Shishkin et al. 2013: 30-31). In general Russian medical staff can be categorized as a low-income group. If the average salaries of homeopaths are even lower than medical staff, this gives a good indication of the low economic status of homeopaths in Russia.
Professional training
Developing education and competence filters, such as a large variety of aptitude tests, licensure and certification, are all examples how formal social closure mechanisms function. Homeopaths in Russia are required to hold a diploma in advanced medicine and have a certificate demonstrates that the required level of training in homeopathy has been reached. Training of homeopaths in Russia is conducted in special centres and schools in the form of lectures and training courses. These are made up of 216 hours of training in general and 72 specific to homeopathy (Edict of the Ministry of Public Health and Medical Industry 1995). The doctor is required to complete refresher courses in both his or her special field and in homeopathy once every five years. After the successful completion of these
1 Data on wages is based on exchange rate of rubles at the Central Bank of the Russian Federation on 20 October 2016.
2 Including doctors and medical workers of organizations who have higher medical (pharmaceutical) or other higher education, providing medical services.
courses, the doctor is given a certificate that proves they have upgraded their homeopathy qualifications.
In interviews homeopaths assert that they must go through training more often than the once every five year requirement written in the law. This training is often expensive and must be paid for by homeopaths themselves. Continual training sessions are seen by informants as a necessary measure to ensure the quality of those practising homeopathy, in as far as the use of homeopathy is seen as a complex task that cannot be 'learned completely'. One doctor made this point in a very categorical fashion:
You need to read a lot of literature; not just the classic works but also modern journals. And, of course, you need to work as much as possible because the main thing needed to maximise one's capabilities is experience ... that is the most valuable quality (H15).
At the heart of this are issues about control over the processes that govern how expert knowledge is disseminated, especially through the monopolisation of the market for its services. One of the more effective and widespread mechanisms for the regulation of access to and exclusion from professional groups would be educational filters^the requirement to maintain professional qualifications and training standards in a given profession._It is precisely for this reason that it is so important, especially for professions-in-process such as homeopathy, to ensure that its educational programmes are represented in the country's higher educational institutions.
Autonomy and self-regulation
It is worth considering the role of homeopathic associations in shaping autonomy of the profession. From the start of the 1990' s, several associations of homeopaths with representative bodies have been in existence in many regions of Russia. The largest of these is the Russian Homeopathic Society (RHS), which has branches in 41 of Russia's 89 regions. The RHS and other associations of homeopaths, in accordance with their stated aims, actively popularise homeopathy, organise events in which homeopaths participate (congresses, conferences) and carry out consultative functions.
The responses reveal that homeopaths rate the contribution of associations fairly highly in the following areas: the maintenance and reinforcement of medical ethics (56.3 %), raising the prestige of homeopathy (72.5 %), and improving the status of homeopathy in the Russian healthcare system through promoting the passing of necessary legislation, standards and regulations (68.4 °/o). In an interview one homeopath emphasised some of the achievements of homeopathic associations:
I know some leading professionals, I know what they are aspiring to <.. > they work a lot in order to develop homeopathy service. Homeopathy professionals are already being certified by edicts from the Ministry of Health,
homeopathy has the same rights as other treatments. This is the work of associations. Now for us every conference ends with the passing of some new draft regulations (H19).
While the associations on the whole are capable of influencing the professionalization of the group, de facto they do not make significant decisions without the direct participation of the Ministry of Health, which has monopoly control over healthcare. The following perception of the division of functions between the state and the associations is illuminating:
The Ministry of Health mostly certifies homeopathic remedies, exercises control to ensure their quality, issues licenses to operate. The association handles professional growth, instruction, anything to ensure homeopathy develops and proves its relevance. (H3).
Indeed, the order of the Ministry of Health defined the requirements for the level of training of homeopaths, and services quality is controlled by state institutions such as the Rospotrebnadzor and Roszdravnadzor1. This is evidence of the state's significant role in regulating the medical profession in general and doctors of alternative medicine in particular.
In interviews, the majority of informants admitted that their participation in associations was largely formal or official in nature; there were seen to be neither tangible benefits nor concrete obligations connected to membership in such associations. Some homeopaths offered a sceptical assessment on the influence of associations:
Associations in our country do not function at all. (...) It's not like abroad; there they are bodies with real authority. Here people only seem to have faith in the edicts of the Ministry of Health. We follow whatever is written in them (H10).
These varied homeopaths' assessments regarding the homeopathy associations' activity accord in that the leading role in regulating the medical profession is performed not by the associations but by the state. The association's goal today is not to execute self-regulation of the professional group; it is less ambitious and is reduced to advisory functions. It appears that this situation is caused by the paternalistic relationship characteristic of Russian social and occupational structures in general and the medical profession in particular (e.g. Romanov, Iarskaia-Smirnova 2015).
Since 2010, the question of self-regulation has been increasingly discussed within the medical community. In particular, the National Medical Chamber has even managed to earn the right to participate in the writing of a new law in the provision of healthcare (Federal law 2011). Doctors are gradually realising
1 Rospotrebnadzor stands for 'The Federal Service for the Supervision of Consumer Rights and Human Welfare' and Roszdravnadzor is the 'The Federal Service for the Supervision of Public Health'
the advantage of using independent bodies to carry out regulation of their professional activity. However, we are, by all appearances, still far away from the kind of system similar to one in developed countries that would see every medical association enjoying the exclusive right to regulate their own profession. Today the National Medical Chamber is composed of over a hundred medical associations, yet none of them are homeopathic.
As for individual autonomy, the situation appears to be somewhat different from that of the macro (group) level. This is what Stephen Harrison and George Dowswell, termed 'clinical autonomy' (Harrison, Dowswell 2002: 221). In order to define the level of individual autonomy among homeopaths, we developed quantitative indicators. Given that the everyday work processes of a doctor are made up of decisions and actions relating to various spheres of competency and management in his or her medical practice, it would seem autonomy can manifest itself in a variety of ways in these spheres. We highlighted three such significant spheres of everyday practice that act as variables: (1) the choice of method; (2) the length of the appointment; (3) the number of patients per day.
Using the Index of autonomy we determined that the majority of respondents rated their level of individual autonomy highly in all three parameters. As such, 58 % of those surveyed ended up in the group with highest autonomy (13-15 marks, at a max. of 15), 29 %% in the group with middle level autonomy (9-12 marks) and 13 %% in the group with lowest autonomy 8 marks or less). The interviews showed that the absence of strict standards in homeopathic activity is an important condition for the autonomy of homeopaths. We can find homeopaths asserting that their treatment method cannot be subject to standardisation because it is based on an individual approach to treatment:
For every person, for every situation a specific medicine is selected, or two or three medicines <...>. Homeopathy cannot really be standardised (H15).
Because homeopathy is difficult to standardise, the control over homeopaths by the state is rather provisional:
Well, what can they check?! They can come and ask whether we keep medical records. We do. If you need to report, we will write a medical history, as would a conventional doctor. What can the authority in charge tell me? I just give the medical history as required (H13).
In the above quotes one notes the particular nature of homeopathic knowledge. This knowledge can hardly be codified; it is like an art that is passed on and mastered through practice. Although the control of the Ministry of Health imposes restrictions on the self-regulation of homeopathy, in the opinion of respondents, this control does not affect their individual practice. This means that the knowledge and skills possessed by homeopaths retain their esoteric properties. Therefore, homeopaths evaluate their level of autonomy to be sufficiently high. So the impossibility of standardising homeopathy can be presented as an advantage, a source of autonomy.
Classical vs. clinical homeopaths: two strategies of professionalization
The data discussed above concerning the professional status of Russian homeopaths characterises the subject of the study as a whole. However, this professional group is not homogeneous and its members differ in their chosen strategies of professionalization. Differences in these strategies match those in the distribution of autonomy and the means of social closure.
Changes in the practice of applying homeopathic knowledge have provoked significant discussions: in extreme cases, the stricter advocates of homeopathy - classical homeopaths - are critical of those colleagues who modify the fundamental principles of homeopathy, simplify and reduce its unique knowledge to the external institutional rules and requirements of the ruling medical system or conventional medicine. The latter we categorise as 'clinical homeopaths'. Unlike classical homeopaths, clinical homeopaths are more prepared to allow the synthesis of conventional medicine and homeopathy and do not see an obvious conflict between the two. There are those who see homeopathy as only one of the instruments in a doctor's toolbox, which can be combined with other methods as they see fit. It would be hardly imaginable for a classical homeopath to accept this, as it would mean practising homeopathy only in a partial manner. In interviews classical homeopaths spoke out against 'clinical homeopaths':
Something called 'clinical homeopathy' - is, in fact, not homeopathy because homeopathy has its own principles, methodology and philosophy. Clinical homeopathy does not fit the above, the approach here is like in conventional medicine - based on diagnosis. My understanding is that doctors do not realise what they are doing, they have an insufficient level of education in the field of homeopathy (H15).
Such opposition to clinical homeopaths can be interpreted as striving for self-identification as the carrier of the single 'correct' knowledge of homeopathy. This version works as a symbolic lever of social closure. Classical homeopaths see their counterparts as 'apostates' who threaten their reputation and seemingly discredit homeopathy by betraying its basic principles rendering it inefficient and even dangerous.
Clinical homeopaths are less categorical, they adhere to pluralism in the use of the homeopathic method, and, apparently, consider classical homeopathy to be one of the options of homeopathic practice:
Well, no, homeopathy comes as a part of general medicine. It's just that a lot of people engaged in homeopathy for many years do not see the connection of homeopathy and conventional medicine. Homeopathy is not a panacea. I think in some cases homeopathic treatment can work as the primary one, while in some cases - as an additional, complimentary one. This is for the doctor to decide (H2).
The difference in attitudes between classical and non-classical homeopaths brings us to the problem of their professionalization (Sadykov 2012). Since
homeopathy exists in the system, dominated by another therapeutic model, the question of professionalization is closely related to the issue of integration into conventional medicine. Attitudes toward integration differed in each of the categories of homeopath we studied. Clinical homeopaths aspire to overcoming ho-meopathy's 'alternative' status as a treatment method, welcoming increasing cooperation between homeopathy and conventional medicine, striving to occupy a more prestigious position within the healthcare system that will allow them to be equal to other doctors (H6, H12). For this category of homeopaths, integration represents a possible path to increased recognition and additional resources. If we shift the focus of this problem to the institutional level, we can describe the integration of homeopathy as its absorption into state structures. It is precisely in this question that clinical homeopaths understand the future development of their treatment method. The case of classical homeopaths illustrates that not all groups within alternative medicine are prepared to follow the path of integration in order to achieve professionalization. Instead, there is a preference for strategies of demarcation and insulation through presenting themselves in stark contrast to conventional doctors and clinical homeopaths. They prefer to maintain a relatively high level of individual autonomy and specific identity rather than sacrifice this for potential gains and benefits they could receive from the state.
Conclusion
In this article, we explored professional status and processes behind professionalization of homeopathy in Russia. We found that in terms of economic, power-related (autonomy and self-regulation) and socio-cultural (identity) parameters Russian homeopaths are relatively marginalised. The role of homeopathic associations in self-regulation is negligible, largely due to the institutional characteristics in Russian healthcare, which is centralised and paternalistic. The relatively weak mechanisms of formal closure are a consequence of low self-regulation. As demonstrated by interviews with homeopaths, the existing filters to admission to homeopathic practice cannot be considered effective and, therefore, the boundaries of the group are quite permeable.
In this article we can see that the failure of self-regulation mechanisms to develop influences homeopaths in their selection of professionalization strategy. This choice arose because within the group of homeopaths opposing methods of identification of homeopathy and its professionalization are observed. One professionalization strategy consists of standardising homeopathy to better integrate it into conventional medicine. The other is to reject standardisation and integration and preserve uniqueness and identity. While classical homeopathy sees standardisation as a threat to preserving its uniqueness and identity, clinical homeopaths, in contrast, see it as a chance to integrate into conventional medicine and achieve new status and privileges. The choice between these starkly different professionalization strategies is an important
dilemma for homeopaths, as each option possesses its own advantages and restrictions.
Acknowledgements
I would like to express my deepest gratitude to the late professor Pavel Romanov, who tragically passed away due a serious illness when I began work on this article. His considerate comments and suggestions helped conceive the core ideas of the article. I also want to thank my colleagues at the Higher School of Economics, most of all professor Elena Iarskaia-Smirnova for their comments, constructive criticism and helpful suggestions. I would also like to express gratitude to participants of the workshop 'The Professions in the Welfare State' at the Higher School of Economics.
Funding
This research was partly supported by the Russian Science Foundation in 2014, grant № 14-18-03784 (as to study of social-professional status and basics of group integrity presented in the analytical parts which entitled Theoretical framework, Methods and Results and discussion) and Basic Research Program at the National Research University Higher School of Economics (HSE) in 2015, grant № 137 (as to study of on the strategies of professionalization presented in the last analytical part of article).
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