Iarskaia-smirnova e

Iarskaia-Smirnova E., Romanov P. Culture matters: integration of folk medicine in health care in Russia, In: Ellen Kuhlmann and Mike Saks (eds) Rethinking professional governance: International directions in health care, Bristol: The Policy Press, 2008. P. 141-154 Culture matters: integration of folk medicine
in health care in Russia*
Elena Iarskaia-Smirnova and Pavel Romanov Introduction
The integration of complementary and alternative medicine (CAM) into orthodoxhealth care systems and the professionalisation of these services are global phenomena. These developments place new challenges onboth the governance of health care and the dominance of orthodox medicine (Saks, 2006). However, national governments and professional bodiesrespond in different ways to these new demands. Integration and professionalisation are driven by various forces and the success of new professionalprojects is uneven. This chapter explores the processes of integration of CAM into the official health care system in Russia. It places thedemand for, and supply of, 'folk medicine' in the context of fundamental political and cultural changes in Russian society; this includes tensionsand contradictions in the discourse of 'folk medicine' and the professionalisation of alternative medical practitioners.
We introduce an anthropological approach to the study of professions thathighlights the significance of culture and context. We explore the dynamics here to answer three main questions: What is the global context for theintegration of professional cultures in health care? What are the main cultural, economical and political conditions that shape the dynamics of relationsbetween CAM and orthodox medicine in Russia? What is the nature of contemporary collaboration between CAM practitioners and orthodoxdoctors? We draw on material from the research project on ‘The dynamics of social and professional status of traditional medicine specialists in Russia’,which builds upon a larger project funded by INTAS, the European Union Fund for Eastern European research (for details see Yurchenko andSaks, 2006). The research is based on a content analysis of popular medical periodicals over the last 15 years and qualitative interviews withCAM providers who practise different forms of ethno-treatment. Here we focus on the in-depth interviews with medically qualified and lay practitionersof CAM in the provincial city of Saratov.
The chapter starts by discussing the global dimensions of the integration of CAM with orthodox health care, arguing for cross-cultural sensitivity.
This is followed by an analysis of the integration of CAM services in the context of the changing Russian society and health care system. The findingsfrom our interviews highlight the flexibility of boundaries between doctors and healers and the diverse strategies of professionalisation in thecontext of Russian culture and market-driven transformations. Finally, some conclusions are drawn on culture as a resource for professionalisation.
Integration of diverse professional cultures: global dimensions and
local conditions
Scholarly debate highlights the pressures for more integrated health caresystems in different national contexts. Changes are driven by CAM users and specialists, by business and sometimes also by official medicine. Integrationmay appear in the shape of unification, incorporation or subordination of CAM practices to biomedically dominated health systems (Saks,2006). Integration may be furthered by occupational groups at the margins of biomedically centred health care systems that promote more flexiblemodels of professionalisation and the permeability of professional boundaries (see for instance, Hirschkorn and Bourgeault, 2005; Kelner et al,2006; Kuhlmann, 2006; Saks, this volume). However, it is not only the non-medically qualified groups, but also doctors and other health professionalswho may accelerate the ingress of CAM into health care systems, following market interests and pragmatic approaches (Saks, 2003; Shuval,1999). Existing research highlights highly diverse strategies and interests relating to the provision of CAM services and the professionalisation ofthese groups. For instance, CAM specialists may use potential of evidence- based practice and research in order to support arguments for theeffectiveness and efficacy of these services (Giordano et al, 2003; Lee- Treweek and Oerton, 2003), but they may also oppose an evidence-basedapproach to specific therapies as it challenges a more holistic approach.
The ‘incorporationist scenario’ (Saks, 2006) seems to be an outcome ofdifferent stakeholder arrangements and power relations in health care.
One key dimension that may lead to the success or failure of professionalisationis the state-profession relationship and the regulatory structure of health care systems (Kelner et al, 2004). In drawing on historical analysisand a comparison of Britain and the United States (US), Saks (2003, p 89) was able to demonstrate the significance of the “differential legal terms onwhich the exclusionary social closure of medicine was based”. His research revealed a more rapid move towards the integration of alternativemedicine in the US as compared to Britain (Saks, 2003). Accordingly, tighter regulation together with market driven interests may further the integrationof CAM practices.
Another important driver towards inclusion is consumer demand, although it does not necessarily translate into a 'public' interest. Kelner and colleagues(2004) assessed the views of Canadian government spokespersons on the efforts of CAM groups to take their place in the formal healthcare system. Their findings highlight tensions between the mandate of the state to protect the public and its obligation to respond to consumer demand(see also Saks, 2003). While expressing some sympathy with CAM, the interviews with governmental representatives nevertheless indicatedhesitation and caution (Kelner et al, 2004). Another example is in the US where many CAM services are not covered by health insurance, although they meet the needs and demands of patients (Vallerand et al, 2003). Inthese circumstances, integration is especially supported by the wealthier A third dimension that shapes patterns of integration, and the very conceptof CAM itself, is 'culture'. In Turkey, for instance, the CAM integration project conflicts with earlier modernisation policies that oppose longstandingforms of religious and political culture represented by traditional healers.
This has led to its marginalisation (Dole, 2004). In drawing on Asian medicineand acupuncture, Kim (2006) directs our attention towards the interaction between traditional medicine and science and introduces the notionof ‘transculturalism’ to grasp hybrid formations.
Globalisation shapes the provision, content and organisation of health care services. In particular, the introduction of internal markets and the politicsof evidence-based medicine and medical performance further the legitimation of certain types of services and the establishment of global standardsand rules of conduct for practitioners. For example, Tibetan medicine is widespread in Europe and North America. Although Tibetan medicine isproduced globally, it is consumed within a ‘local’ tradition (Janes, 2002).
This illustration highlights that globalisation cuts deeply into local contextsvia various flows of people, images, technologies and ideas; it enhances redefinitions of identity, suffering and corporeal practices among consumersand providers in different parts of the world. Mass consumption of local healing practices is structured by the laws of the global market, and at thesame time these practices may be locally produced and consumed.
We argue that there is a need for cross-cultural sensitivity in the study ofmedical practice, especially the use of knowledge about illness and treatment experiences shared by a patient and a practitioner (Seymour-Smith,1986). We can explore the cognitive and symbolic assessments of situations, symptoms and feelings that are linked to treatment practices. Wehave to acknowledge, however, that medicine of any type is also an ideological practice and the symbols of healing are the symbols of power.
The health care system in Russia: from monopoly to inclusion?
Classification of the types of medical systems suggested by Stepan (1985)
distinguishes monopolistic/exclusive, tolerant, mixed, inclusive and integratedmedical systems according to their openness to different healing practices. A typical example of an exclusive or monopolist system is theSoviet health care system where doctors were state servants employed by the Commissariat (later the Ministry) of Health, while all other groups ofhealers were banned in the USSR in 1923.
Although under socialism CAM "did not fit into modernized socialized medicine based on biomedical principles" (Yurchenko and Saks, 2006, p110), the interest in folk medical practices, especially herbal remedies, was noted in the history of Soviet medicine. In 1919, for instance, a laboratorywas established in Leningrad to study the healing properties of plants and herbs. The All-Soviet Chemical and Pharmaceutical Research Institute began systematic research into folk medicine in 1928 and, in1931, a special All-Soviet Research Institute of Herbs and Aromatic Herbs was established, which even operated experimental laboratories in theprovince.
Interest in Fitoterapiya (herbalism) greatly increased during World War II, the 'Great Patriotic War', due to the shortage of drugs and medical ser-vices (Kovaleva, 1972; Luria and Sarkisov, 1941). Herbs were collected with the help of schoolchildren and teachers and subsequently processedon an industrial scale. While lay healers continued to perform their work underground, official medicine’s interest in herbal treatment continued togrow. Pharmacies sold different kind of herbs and doctors often prescribed The rise of CAM as a means of political and cultural changeUnorthodox remedies and services started to become more widely popular in the early 1980s. Medical schools also started offering further qualificationcourses in manual therapy and reflex therapy. A medical counter culture emerged in Russia that mirrored earlier developments in Westernhealth systems (Yurchenko and Saks, 2006). The growth of CAM popularity was part of a process of liberation in Russia, and the sign of a new willingnessto end the mono-ideological system of knowledge and beliefs. Soviet power was on the wane throughout the 1980s and 1990s and crucialchanges took place in society, leading to the transformation of the planned economy into a market economy. The health care system was in crisis andscience, industry, technology and social services lagged far behind Western European countries. Soviet medicine was starved of resources, especiallyin rural areas (Yurchenko and Saks, 2006). In urban areas, patients were dissatisfied with health services and technologies and with the natureof communication with medical doctors. Queuing was a way of life at the health centres (polikliniki) and psychologists and social workers lacked thenecessary skills to assist people with diseases, traumas and other ailments In this climate of change, reports abounded in the mass media that eithervalidated or repudiated the beneficial effects of telekinesis, clairvoyance, astrology, psychic power, magic, and other similar services (Romanov andIarskaia-Smirnova, 2007). Towards the late 1980s and early 1990s numerous healers became national heroes by allegedly treating the wholepopulation through free and accessible television and radio performances that included hypnotism, brightening water and even ‘curative silences’.
Such 'miracles’ and 'heroes' served public demand well as a sort of ‘cargocult’ during a transitional period when the loss or painful revision of politicalideals caused feelings of uncertainty. According to Vein (1990) diverse political, cultural and social movements began to surface, views becamemore polarised and the interests of many people inclined to mysticism.
In 1996 the Ministry of Health of the Russian Federation – concerned withthe high risk of the mass hypnosis of the wider public – approved a statute to regulate non-traditional healing methods (Ministry of Health Care, 1996), thus putting an end to curative psychics’ television séances. The‘medical counter culture’, however, was socialised to some extent by the earlier efforts of Soviet health care authorities. Official medicine in SovietRussia had gradually opened up to CAM practices and methods, although the acknowledgement of CAM practitioners as legitimate agents of thehealth care system was still a matter of public concern and suspicion.
There were attempts to replace the various healers with medically qualifiedCAM specialists. Yurchenko and Saks (2006) highlight that the Ministry of Health was willing to protect the public from ‘quacks’; it was argued that“the supply of medically qualified doctors with knowledge of CAM therapies should be increased to the point where there would no longer be demandfor lay CAM therapists” (Karpeev, cited in Yurchenko and Saks, Culture: the symbolic and social capital of CAM practitionersMany lay folk healers oppose medical qualification per se, as it contradicts the nature of their 'symbolic capital'. Then, as now, folk healers see themselvesand their healing powers as part of a long tradition. This is reflected, for instance, in traditional Russian or exotic names - like ‘BabaAnia’ (Granny Ania) or ‘Iverona Sigismundovna’ - mysterious biographical facts and claims to have inherited a 'special gift', the leitmotiv in interviewswith folk healers (Iarskaia-Smirnova and Grigorieva, 2006). The concept of professionalisation, generally perceived hitherto as a means to obtain‘ranking signs’, such as diplomas, theoretical knowledge, status and higher wages, is reconsidered here in the context of the contradictions of the folkurbansymbolic continuum. Notably, some of the medically qualified CAM specialists emphasised their modern and 'rational' qualifications and, atthe same time, legitimised their choice of practice through the roots of their family trees and socialisation - for example, growing up in a certain, usually‘oriental’, ethnic community.
An official discourse has stressed that medical diplomas are important indicators of 'real’ doctors as opposed to ‘quacks’ (Serebriakov, 2000, p 35).
However, the discourse often falls short of reality (Yurchenko and Saks, "There are no good or bad, right or wrong methods. There are onlygood or bad doctors. There are more than enough frauds that have got their diploma and are working in medicine." (Acupuncture specialist) In 1993 a legal framework for regulating CAM services was established.
This law "proclaimed that only medically qualified doctors who received state registration could practise CAM therapies. Only one group of laypractitioners was exempt, namely officially termed ‘folk healers’ who could prove that they had a special gift for healing” (Yurchenko and Saks, 2006,p 113). The healers, too, in order to get the right to work in the area of ‘folk medicine (healing)’ have to obtain an official certificate and go through theauthority’s licensing procedures.
The debate on ‘non-traditional’ medicine was at the top of the agenda duringthe 1990s. However, at the turn of the twenty-first century Russian popular-scientific medical journals reported irregular renewal of, and evenfalling, interest in folk medicine (Iarskaia-Smirnova and Grigorieva, 2006).
It is interesting to note here that the contemporary Russian medical discourseruns counter to international developments. For instance, in 2002 the World Health Organisation established the first global strategy aimedat the integration of traditional and alternative medicine (Holliday, 2003).
By the late 1990s the ‘industry of sorcery’ had lost its democratic missionary nature and become selectively available to different socialclasses of consumers. It was possible to find not only such figures as a neighbourhood fortune-teller or healer from the free-ads newspaper, butalso ‘corporate magicians’ – exclusive herbalists with exotic diplomas working in parlours known to only a small circle of the initiated. The fashionamong the political and celebrity elite thereby enabled some healers to successfully turn their symbolic capital into market power.
Demand and supply: drivers towards inclusion of CAM servicesWhile CAM providers use the media to promote their interests (see Valente, 2003, for developments in Canada), orthodox doctors make use oftheir power to shape the official discourse. They predict a limited demand for folk medicine and attempt to link the provision of CAM to specific ethnicand cultural groups and/or mentally ill people, effectively reducing demand.
In contrast to this, however, the INTAS project data reveal that upto half medical doctors working in state or municipal health services also practise CAM. Their motives for doing so are diverse, but include "easingthe workload for problems that orthodox medicine cannot solve" (Yurchenko and Saks, 2006, pp 122-3). Financial motives also play a part,as CAM services are in demand among more affluent clients, but are not included on the list of Obligatory Medical Insurance Law. Patients have topay for these services themselves and, in addition, providers do not need expensive equipment and can even see patients at home.
However, doctors practising CAM are not only following their own particularinterests, they are also responding to public demand. They are in an emerging labour market for medical professionals and take part in the newmarketing strategies of pharmaceutical companies. Within the group of CAM practitioners, manual therapists, herbal therapists, homoeopaths andhealers are most actively engaged in private practice. According to our interviewees, private practice can take the form of office-based specialists,specialists at a private hospital or a state medical institution, or by offering home visits with or without a license.
Survey data from 1,500 respondents in 44 Russian regions confirm thedemand for CAM services: in 2002 every fourth Russian citizen consulted CAM specialists, although only nine percent said they trusted them morethan those practising orthodox medicine (Fund of Public Opinion, 2002).
However, the wording of the question in this survey may have heavily shaped the responses: ‘Have you or have you not appealed to the servicesof non-traditional medicine (folk healers, herbalists [travnikov], psychics, etc.)?’ The illustrations given of the category ‘non-traditional medicine’represent the most contested areas and less ‘scientific’ and ‘rational’ forms of 'non-traditional medicine'. Moreover, the word ‘travnik’ was usedto define a herbalist instead of ‘fitoterapevt’. Consequently, the list of practitioners is exclusively associated with backwardness and irrationality andmay well have skewed the answers. Interestingly, this report is published on the Fund of Public Opinion website under the rubric of ‘mysticism’.
A broader range of 'non-traditional medicine' and less stereotyped categorieswas used in another survey of 1,004 respondents in St Petersburg (Goryunov and Khlopushin, 2005). This survey revealed an overall higherdemand for CAM services, which were defined as ‘manual therapy, herbal treatment, acupuncture, bioenergetics and natural healing methods’. 73percent said they had consulted a CAM specialist at least once, with manual therapy and herbal therapy the most frequent. These services wereseven to ten times more popular than acupuncture, bioenergetics and spiritual healing. The preferences may be the result of the cultural identityof the consumers and also mirror the supply of CAM services. According to the INTAS data on 604 medical practitioners from three different regionsof Russia, the most popular forms of CAM among the medically qualified were herbalism (51 percent), homoeopathy (28 percent) and acupuncture(13 percent), while the least popular method was healing that was practised by only 3 percent of medical practitioners (Yurchenko and Saks,2006).
Users of folk medicine have different motives, depending on their level of income. More wealthy consumers emphasise the specific nature of thehealer-patient relationship, while the less affluent say they choose CAM because it is cheap, but offers healing remedies. Rich people are more inclinedto follow prestigious consumption practices by having their own personal healer or a ‘famous sorcerer‘; such practices are increasing, especiallyin show business and similar circles. We can conclude that the provision of CAM services is driven by both demand and supply led changes.
The following section further explores the latter.
Pathways to integration: flexible professional strategies and the significance
of culture
Qualitative interviews with medically qualified CAM specialists provide
deeper insights into professional interests and power relations that influencethe integration of CAM services in the provision of health care. The interviews take into account the different organisational forms of providingCAM services; six participants in the study worked in state and municipal health centres, one in a medical department of an industrial enterprise andthe others in private settings.
One important finding was that most of the interviewees did not like to be called ‘non-traditional’ doctors; they perceived this label as derogatory and saw it as representing an attempt to separate them from the mainstreamof the Russian health care system. They criticised the division of treatments and healing approaches as a social construction and called for theintegration of different perspectives: "The term 'alternative medicine' depends on one’s point of view. If we speak about a patient, there is no ‘alternative’ or ‘not alternative’ medicine.
In the first place doctors have to help a patient. And we have to decide whether to use bees, to beat the drum and to conjure out evilspirits or give aspirin for headache. Irrespective of what will help, it is the result that matters. 'Folk medicine'? I don’t know who has differen-tiated between these terms! … How can we distinguish them? All the terms and classifications are context dependent." (Manual therapist)CAM practitioners criticised the building of barriers between disciplines, professions and approaches in order to divide power and resources. At thesame time, they stressed the differences between alternative and orthodox medicine. The interviewees stated that - in contrast to orthodox medicalpractitioners - diagnostic procedures are more accurate and they have more time to talk to patients. Apart from this, CAM practitioners stressedtheir holistic vision of 'do not just treat but cure' and paying attention to the patient’s body and soul. They also stressed their distinct cultural identity,but claimed that they had a general commitment to medical ethics: "Ethics of doctor-patient relations must be upheld whatever methods one uses"(Manual therapist). At the same time, economic aspects interface with this 'moral space' and can result in different qualities of service: "A personcomes here and pays money. Thus, one can treat medicine like a product and in this case it can be of high or low quality" (Hirudo therapist).
Unorthodox remedies and services were not necessarily cheaper thanbiomedical therapies. As Russia was entering a global market in the early 1990s commercial networks, like Herbalife, entered the market. Somemedical doctors, who might have sincerely believed in the value of herbs, actively promoted such networks. However, their 'altruistic mission' couldbe questioned as these doctors benefited from financial rewards from these networks. Even today, medical doctors working at health centresand clinics are involved in the advertising and dissemination of specific CAM products. Some are even part-time employees of the companieswhose products they recommend and prescribe to their patients.
CAM specialists refer to culture and ethnicity in order to gain the trust ofconsumers and assure a high quality of service; one example is the ethnic Korean specialists who represent an Oriental school of reflex therapy. Thefindings of the qualitative interviews highlight how market conditions and cultural identity are merged into a specific strategy to promote professionalinterests.
CAM and orthodox doctors: signs of integration and collaboration Relationships between CAM and orthodox doctors vary from acknowledgementand respect to conflict and scepticism, with a prevalence of the latter attitude. The widespread personal and professional prejudice of orthodox doctors towards CAM hampers potential successful integration.
Negative attitudes are supported by fears of “being accused of placing extra financial burdens on the patient” and a doctor "sometimes finds it easierto send a patient to a public service" (Manual therapist). Despite the overall suspicion on the side of orthodox medicine, some of our intervieweesnoted that doctors of various specialties refer their patients to them.
However, as one therapist said, many "people come from polyclinics witha clear diagnosis but without any referral, just on their own" (Herbalist).
The attitudes of orthodox doctors towards CAM differ from one setting toanother and depend on many circumstances. Important predictors for the integration of CAM are the relationships within one institution and mutualcooperation between different specialists. A herbalist explained: "People come to my office from neuropathologists, gastroenterologists,allergists, paediatrics. In this polyclinic it is the official way. I write down my treatment method on their medical card. … I guess a friendly attitudeis the main thing here. I think it’s collaboration and trust. … Among the patients there are many doctors and their children. Theyare interested in the result, they continue visiting me. They show their interest, ask questions, they want to read something on the topic becauseit’s new to them." (Herbalist) Some signs are emerging that point towards an increasing integration of CAM services; for instance, phone calls from polyclinics "that have nospecialists in acupuncture, and they just ask if it’s possible to refer [a patient]" (Reflex therapist). Medical students and doctors doing courses incentres of non-traditional medicine and later referring their patients to that centre are another example of a change: "Certainly, it happens but usuallythese are the doctors who did a course in these centres" (Healer). A further sign of a change in attitude is represented by private health centreswhich integrate CAM services in order to offer comprehensive medical Integration of CAM services and collaboration between orthodox and 'nontraditional'doctors provide a number of benefits, but 'boundary work' and conflicting professional interests persist. According to one acupuncturespecialist, despite signs of change orthodox doctors continue to distrust "In my opinion we have reached a step in the development of medicinewhen the merger of traditional and non-traditional medicine is necessary.
But I don’t know how much time it will take. . Official medicineand people who are at its head do not turn to us." (Reflex therapist) According to a one CAM practitioner, "conflicts already lie in the past but collaboration is still in the future" (Homoeopath), although herbal, hirudoand apio therapists stated that they generally had good relations with official In times of modernisation the health system’s tolerance to natural products is not only related to tradition. It is also advanced by new patterns of preventivemedicine that include unorthodox remedies. It is important to emphasise here that the market economy supports these kinds of CAM servicesin the Russian health system; wealthy consumers often use these services for the prestigious consumption of wellness, fitness and beautyservices. Another driving force, however, is the limitations of orthodox medicine, especially in the field of chronic illnesses. Different market conditionsand professional interests thus shape the various pathways towards Contextualising integration: diversity of professional interests and marketconditions Within the group of CAM providers, healers seem to be the most isolatedgroup. One major area of conflict is the lack of evidence for their activities: "One does not know what it is. . there is some concern, gossip abounds,rumours about this, arguments for and against…" (Healer). Overall, the healers were not satisfied with the level of collaboration with official doctors;they noted the lack of contact, mistrust, and ignorance of their practice and methods - even in the face of evidence of success. Collaborationdepended on context and personal contacts and was usually limited to one In contrast, manual therapists were more optimistic about the future andstressed the importance of professionalisation and increasing integration.
The number of professionals in this area is on the increase; and manualtherapy gained legal recognition and was officially included in the list of "The hardest things are in the past, I mean when a great number ofnon-specialists harmed many people, when manual therapy was not included in the list of medical specialties and everybody did what theywanted. Now we face a rapid development, collaboration with various related areas of medicine, … fundamental research techniques, colleaguesthat share their experience without concern and prejudice.’ Homoeopathy shows yet another configuration of drivers, and barriers, tointegration. Most importantly, homoeopathy clashes with the interests of global pharmaceutical corporations and the provision of very cheap treatmentoptions goes against the business interests of these companies.
The strategies and opportunities are highly diverse but in general CAMpractitioners are keen to believe they can compete with official doctors.
This confidence was initially nurtured by an awareness of the deficits of orthodox medicine: treatment at state institutions is seldom of high qualityand the situation is aggravated by red tape and sometimes rudeness. Participants in our study were also well aware that CAM methods are acknowledgedand widely applied in the Western world. They believe that developments in Russia will follow these pathways and a growing interest in CAM services will emerge by 'enlightening' people via the mass mediaand medical education.
Culture, integration and professional power relations
This chapter has explored the integration of 'folk medicine' into the Russianhealth care system in the context of the political, economic and social transformation of Russian society. We have introduced an anthropologicalapproach and emphasised the notion of culture. The findings reveal that integration is a continuing process driven by various players and interests,as well as by global and local conditions. However, culture provides a 'reference point' for both the users and the providers of services. Within theconfiguration of demand and supply led changes – and professional, gov- ernmental and public interests – culture gives CAM services legitimation and may thus serve to facilitate integration in the health care system. Ourfindings indicate that collaboration between orthodox and alternative medicine and the different groups of providers is largely on the increase. At thesame time, 'boundary work' needs to be undertaken and attempts to monopolise power and resources have not yet been overcome.
One novel aspect, however, is that boundaries are becoming more fluid,the strategies of professionalisation more flexible and resources for constructing professional identity more diverse. Identity is not only based onan orthodox academic community, but also on experiences in a number of different professional and institutional settings. Furthermore, the successand failure of professional services and their legitimacy depend on various conditions, in particular: successful advertising, market conditions anddemand from, and satisfaction of, the target group. The majority of CAM services in Russia are commercial and can be offered in self-sustaineddepartments of state medical institutions or in the private sector. In this situation, different strategies for advancing new professional projects arecombined that are often perceived as contradictory to successful professionalisation.
Our findings highlight classic elements of professionalism(state regulation, academic community and professional identity), market logic (advertising, market conditions and user satisfaction), and cultureused as ‘social capital’. In this respect, the research provides another example of differing pathways towards professionalisation. Developments inRussia partially mirror the strategies of CAM providers observed in Western health systems (Kelner et al, 2006; Saks, 2003) and, more generally,of new professional groups operating at the margins of health care systems Culture furnishes health care providers with 'social capital' that may evenbe transformed into market power (economic capital). However, CAM providers are part of a social, political and economic power system that promotesbiomedical approaches. Representatives of orthodox doctors and administrators of health care organisations express their 'neutrality' andtolerance towards collaboration between traditional and non-traditional specialists; health centres employ medically qualified and certified CAM specialists, and say there is no sound reason to ban holistic approaches.
However, acknowledgement of CAM and its integration has still to be fully achieved, and CAM providers are marginalised in some areas. Most effectivecollaboration is developed within organisational settings – usually private health centres – that offer a combination of orthodox medicine andCAM services at every stage of treatment and rehabilitation.
In conclusion, professional groups use resources like culture and develop new strategies to professionalise; a 'public interest' in these services andimproved collaboration with orthodox health care providers facilitates inclusion in the health care system. However, CAM specialists continue tobe 'unequal partners' in a health system governed by biomedicine. Orthodox doctors may refer to CAM specialists as ‘colleagues’ but nontraditionalmedicine is characterised as ‘grandma’s methods’. This reflects the subordination of CAM services and their control by orthodox doctorsand health care authorities. Consequently, culture may turn out to be a highly ambiguous resource for the inclusion of CAM services and even afacilitator of the 'incorporationist scenario' for biomedicine (Saks, 2006).
* The project is funded by the Russian Foundation for Humanities and supervisedby Professor Valery Mansurov from the Russian Academy of Sciences, Moscow. The material was gathered from 2005 to 2006 in Moscow,Saratov, Balashov and Syktyvkar. The interviews in Saratov were conducted by the authors and other sociologists at the Centre of SocialPolicy and Gender Studies. Particular thanks go to Olga Grigorieva, Natalia Lovtsova, Galina Teper and Tatiana Samarskaya for their valuablehelp with data collection.
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