Raimo Tuomainen – Jyrki Elo – Markku Myllykangas:

Paramedicalization: work for health in the shadow of medicine

(Paramedikalisaatio: terveystyötä lääketieteen katveessa)

Sosiaalilääketieteellinen aikakauslehti (Finnish Journal of social medicine) 1995:3:217-223

As applied and death defying, medical science is closely related to real life problems. Medicine is a key element to solving health problems. Historically, the farther past we take a glance, the weaker position compared with its many alternatives it has (Mountain 1979). Doctors with their medicine achieved their special position not until in the late 1800’s (Rosen 1972, Hermanson 1990).

The antibiotics - their success to treat several deadly diseases - made the medical explanations finally credible for lay people. Medicine was sovereign in treating diseases caused by invisible micro organisms. The supernatural explanations for diseases were vanished (Sontag 1982). Nowadays the transplantation technology era in surgery has given medicine new glamour: man may have the dream of self-renewal of the body as a specific scientific goal.

Medicalization means the growth of the institution of medicine and its mastery over life events and abnormality. In the medicalization process medicine is expanding to the previously non-medical regions (Zola 1978, Hemminki et al 1992). Medicine and health care have expanded to reproduction, growth, aging, beauty, performance and anomaly (Hemminki 1993).

Medicalization appears in our society. It is expressed in concrete in the health-related industries and in the increase of cash flows. Mentally, the phenomenon is expressed in increased risk awareness and in the broadening of the health concept. In social policy the medicalization is noticeable in focusing on the health issues; in practice the status of medicine and health care will increase.

In the western world paramedicalization – the growth of therapies which do not belong to the institution of medicine – has progressed, alongside with medicalization. In our health-seeking society there is a subscription to many alternative healers that manage to maintain our faith in better health. Although medicalization and paramedicalization are partly conflicting, they also feed each other by ensuring that health and disease issues remain in focus in our life. (Tuomainen and others 1993)  

Paramedicalization has the same features as medicalization: attempt to increase their own power and to create new markets, growth-orientation and tendency to monopolize expertise.

This article discusses the essence of paramedicalization – its both positive and negative aspects - and its importance in the Finnish society, and furthermore it contains evaluations of the social conditions of paramedicalization.

Therapies outside of medicine

People have different symptoms during two of every three days (Myllykangas 1986). Only 2 % of the daily symptoms we have results in using medical services (Elo and Myllykangas 1986). Against this background, the medicalization and paramedicalization have almost unlimited breeding. 

Self care is socially desirable. It will presumably lead to improved human health and hopefully cuts the need to the public health care. It has been estimated that humans carry their health disorders, and the need for treatment caused by a disease, up to 80 %, either themselves, relying on layman aid or on informal health care (Meriläinen 1986, cf. also Myllykangas 1986).

As paramedicalization progresses, non-medical therapies acquire more social clout. Paramedicalization covers several commonly-used concepts in Finnish. These concepts are largely overlapping, they often describe the same things in slightly different angles.

Alternative treatments are meant to cover those paradigms, disciplines and health care, which have a problematic relation to the biomedical paradigm, and furthermore scientific testing in the biomedical sense is not required of these treatments. The concept of informal medical treatment is mostly administrative. (Vaskilampi 1992)  

In Finnish the concept of folk medicine is common, which stresses the fact that the treatment is based on folklore, not on the scientific concept system. Folk medicine includes two main groups: traditional care and modern care – the modern care is typically adopted from other cultures and is often characterized by the commercial mass production. (Vaskilampi et al 1984)

The name natural medicine suggests that the therapy relies on what nature has to offer, it expressly avoids anything artificial. The philosophical core of this is that nature provides a confirmation of man's own forces to improve recovery. In Finland, official natural medicines are registered and they must be approved by the pharmacy (Vaskilampi 1992). 

Folk medicine is practiced all around the world. A part of folk medicine differs from modern medicine, its methodology and inquiry: both the concept of illness and the goal of the rite of cure may emerge quite differently (Honko 1981). Without understanding this different approach folk medicine may affect irrational.

In folk medicine they have used also objectively medical products. African therapists have used salicylic acid to rheumatism. From the Inca culture we inherited cocaine and quinine; ephedrine was inherited from Chinese folk medicine. However, in folk medicine these products have had a negligible impact without relevant spells. The vast majority of drugs have been objectively meaningless, but there have also been utterly harmful drugs. For example, in Finland, the "pang disease" was treated with feeding glass splinters, as the internal pangs had to be answered with anti-pangs. The current interpretation is that in folk medicine they have been masters of taking advantage of the placebo effect, including psychotherapeutic methods: the suggestion, hypnosis and shock treatment. The best folk healers could be called pioneers of psychosomatic medicine. (Honko 1981)

The image of paramedicalization

There is a variety of options for maintaining health, some of which might be with a sense of unselfish mission, and a part filled with market orientation - the majority is supposedly a combination of those two. In the name of health the clients might also been deceived, credulous people cheated (Sumuvuori 1986). Different treatments have different concepts and theories of humans, patients, health, diseases and the needs, nature, content and effects of the treatment (Meriläinen 1986). According to Stanway (1982) already in 1973 alternative medicine had more than 130 different types of treatment formats and methods.

There is no clear division into official medical care practice and its alternatives. For example, acupuncture cannot be clearly put into only one of the two categories, as well as the use of variety of vitamins and trace substances. Homeopathy has been in Finland outside medicine more clearly than in many other countries. Obscurity of boundaries of medicine is natural: you cannot speak of one medical truth or one proper care (Payer, 1989), likewise you cannot find the one and only truth in the social sciences and social policy. Likely, however, is that only a marginal group of medical scientists would advocate some alternative treatments, and if these treatments become more popular, that is paramedicalization rather than medicalization. (Tuomainen 1994)

One can experience the formal health care system and medicine being alienated from oneself, for a reason or another. Some people have preferences for the spontaneous and informal assistance. In particular, the doctor may be considered to represent the society, "the system" (Saano 1993). For instance, many people with chronic social problems prefer to rely on just informal support, on one another (e.g. Tuomainen et al 1990, Kumpusalo 1991).

On the other hand, the same people generally use the formal health care services and informal care (Saano 1993). For example, in Kuopio those clothing workers (all women) who often visited the doctors also used alternative therapies more often than others (Vaskilampi and others 1984). Vaskilampi (1992) found that not more than one percentage of the working-age population had resorted only to alternative treatments during one year.

Meriläinen (1986) found that women used all the researched alternative treatments more that men did. Use of natural remedy and other new treatments seemed to be spreading from south to north, from the cities to rural areas, from young to older, from educated to less trained and from women to men. Traditional treatments were least used in southern Finland. The use of alternative treatments seemed to be a protest to medical care. (Meriläinen 1986)

According to Vaskilampi’s (1992) study, the majority of working-age population belonged to the users of formal health care system. Half of the working age population had used the natural pharmacy. A quarter of them had used the modern folk treatments during the previous year, and 14 % had used the traditional folk medicine. A chronic illness and psychosomatic symptoms formed often the background of the natural product use. Especially well-educated women seemed to use natural products. The younger and the urban people used the new treatments and products, the older and the rural residents used the traditional treatments: one can speak about two different use models of alternative medication. (Vaskilampi 1992)

In Finland the alternative medication profile is different from what it is elsewhere in Europe where homeopathy, acupuncture and manual therapies are important. Cupping has almost disappeared outside Finland. In Finland the use of alternative treatments is relatively common, compared to many other countries. (Vaskilampi 1992)

Disappointment in medicine

The thalidomide catastrophe and increased awareness of drug side-effects have violated the illusion of only good-making medicines. Fear of drug side-effects is common nowadays, perhaps only if one uses natural medicines, one is ready to believe in a full cleaning power, even a miraculous cure. (Saano 1993)

Saano (1993) says that is a general to fear that doctors do not believe the patient's symptoms, but say that the patient imagined the disease, while a folk healer wonders at the severity of the symptoms. The explicit attempt to be objective impairs the attractiveness of medicine. A disease is, however, always connected with three factors: medicine, magic and religion (Herzlich 1973). It is obvious that if people seek counterbalance for secularisation, it can happen through using natural medicine (Saano 1993). Regular use of natural medicine is comparable with wearing an amulet, which can fight off the diseases.

The physician's role is an awkward dichotomy: he or she is on the one hand a sympathizer, on the other hand a judge. The doctor cannot fully accompany the client's suffering, but, because of his professional role, the doctor has to maintain some kind of personal distance, and - even suspicion. For a doctor, for example, a patient complaining about back pain is not only the customer but also a potential manipulator of benefits, as pain cannot be clearly, objectively measured. The patient may need unconditional understanding, and a healer with no role conflicts fits to help him.

The counterpart of the expert’s role is the role of a layman. A layman is dependent on the expert's knowledge, interpretations and skills. In practice, a strong expert power leads a layman to regression. This creates dependence structures, which at worst means that the citizens may be at the mercy of the experts. (Lindqvist 1990)

Paramedicalization comes into a competition with medicalization, as people seek power, both in economic markets and in relation to the social decision-making. Some representatives of alternative medicine are emphasizing that medicine is technocratic and has inability in satisfying patients' subjective needs. At the same time, directly or indirectly, they refer to the omnipotence of alternative therapies. Perhaps the idea is that power and markets belong to those who promise more.

Objective and subjective dimensions

A special category of healers is the various experts of magic. Their expertise is so subjective that practically it is not verifiable in any way, but somehow they appeal to the needy people. (Karjalainen and others 1991)

Most therapy movements which are ideologically committed are basically spiritualistic. They regard the spirit primary, and material secondary. In particular, in the movements having much influence from the east, it is perceived that the material world and somatic diseases are illusions or just secondary phenomena. Thus the methods of curing must be spiritual in nature. Self-knowledge, meditation, rituals, and prayer are all prioritized in relation to drugs. (Heino 1984)

In his book dealing with Finnish religious movements, Heino (1984) has included also some therapeutic movements, which he sees to have a roughly religious background. Such alternative therapies have come to Finland over the past few decades; in 1984 a central association for alternative care services was set up. This association aims to train practitioners of alternative care to meet the objective demands of the society. (Heino 1984)

Medical truth issues have turned into issues of scientific research. They are largely technical and organizational by nature. Questions about life, death and suffering have been transformed into the individual's external, technical problems. We try to find solutions to these questions with the bureaucratic-produced technologies. (Vaskilampi 1992)  

But you can see this also in the modern commercial folk medicine: outsourcing and emphasizing of technology is evident. In Finland during the 90's, free papers full of information about alternative medicine became more common. Central phenomenon appears to be creating a formation of an alternative Pharmacopoeia. Old traditional public pharmaceutical manufacturing has almost stopped (Hernesniemi 1987). Many health products are living a certain period of enthusiasm, but there are also some classic products such as ginseng root. Some of the products are sold in pharmacies; a part is sold by health food shops. Also Vaskilampi (1984) mentions, that the alternative treatments are becoming more technical, institutional and scientific. However, she says, at the same time mystical, magical or religious nature of alternative treatments has become stronger.

The social boundary conditions for paramedicalization

Saano (1993) has interpreted that one essential base for paramedicalization in western countries is the change in age structure: when the number of elderly people have increased, the number of orthopaedic inconveniences, cancer diseases and cardiovascular diseases has also increased. These illnesses are not easily medically treated; neither do they have easy, popular explanations. Science has not fulfilled its promises, those promises which, according to Saano, the medicine has not even given. Sumuvuori (1986) detected that the majority of cancer patients in Finland has tried some of the alternative therapies.

Vaskilampi (1992) stresses that, when growing, the welfare state included more and more social interests in official health care. Only one legitimate doctrine was adopted, namely the medicine leaning on natural science, while other treatments were left outside the public subsidy and regulation. That is how people’s health and medical issues are shifted from private to public area. In practice, the health cultures became bureaucratic and professional (Freidson, 1970, Illich 1976). The criticism against the welfare state has questioned legitimacy and effectiveness of the power systems (Mishra 1984), which is also reflected as critical views concerning the health care system (Vaskilampi 1992).

As the society has become secular, health has become the focal area in which we seek the real truth (Tikkala and others 1991). The health doctrines proffer people answers to their worries about how to live. Medicine, however, with its striving to be objective, gives only cold facts. It does not provide the message of salvation. Its approach is technical and mundane, despite of the laymen’s difficulty to understand it. 

Humans have a common desire to believe in something that is more than normal everyday life. The sacred and mystical make everyday life feel more meaningful. The pursuit of purpose is close to the desire for a harmony, an experience of self-management. Medicine pushes such spiritual growth targets outside the healing process.

Alternative medicine relies on certain fundamental ideals, values, such as natural character, universality, individuality, lenience, vitality and purity (Vaskilampi 1992). If such values are reinforcing in society, the advertising value of alternative medication grows, too. Alternative medicine dares to promise even super-health (Vaskilampi 1992).

Popularity of the private health care and alternative medicine may be due to the fact that they are not patriarchal. Formal system is not as favourable to the use of services without any apparent cause; the ultimate hope is that the use of public medical services is a consequence of a health problem which is accordant with objective diagnostic criterions. Doctors have very patriarchal gatekeeper role: human subjective nausea is not enough for getting certain benefits, but a doctor has to determine the actual status, the "objective" need. In commercial health business the subjective experience of the customer is not ignored, because of the economic interests. (Elo et al, 1989)

Saano (1993) has estimated that the vast majority of the popularity of natural medicine has been commercially created. Also in Finland it seems to be over-consumption of self-care painkillers, which is commercially caused (Arola 1993). In the USA, which is a country of particularly effective marketing methods, about 40 % of the population use nutritional supplements (natural medicines, vitamins and trace elements) (Levy and Schucher 1987). The glorification of youth in USA has created a large need for products to prevent the decay of the ageing body.

Commercialization and market orientation of the alternative therapies can be seen, if one analyses the numerous free papers. Alternative medicine has a tendency to become a speciality of its own outside of medicine and the growth of the alternative product market expresses the same objective.  The growth of markets is pursued by obscuring the border to official health care, among other things by presenting quasi-scientific studies of treatments.

Both medicalization and paramedicalization are growth-seeking. Constant growth in the industry guarantees more secure livelihood. In this growth-seeking the two trends support each other.

Since alternative treatments are not publicly supported, they are forced to operate largely on a commercial basis. Thus paramedicalization, perhaps without the alternative operators’ will, has to move forward by creating great dreams by advertising – these dreams may also be a resource, though, the suggestive effect.

Are the boundaries of medicine insurmountable?

One can argue that the power circuit of alternative medicine is transcendent. After all, it extends to all areas of human activity, but in addition it covers the period before birth and after death (Vaskilampi 1984). Medicalization has thus more evident borders than paramedicalization has.

It seems to be true that the medicine, as it has become more natural science, has the risk of losing the grip on the human experience, a sense of distress. Alienation from the part of human being which is not to be explored scientifically may not serve the cause for health. Irrational, scientifically thinking naive factors may, quite well, have effects that support the health and well-being of man. These factors and effects are not, at any rate, underestimated by alternative medicine.

Several alternative medicine therapies and educational doctrines are developed by doctors. One can mention homeopathy, Alexander-technique and Bach-herbalism. Nowadays the young doctors, general physicians and psychiatrists are among doctors the most interested in alternative medicine. (Vaskilampi 1984)

Thirst for power increases the dependence between medicalization and paramedicalization as alternative treatments develop doctrine disputes inside the official medicine. The pursuit to influence on social decision-making and to control it will create pressure on alternative medicine to formalize its look, even though its concept system maintains original. Concretely, the power of paramedicalization has been seen in parliament. You can notice an interest in alternative therapies there. A part of the members of parliament want public support to alternative therapists with a public status, and also they want to avoid or reduce legal restrictions on the market.

In practice, the limit of medicine and non-medicine is tied to various authorities, particularly to the approval of people having scientifically great merits. If an alternative treatment is positively evaluated in a medical thesis, it can be soon a part the official medical culture.

Paramedicalization has also its professionalism, even though the treatments emphasize the patient’s influence. Often only the initiated can give the "correct" treatment and has “right” understanding of human problems. In paramedicalization, professionalism works in the same way as in medicalization, it is an instrument of power. In addition, it is important in preventing excessive merging into formal health care.

In medical practice the doctor does not necessarily promote the medical reference frame seriously. In a human communication, in addition to the science, also other aspects are utilized. An eminent doctor does not live in a scientific vacuum, but uses his communication skills in health promotion and thus meets a subject, not just an object entity. The different types of medicating are not actually opposed to each other: medical practise can be an enlightened folk medicine.

LITERATURE

 Arola H. Lääkemarkkinointi lisää turhaa käyttöä. Kelan Sanomat 1993:9:14.

 Elo J, Myllykangas M. Koetut oireet ja niiden johdosta suoritetut toimenpiteet. Sosiaalilääketieteellinen Aikakauslehti 1986:23:28-38.

 Elo J, Tuomainen R, Myllykangas M. Turha terveyskeskuskäynti - terveyskäsitysten kriisi. Sosiaalinen Aikakauskirja 1989:3:9-15.

 Freidson E. Profession of medicine. Harper & Row, Publishers Inc., New York 1970.

 Heino H. Mihin Suomi uskoo. Uskonnolliset ja maailmankatsomukselliset liikkeet. WSOY, Porvoo 1984.

 Hemminki E. Nainen ja terveydenhuolto tutkimuksen kohteena. Sosiaalilääketieteellinen Aikakauslehti 1993:30:169-175.

 Hemminki E, Kangas I, Topo P. Lääketieteellinen teknologia ja vaihdevuodet - esimerkki medicalizationsta. In Karisto A, Lahelma E, Rahkonen O (toim.). Terveyssosiologia. WSOY, Porvoo 1992, p.96-106.

 Hermanson T. Kilpailutilanteesta asiantuntija-asemaan. Suomen Lääkärilehti 1990:45:3117-3119.

 Hernesniemi A. Kansanparantajat terveydenhuollon kentässä. In Hänninen O, Sumuvuori H, Meriläinen P, Vaskilampi T (toim.). Kansanparannus eilen ja tänään - huomisen tutkimushaaste. Lääkintöhallituksen julkaisuja, nro 96. Helsinki 1987, p.60-71.

 Herzlich C. Health and illness. A social psychological analysis. Academic Press, London 1973.

Honko L. Uskontotieteen näkökulmia. WSOY, Juva 1981.

Illich I. Medical nemesis. Pantheon Books, Inc., New York 1976.

 Karjalainen J-M, Lindqvist M, Saares K, Voutilainen P. Terveyden portinvartijat. Preventio ja asiantuntijavalta terveydenhuollon eettisenä ongelmana. Sosiaali- ja terveyshallitus. Raportteja 39/1991. Helsinki 1991.

 Kumpusalo E. Sosiaalinen tuki, huolenpito ja terveys. Sosiaali- ja terveyshallitus. Raportteja 8/1991. Helsinki 1991.

 Levy AS, Schucher RE. Patterns of nutrient intake among dietary supplement users: attitudinal and behavioral coordinates. J Am Diet Ass 1987:87:754-760.

 Lindqvist M. Auttajan varjo. Pahuuden ja haavoittuvuuden ongelma ihmistyön etiikassa. Otava, Keuruu 1990.

 Meriläinen P. Väestön terveydenhoidon kokonaisuus: itsehoito, virallisten ja epävirallisten terveyspalvelujen käyttö sekä niitä määräävät tekijät. Kuopion yliopiston julkaisuja. Yhteiskuntatieteet. Alkuperäistutkimukset 1/1986. Kuopio 1986.

 Mishra R. The welfare state in crisis, social thought and social change. The Harvester Press Publishing Group, Brighton 1984.

 Myllykangas M. Päiväkirjamenetelmä koettujen oireiden ja lääkkeiden käytön tutkimisessa. Kuopion yliopiston julkaisuja. Kansanterveystiede. Alkuperäistutkimukset 2/1986. Kuopio 1986.

 Payer L. Medicine and culture. Notions of health and sickness. Victor Gollancz, London 1990.

 Rosen G. The evolution of social medicine. In Freeman H, Xevine S, Reeder L (toim.). Handbook of medical sociology. Prentice-Hall, New Jersey 1972, p.30-60.

 Saano V. Luonnonlääkinnän suosion taustalla olevat tarpeet. Suomen Lääkärilehti 1993:48:3271-3275.

 Sontag S. Illness as metaphor. Penguin Books, Harmondsworth 1982.

 Stanway A. Alternative medicine. A guide to natural therapies. Penguin Books, London 1982.

 Sumuvuori H. Kansanlääkinnän asema virallisen terveydenhuollon rinnalla. In Hänninen O, Sumuvuori H, Meriläinen P, Vaskilampi T (toim.). Kansanparannus eilen ja tänään - huomisen tutkimushaaste. Lääkintöhallituksen julkaisuja, nro 96. Helsinki 1987, p.111-120.

 Tikkala H, Myllykangas M, Tuomainen R. Sekularisoituminen vai uskonnollistuminen? Malli elämänkatsomuksista kognitiivisen dissonanssin vähentämisstrategioina. Kirkon tutkimuskeskus, Sarja C nro 39. Tampere 1991.

 Tuomainen R. Lääkäri ja maallikko medikalisaation paineissa. Suomen Lääkärilehti 1994:49:2363-2366.

 Tuomainen R, Hirvonen J, Martin M, Mönkkönen U. Lähikuva järjestäytyneestä syrjäytyneestä. Sosiaalinen Aikakauskirja 1990:5:16-20.

 Tuomainen R, Myllykangas M, Elo J. Medicalization: terveyden mielikuvin kohti menestystä. Sosiaalinen Aikakauskirja 1993:5:22-28.

 Vaskilampi T. Vaihtoehtoinen terveydenhuolto hyvinvointivaltion terveysmarkkinoilla. Jyväskylän yliopisto. Jyväskylä studies in education, psychology and social research 88. Jyväskylä 1992.

 Vaskilampi T. Vaihtoehtolääkinnän monet kasvot. Sosiaalilääketieteellinen Aikakauslehti 1984:21:145-148.

 Vaskilampi T, Elo J, Myllykangas M. Kansanlääkinnän ja luontaistuotteiden käyttö - tutkimus kuopiolaisista vaatetusalan naistyöntekijöistä. Sosiaalilääketieteellinen Aikakauslehti 1984:21:149-157.

 Vuori H. Lääketieteen historia. Gummerus, Jyväskylä 1979.

 Zola IK. Medicine as an institution of social control: the medicalizing of society. In Tuckett D, Kaufert JM (toim.). Basic readings in medical sociology. London 1978, p.254-260.

- The text in Finnish, sama suomeksi