Leslie Solomonian,1 ND, MPH, Bethany Osborne,2 PhD
ABSTRACT
The premise and attrition model of resistance proposed by some in the anti-psychiatry movement are relevant to all subspecialties of medicine. Themes of monopolization, capitalization and marginalization harmfully affect the delivery of health care across all domains and minimize systemic and structural contributors to health and disease. Naturopathic medicine offers promise to effectively support individuals and communities in navigating modern obstacles to good health but may, in practice, be inadvertently reinforcing the dominant paradigm. The attrition model offers guidance for a steady, strategic resistance instead.
Key Words Integrative medicine, social and ecological determinants of health
The anti-psychiatry movement posits that the modern medical paradigm has harmfully pathologized diverse emotional and cognitive experiences of the world, simultaneously monopolizing the field of mental health.1 What is pathologized as mental disease may be an attempt by the human brain to cope within a deeply wounded social and ecological environment.2
The tendency of the dominant medical model to reduce disease to parts and separate individual health from the environment is not unique to the field of psychiatry. Almost all medical disciplines tend to pathologize the individual, rather than seeing signs and symptoms as a body’s struggle to respond to unhealthy social and ecological influences in an attempt to survive.3,4 Human DNA, and the cells, tissues, organs and body systems commanded by its code, evolved to anticipate certain conditions for optimal health. When the environment does not provide these conditions, the body and mind activate complex mechanisms to adapt to the perceived threat,5 manifesting as “disease.”
The principles and practice of naturopathic medicine honour this complex holism of human health, its dependence upon ideal conditions, and its efforts to adapt to less-than-optimal circumstances. However, the profession arguably struggles to play a more meaningful role in the healthcare sector amidst the hegemony of the biomedical paradigm, a dominance which is reinforced by oppressive social, political, and economic systems. The naturopathic profession is not immune to these forces and may in fact be reinforcing them through its own efforts to legitimize.
The attrition model was first described by those involved in the movement for prison abolition and later applied to members of the anti-psychiatry movement, notably Bonnie Burstow.1 Advocates of attrition argue that a feasible approach to challenging or reforming a dominant system is a process of wearing down or chipping away. Guiding questions can provide direction for thoughtful tactical planning towards a long-term goal:1
If successful, will the actions or campaigns that we are contemplating move us closer to the long-range goal of [reformation]?
Are they likely to avoid improving or giving added legitimacy to the current system?
Do they avoid “widening” the net [of the dominant system]?
We argue that, despite the promise of naturopathic medicine to address the current gaps in the healthcare system, efforts by the naturopathic profession have mostly served to reinforce the dominance of the biomedical paradigm as opposed to effectively challenging it. The naturopathic profession would do well to look to the framework of attrition to anchor strategies of advocacy and avoid perpetuating dominant systems.
The dominant Western “health” system is coloured by capitalistic, objectivist, Eurocentric worldviews that place profit ahead of the health or well-being of people or the planet.6–9 The history of institutionalization of “madness,” in particular, runs closely parallel to systems of colonization and incarceration for the purpose of control.10,11 These same forces underpin the evolution of modern medicine in the form of abhorrent experimentation on racialized, enslaved, and incarcerated individuals.12–14 Colonization, genocide, and ecosystem destruction have also resulted in catastrophic loss of ecological memory and traditional knowledge.15,16 In the end, this loss harms all who share the planet.
Although this machinery has been in motion for centuries, the Flexner Report grounded North American medical training in North America in a reductionistic, biomedical paradigm, effectively excluding other models.9,17,18 The rise of pharmaceutical medicine in the mid-20th century informed the ways in which Canada’s publicly funded healthcare system was first designed. The priority was ensuring that all Canadians had access to both hospital care and the substances required to address the leading causes of morbidity and mortality at that time. The vision for universal health care was never intended to stop there and remains limited to a small sphere of regulated healthcare providers.19 Since then, shifting social and ecological determinants of health have led to a tsunami of non-communicable chronic diseases for which psychophysiological mechanisms well adapted to the conditions in which the human genome evolved are less helpful.20,21 In a publicly funded system limited by finite resources and radically rising costs of health care, medical doctors must restrict time spent with individuals in order to serve more patients, significantly limiting the ability to practice patient-centred care.22
While the approach typical of the biomedical paradigm—even the biopsychosocial paradigm—can be lifesaving, it fails to address underlying causes of illness. The model of medicine that came to be in the first half of the 20th century is neither a cost-effective nor efficacious approach to these concerns; the dominant medical system was not designed to deal with them and contributes directly to the drivers that created them.9,23 When so many resources are poured onto the worsening fires of planetary, community, and individual health, little remains to expand or reform the public health system to better prevent or mitigate them, even if the will was there, by those who hold power (see above).24 (Some domains of dominant health systems, particularly nursing and the specialization of family and community medicine, acknowledge this.25 Many publicly-funded healthcare providers are active and vocal advocates for structural change.)
Naturopathic medicine and other holistic paradigms are arguably better equipped to manage the dynamic complexity of individual health26,27 but have been systematically marginalized.9,27 Forces of global capitalist systems and Eurocentric ways of knowing bias medical scholarship and unduly influence disease management to the benefit of few and significant detriment of most.28–31 The lobby power of philanthropists and pharmaceutical companies unduly sway health policy and practice.32–34 While members of other health professions may be partially funded through socialist mechanisms, most are reliant on private enterprise. This inherently makes their commodified services inaccessible to many, or deprioritized in a system in which health care is perceived as “free,” or dismissed as “alternative” at best and “quackery” at worst (see https://en.wikipedia.org/wiki/Naturopathy as a very public example). Consumers of privately provided healthcare services such as naturopathic medicine tend to sit in the upper strata of income and education, paying out-of-pocket, or using extended health benefits from employment.
This tiered system presents a harm of omission, denying others choice, and the opportunity for informed consent in health care,35 and is a contributor to the complex mechanisms by which poverty predicts poor health.36 It forces most people into the biomedical system, which has myriad consequences, including denial of care for those who do not meet the necessary criteria for a pathology,37 stigmatization through pathologization of a normal state of being, disempowerment when told that healing lies solely within the biomedical domain or that a treatment does not exist at all. Those who only have access to dominant approaches such as pharmaceutical or surgical treatments also experience harms of commission when they suffer from unmitigated adverse effects. This is particularly true if a system only values “disease-oriented” as opposed to “patient-oriented” outcomes.38
Naturopathic medicine is not innocent of the hegemony inherent in the dominant biomedical model, nor is it immune to tainting by the same themes of white supremacy and neoliberalism. The current framework of naturopathic medicine emerged from a Eurocentric origin, and has built itself through misappropriation and colonization of healing traditions from around the world.39 Efforts to regulate naturopathic medicine make entry inaccessible to many due to educational and economic barriers, most notably members of marginalized communities from which many practices have been co-opted.40,41 This also marginalizes and stigmatizes non-regulated traditional healers,42 with dire consequences when the disregard for non-Eurocentric epistemologies in which these paradigms are rooted threaten planetary health overall.4,43
Efforts to meet mainstream standards of medical education and healthcare delivery in an attempt to demonstrate the profession’s credibility perpetuate the biases that underpin the dominant paradigm. The construction of the system of modern medicine has been actively reliant on racism, misogyny, classism, heterocisnormativity, and genocide that caused and continue to cause devastating pain and suffering.44 From the “Tuskegee Study of Untreated Syphilis,” which withheld treatment from African American men to observe the natural progression of syphilis,45 to the systematic exclusion of women from clinical trials,46 to horrific nutritional experimentation on Indigenous children in residential schools,47 to the pathologization of non-heterocisnormative sexual behaviour,48 harm continues to reverberate through interpersonal and generational transmission of trauma and deeply embedded implicit and explicit bias resulting in systemic inequity across all of society, including medical training and healthcare delivery—naturopathic too.49,50
Yielding to pressure to prove that naturopathic medicine is evidence-based according to dominant standards—which are biased by forces of reductionism and capitalism—risks minimizing the complexity of health and disease that naturopathic medicine claims to honour.51,52 Success at generating acceptable evidence not only reinforces dominant paradigms, it empowers co-optation of these approaches in the form of the subspecialty of “integrative medicine.”42,53
Due to the exclusion of naturopathic medicine from many collectivist insurance schemes, the cost of training demanded by regulatory standards, and the increasingly high cost of living, business training is a core element of naturopathic training to ensure that graduates are entrepreneurially competent. This can stray towards a mercenary approach.54 Botanical and nutritional approaches are not immune to the siren call of the “natural health product” industry, such as the nutriceutical portfolio acquired by Nestle,55 reducing systems of medicine to a commodified resource which not only introduces a conflict of interest but may also increase the risk of harm to both individuals56 and the environment.57 The emphasis on the use of for-profit laboratory investigations in the name of individualized or holistic health risks legitimizing a biomedical approach. Judging the success of doctors by the economic health of their business runs counter to the urgently essential role of the healthcare system in stewarding the health of the planet.58
The “therapeutic order” is a framework by which naturopathic principles can be integrated and applied to assess and manage health concerns, typically at an individual level and from a pluralistic perspective.59 Truly seeking root cause and treating the whole, however, requires a broader perspective when we consider how much of individual health is impacted by social and ecological determinants.60 Deeply embedded factors such as behavioural norms, economic circumstances, educational opportunity, and access to blue and green space have far more influence on individual health—even behavioural “choices”—than most naturopathic doctors (NDs) tend to acknowledge, placing a significant emphasis on docere and the onus for health on the individual. This tendency is rooted squarely among the meritocratic and individualistic values on which capitalism relies.61
Colonizing, controlling, commodifying, and individualizing naturopathic medicine perpetuates the problems within the dominant structures, as opposed to wearing them down.
We argue that efforts by the naturopathic profession to legitimize itself have mostly served to reinforce the dominance of the biomedical paradigm as opposed to challenging it and propose some reflections on a different approach. The attrition framework lends shape to a long-term goal of deconstructing a powerful system, such as the dominant medical institution. A particular tactic is unwise if it does not effectively serve to achieve this goal, particularly if it serves to reinforce hegemony.
Diversity is recognized as beneficial to the resilience and health of systems,62 from ecological to cultural.16 “Mad Pride,” as a part of the broader anti-psychiatry movement, encourages a celebration of diversity as opposed to categorization and pathologization.63 Rather than attempting to demonstrate that naturopathic training is legitimate because of the ways in which it is similar to conventional training, we recommend a celebration and elevation of diverse and non-reductionist approaches. We encourage members of the naturopathic profession (and other non-dominant healing paradigms) to unapologetically embrace and claim their distinct way of being in the world, challenging the dominant framework as opposed to contorting in an attempt to fit it.
Countering the racist, colonialist, and patriarchal foundation of modern health care requires naturopathic institutions to critically acknowledge the profession’s roots in the same soil and take meaningful action to make reparations. This includes a centring of anti-oppression, social justice, and planetary health in core naturopathic curriculum, not just in the form of adding graduate competencies, but equally in program design and delivery.64,65 It requires an active integration of and commensurate compensation for the traditional knowledge systems that provide context for the medicines on which the profession relies in order to use them without misappropriation. This may also require us to humbly relinquish the use of some altogether.
Eurocentric approaches to knowledge must be actively questioned instead of blindly accepted as truth.66 This requires a critical analysis of what we mean by and how we teach, generate, and apply “evidence” and directly name and interrupt the violence of epistemicide,67 defined by Patin et al. as the “killing, silencing, annihilation, or devaluing of a knowledge system.”68
The profession must resist the pressure from dominant systems to adhere only to a biophysical view of life. Vitalism is a philosophy of health that has deeply informed the evolution of naturopathic medicine and parallels other healing traditions that recognize a life force beyond the biochemical.69 We encourage the profession to continue to defer to the healing power of nature, the force that links all parts of the interdependent web of life on this planet and presses toward homeostasis at all levels if not interfered with.70,71
Part of the challenge with centring concepts of vitalism in naturopathic practice is that it is difficult to measure using standard research methodologies that seek to reduce variables to their simplest components. Some within the naturopathic profession are engaging in “whole-systems” research, which achieves acceptable standards of evidence while upholding a holistic model of care.72 If paired with cost–benefit analyses, positive results may interest those that manage budgets. Emphasizing patient-oriented outcomes in research is also a way of understanding the effects of naturopathic practice.73 Patient-centred models are also essential in training and practice as a fundamental domain of evidence-informed practice.74,74 Naturopathic doctors must continue to see patients as people first, avoiding the temptation to specialize in diseases, as current approaches to training and practice can do.
Naturopathic doctors deserve to be adequately compensated for their time and expertise. However, a transactional model of health care introduces an unavoidable conflict of interest, shifting the role of provider towards entrepreneurship as opposed to that of providing a service to society.76 Some NDs enjoy funded positions that allow for the provision of integrative care (although many are still for-profit organizations, such as the Cancer Treatment Centers of America). Some have established practice models that increase access to naturopathic care. We encourage educational institutions and professional associations to build capacity in social innovation and to nurture relationships that allow for a more equitable model of care provision,77 as well as knowledge generation and translation.78 Expanding public funding to include NDs and other allied professionals may increase access to health care, but it risks further diluting resources and forcing a reductionistic and reactive approach, compromising the model of care on which naturopathic medicine is based. Thus, any solution in this domain must involve radical interrogation and reconstruction of deeply embedded social and economic systems in order to effectively address and mitigate the fundamental causes of disease, domains that may or may not be traditionally viewed as health-related. This includes but is not limited to a reworking of the system by which health care is provided and compensated,79 investment in early childhood education,80 overhaul of food supply systems,81 healthier urban design,82 and an overall multidisciplinary implementation of strategies to propel towards an ecological civilization that seeks to operate within (rather than be superior to) the laws of nature.83
This is a massive task that requires skills of effective advocacy. More NDs are seeking credentials and positions in public health, policy, and academia. Advocating for holism within dominant systems has the potential to shift policy. An ND was instrumental in creating the most recent iteration of the Canada Food Guide.84 Representatives from the naturopathic profession have sat on the Natural Health Products Advisory committee. Naturopathic doctors also feature prominently in the conversation about elevating principles of planetary health,85 and they hold public office.
While change from within is critical, NDs who sit outside the walls of power are also encouraged to engage in coordinated advocacy to shift dominant systems, including partnering publicly with other movements pushing for social and ecological change. Naturopathic doctors can disseminate knowledge by writing for and speaking to audiences outside the profession as a means to challenge dominant narratives and elevate naturopathic philosophy in common awareness. Advocacy efforts can also include galvanizing members of the public to push for electoral reform, aggressive climate action, and social changes that improve health. Direct action such as becoming involved in community gardens or other grassroots initiatives fulfill naturopathic principles while creating alternatives to the dominant structure.
We don’t pretend that these recommendations aren’t daunting, or potentially risky. Facing a formidable and powerful structure with courage and tenacity is the spirit of the attrition framework. “Backcasting” is a strategic approach that “is particularly helpful when problems at hand are complex and when present trends are part of the problems.”86 This dovetails nicely with the principles of the attrition model in that it requires one to envision the ultimate goal, and determine what tactics are necessary to arrive at that goal. We encourage those within the profession—whether in a leadership role, or individual practitioners—to ponder the following questions when considering how best to advocate for or from within the profession:
How is the biomedical model of health care limited in the face of current global determinants of health?
Given the increasing threat of planetary breakdown and escalating global inequity, how must the healthcare system evolve in order to optimally support population health?
What will the consequences be for individuals and communities if responsive changes are not implemented?
What are the underlying values of an ideal healthcare system? How does that look?
In what way do the paradigm and principles of naturopathic medicine (and other non-dominant systems) intersect with these values?
The attrition model provides guidance for applying strategic pressure to a dominant structure, seeking to challenge and erode it over time. We argue that the naturopathic profession—in attempting to legitimize its place—has thus far failed to challenge the dominant system. Rather, efforts have served to perpetuate its premises, and widen its hegemonic net.
We propose that a multidisciplinary and holistic approach, appropriate reliance on evidence, and genuinely informed consent requires that power structures be challenged to create space for and universal access to approaches other than an exclusively biomedical one. This requires deliberate integration of diverse epistemologies of medicine, decolonizing medical education, prioritization of lifestyle medicine and the principles of planetary health, and more effective structures to integrate care. Naturopathic medicine holds great promise in these domains, but only if this end goal is held in mind and not undermined.
Opportunities exist through naturopathic education, scholarship, clinical practice, and advocacy to erode the dominant model of health care and reshape it into an integrative system that draws from many diverse healing traditions and ways of knowing. At its core, this requires a deep questioning and humble profession-wide reflection of the origins of and influences on the naturopathic approach, and a willingness to radically critique the way in which the naturopathic profession contorts to and perpetuates the colonial and capitalistic foundations of the dominant system. We encourage naturopathic doctors and all champions of non-dominant healing paradigms to have confidence and pride in the ways in which diversity tends to make all things better, and to remain grounded in the goals and guiding questions of the attrition model.
1Canadian College of Naturopathic Medicine, Toronto, ON, Canada;
2Ontario Institute for Studies in Education, University of Toronto, Toronto, ON, Canada; currently Program Coordinator and Professor, Bachelor of Social and Community Development, Sheridan College, Hamilton, ON, Canada.
We acknowledge the many colleagues with whom we have discussed and shaped these ideas over the years.
The authors have no conflicts of interest to declare.
This research did not receive any funding.
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Correspondence to: Leslie Solomonian, 152 Manor Rd. East, Toronto, ON M4S 1R6, Canada. E-mail: lsolomonian@ccnm.edu
To cite: Solomonian L, Osborne B. Applying the attrition model to the medical system: a critique of the current resistance by the naturopathic profession in Canada to the dominant paradigm. CAND Journal. 2023;30(3):17-22. https://doi.org/10.54434/candj.139
Received: 15 Mar 2023; Accepted: 14 August 2023; Published: 28 September 2023
© 2023 Canadian Association of Naturopathic Doctors. For permissions, please contact candj@cand.ca.
CAND Journal | Volume 30, No. 3, September 2023