Abstract
Churchill-Livingstone/Elsevier, 2012, 244 pages, ISBN: 978-0-7020-3021-5, Paperback $49.95, Kindle $34.17.
This time around, East Asian Medicine (EAM) is entering a self-consciously “scientific” milieu, which, in the last 30 years, has demanded research to “explain how (well) acupuncture works,” especially in comparison to biomedicine (there's been much less focus on herbal medicine). This time around, too, we are self-consciously a “global society,” and yet, to a considerable extent, have not yet applied the lessons of culture and history—that things change and that those changes inevitably reflect the surrounding wants and expectations of the locality—to the clinical study of EAM. Thus, we are led to the conundrum that much research has been carried out on a theoretical construct, an invented medicine that is tested by biomedical models while the practice of EAM has been largely ignored. This path has been supported by some Western perceptions, not only positivism, but also a tendency to divide reality into opposing dichotomous and boundaryless abstractions—science/belief, reductionistic/holistic, objective/subjective—which have resulted in a sense of futility for some: How can EAM retain its cultural authenticity, and how can EAM remain true to its pragmatic and patient-centered roots, when the surrounding dominance demands population-based, “scientific,” or “evidence-based” standards?
The book's authors propose a way out, insisting that there are no incommensurable differences among the Medicines when one begins from their pragmatic goal—to treat patients—and accepts that this process can never be strictly objective/technological, but is dependent upon clinical interpretation and judgment. To support their argument, they develop four themes in 12 chapters, adduce evidence, and describe appropriate methods to find the commonalities and measure success realistically.
Theme 1 offers three chapters that discuss the practice and practitioners of East Asian Medicine. Volker Scheid begins by contrasting “best practice” (population and evidence-based medicine) with “best practitioner” (focused on the individual), and demands that we move beyond such a dichotomy by incorporating analytical insights from the humanities, social sciences, and business models. Judith Farquhar continues the theme by showing how standards of best practice break down within office practice because judgment eventually trumps data derived from technology. Trina Ward ends the set with a fascinating ethnographic study from which she identifies six distinct ways—enactments—in which EAM is practiced along a continuum that links to biomedicine at one end, and at the other insists upon its cultural and philosophical uniqueness.
Theme 2 examines standards developing within EAM, standards that concern needles, point location and point naming, and best practice guidelines. Sonya Pritzger leads off with a discussion of translation: How do you translate words and concepts from one language to another, and accept one translation as standard, when these words and concepts may come from Chinese, Japanese, Korean, Cambodian, or other Asian languages, each with its own standards of cultural perception? In a series of “snapshots,” Pritzger explores language as a living entity respondent to the surrounding milieu and shows how even “standard” translations are reinterpreted in practice. Christopher Zazlawski and Myeong Soo Lee take the next chapter, examining how quests for “modernization” of EAM to promote it on a global stage tend to demand standardization. They examine the advantages and disadvantages of standardization—a safe, reliable, consistent product, which may, on the other hand, reduce the authenticity of the practice or affect freedom of clinical judgment. Chapter 7, by Sean Hsian-lin Lei, Chiao-ling Lin, and Hen-hong Chang, offers a case study in China. In an effort to achieve standardization, an innovative and “objective” photographic standard for tongue diagnosis was developed. Would it help unite practitioners? The chapter continues the examination of the tension between authenticity and innovation.
Theme 3 focuses on clinical research and how to build a scientific evidence base for EAM. Rather than assume that this is self-evident, authors explore the wider context of research and propose ways to improve research so as to assess EAM in terms that matter widely. Claudia Witt and colleagues distinguish among RCT designs to assess efficacy, effectiveness, and efficiency, as well as pragmatic versus explanatory intentions, emphasizing the need for fitting the design to the question. Andrew Flower and colleagues examine the political dimensions of implementing research evidence, critiquing the evidence-based movement for its positivist emphasis, insisting that there are no incommensurable paradigms, and proposing appropriate methodologies. Finally, Elizabeth Hsu approaches treatment evaluation from an anthropological perspective, discussing healthcare delivery as ritual, then analyzing the synchronicity of the patient–practitioner relationship and ending with a demand that future research assesses the context of treatment.
Theme 4 focuses on globalization with case studies of EAM as practiced in the Philippines (Paul Kadetz) and Cuba (Vivienne Lo, Adrian Renton), and an ethnographic case study of health spas in India (Laurent Pordie), accompanied by a discussion of branding as an issue in delivering an “authentic” experience of Ayurveda. The burden of these chapters is that EAM—or any Medicine—will be practiced in ways that reflect the needs and assumptive biases of the country where they are located. Thus—a point reiterated in the book—there is no “one” or “stable” expression of East Asian Medicine, but many, each “authentic” to the extent that it fulfills its role in its own society.
The final chapter is by Elizabeth Montgomery and ties together the discussions that preceded it. Her points are several, but the one I will select here concerns her proposal that one of the strengths of EAM is its tendency to be self-reflective, a feature that opens research potential in novel and constructive ways. She remarks as follows:
Biomedicine's faith in science as the unmediated discovery of reality means that biomedicine is not self-reflective. Meanwhile, complementary and alternative medicine, faced with the power imbalance between the two regimes, is inspired to wrestle with important questions about the nature of skill, the constitution of evidence, the role of autonomy in standardized practice and the challenges of ‘integration’ in a range of circumstance outside of East Asia. Above all, complementary and alternative medicine must seek out and defend appropriate research methodologies for questions that biomedicine, for the most part, neglects, even fails to recognize.
Montgomery emphasizes practice as the proper focus of research, reiterating earlier points about context, and the multiple expressions of EAM, each one reflective of the surrounding historico-cultural milieu. She argues that if practice—its tensions shared by all Medicines—is the focus of research, then apparent differences—those dichotomies with which the book and this review began—will fade in importance, and constructive new research designs will emerge that will more convincingly describe EAM, providing a solid evidence base, even permitting appropriate standardization.
Integrating East Asian Medicine in Contemporary Healthcare grew from two conferences expressly designed to explore the topics that are developed in the text. The authors are many, but their argument is integrated and well developed. Each chapter features short Vignettes that provide detail on issues examined in the chapter. References are provided at the ends of the chapters, not at the end of the book, and (fortunately) not in a separate CD. The authors are introduced at the outset, and a useful index concludes the book.
As reviewer, I am expected to identify this book's limitations, and this I have found difficult to do. I am sure some will find the argument iconoclastic—and I am happy to see those gods spoken . . . and broken. Indeed, we've been waiting a long time, and I find it delightful to read coherent critiques of issues such as the unquestioning belief in “science” that has (mis)guided much EAM research to date; the awareness of C.P. Snow's two cultures (“hard” sciences vs. “soft” sciences); the emphasis on the political, historical, and cultural context of medical theorizing and practice; the insistence that practice should be the focus of research; and that qualitative analysis is essential to our greater task. The book is, frankly, a tour de force, and I gladly recommend it to researchers, funders, practitioners, and regulators as well.