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Abstract

Regulation of traditional acupuncturists has proven controversial in several jurisdictions. In this work, we detail and analyze the range of English-language registration, practice, and record-keeping requirements for regulated traditional acupuncturists across Canada, the United States, and Australia. Drawing on the results of an extensive documentary review and 28 qualitative interviews, we identify five primary themes underpinning policy-related discourses and debate: patient safety; standardized, integrated health care systems; economic considerations; traditional knowledge protection; and culturally inclusive care delivery. We critically examine these policy discourses, positioning them within a broader literature related to language policies in multiculturalist states and considering their relevance to the question of traditional medicine professional regulation in diaspora. With reference to the principle of regulatory equity, and to the concept of a pluralistic public, we present a set of recommendations for traditional medicine regulators contending simultaneously with clinical and cultural considerations.

Keywords

traditional medicine medical pluralism language policy equity acupuncture

Introduction

Medical pluralism, in which multiple “differentially designed and conceived medical systems” co-exist in a single culture or state (Janzen, 1978, p. xviii), is increasingly the norm worldwide (Frankel & Lewis, 1989). Global migrations have resulted in the “export” of many traditional medicine (TM) systems and practices into a diverse diaspora outside of their nations of origin. Immigrant influxes between global South states and the global North (Cant & Sharma, 1999; Jennings, 2005) have brought “both a demand for, and, crucially, practitioners of a range of alternatives to biomedicine” (Green, Bradby, Chan, & Lee, 2006, p. 1499). Originating in the indigenous medicine systems of Eastern Asia, acupuncture is a health care practice that exemplifies the TM diaspora phenomenon. Although acupuncture remains in widespread use across its geographies of origin (Hsu, 1999; Scheid, 2002; Unschuld, 1992), it is practiced today in 80% of nations worldwide and regulated in 29 countries (World Health Organization [WHO], 2014).

A considerable body of scholarship (e.g., Albert, Nongrum, Webb, Porter, & Kharkongor, 2015; Prasad, 2007; Sussman, 1981; Zhang, 2007) has examined the dynamics surrounding medical pluralism in many global South states, where indigenous TM medicine systems remain predominant (and often state-regulated) forms of health care. Although such accounts are diverse, reflecting the range of global contexts, biomedicine’s epistemic and political dominance in relation to TM systems and practices is a common theme across them. As Zhang (2007) has noted, “[m]edical pluralism . . . is a site of contestation and struggle” (p. 83). Khan (2006) has asserted a “need to go beyond the liberal pluralist tendencies” that have previously dominated scholarly discussion around medical pluralism and instead engage more critically with issues of “power, domination and hegemony” by locating related research within a “larger historical, social and political context” (pp. 2786-2787).

The concept of equity “has been increasingly characterized as an important driving principle in producing socially-just state policies around non-biomedical healing systems and practices” (see Ijaz, Boon, Muzzin, & Welsh, 2016, p. 98). As a policy-making principle, equity—which takes fair outcomes as its goal—may be contrasted with the notion of regulatory equality, predicated upon the notion of equivalent treatment for diverse parties, regardless of contextual or historically related factors (Arnaud, 2001; Stone, 2012). Conceptualized as an underlying principle through which other policy-making parameters—such as “the public interest”—may be illuminated, equity provides a potent driver for “crafting regulatory approaches to redress injustices arising from broader contextual conditions” (Ijaz et al., 2016, p. 98).

Critical scholarship that addresses equity-related issues surrounding medical pluralism in the global North represents an emerging area of research (e.g., Baer, 1989; Cant & Sharma, 1999; Green et al., 2006; Hollenberg & Muzzin, 2010; Marian, 2007a, 2007b). In such settings, it is not only biomedicine’s dominance in the health care sector and the health care needs and preferences of immigrant ethnic minority patients (e.g., Han, 2000; Rochelle & Marks, 2011) that increases complexity but also the potential for immigrant TM practitioners to be systemically disadvantaged (e.g., Chiu, 2006; Ijaz, Boon, Welsh, & Meads, 2015; Shroff, Hlaing, & Wu-Lawrence, 1997).

In this work, we critically analyze one such equity-related controversy at the cultural/clinical intersection: linguistic regulatory requirements for East Asian immigrant practitioners of traditional acupuncture in three English-language dominant countries (Canada, the United States, and Australia). In recent years, considerable contention has surrounded the question of English-language proficiency and record-keeping requirements, as well as English-only versus multilingual professional entry examinations, for such practitioners. Our aims in this study are threefold: (a) to detail the range of linguistic certification and regulatory requirements for traditional acupuncturists across Canada, the United States, and Australia; (b) to report on recent related controversies in each of these countries; and (c) to characterize and critically interpret the competing discourses at the heart of these controversies. We begin with an overview of two primary literatures relevant to the issues under study: linguistic entry requirements in regulated health professions and multiculturalist policy frameworks in Canada, the United States, and Australia.

Professional Entry and Language Requirements

Many regulated occupations in English-language dominant nations require high-level English proficiency of their members, presenting barriers to immigrant professional entry (e.g., Ngo & Este, 2006; Novak & Chen, 2013; Sakamoto, Chin, & Young, 2010). In the case of biomedical professionals, a primary discourse used to justify such linguistic requirements involves an assertion that public safety may be protected by ensuring competent communication between clinician and patient in the jurisdiction’s dominant language (see Lynch, 2016). That said, the degree of language proficiency seen to achieve this aim is a matter of contention (Jacoby & McNamara, 1999), and language competency requirements (e.g., for nurses in Canada, the United States, Australia, and New Zealand) consequently vary considerably across jurisdictions (O’Neill, 2007). Professional language proficiency requirements have furthermore been shown to be a significant disincentive to the migration of health care professionals (e.g., nurses) between nations (Kingma, 2001).

Linguistic Regulatory Requirements for Immigrant TM Practitioners

In Canada, the United States, and Australia, where traditional acupuncture practitioners have been increasingly regulated, East Asian immigrants commonly represent a significant proportion of practitioners (Chiu, 2006; Ijaz et al., 2015; Zhou et al., 2012). Survey data from the province of Victoria, Australia, in 2012 showed 38% of registered Chinese medicine practitioners have Chinese as their first language, a proportion that increased substantially with age, up to 80% in the above-65 age group. Over a quarter of the same jurisdiction’s practitioners surveyed self-rated their English skills as “average” rather than “fluent,” and a small proportion (~5%) “considered their spoken English to be at a minimal level” (Zhou et al., 2012, p. 65). Practitioner surveys of traditional acupuncture practitioners in various American states indicate that a smaller, but still significant, proportion of practitioners (~17%-29%) are of Asian ethnic origins (Cherkin et al., 2002; Lee, Highfield, Berde, & Kemper, 1999). Lee and colleagues (1999) further note that 23% of practitioners surveyed in one urban area had been trained in China, and that their study had under-represented acupuncturists with low English proficiency.

Chiu (2006) has briefly discussed language barriers as impeding immigrant professionals’ practice of traditional Chinese medicine in the Canadian province of British Columbia. There, she describes English-speaking patients in British Columbia, Canada, as voluntarily bringing their own interpreters to sessions with particular immigrant Chinese medicine practitioners. However, Chiu’s work does not position these issues in policy context.

Cultural Pluralism, Multiculturalism, and Language Policy

Canada, the United States, and Australia are culturally pluralistic nations characterized by English-language dominance. Amid such ethno-cultural diversity, Canada’s federal government has designated both English and French as official languages. Australia and the United States, by contrast, have no official national language, though government affairs are largely conducted in English. About half of American states, however, have designated English as their official language. As discussed elsewhere (e.g., Dauvergne, 2016), the three countries under discussion are all marked by the subordinate socio-political position of non-Anglo/European ethno-linguistic minority groups in relation to Anglo/European colonial settler culture.

Despite their divergent “official language” approaches, all three countries under study have adopted “multiculturalism” as a national policy principle (Gozdecka, Ercan, & Kmak, 2014). Kymlicka (2011) has characterized state multiculturalism policies as aiming to “recognize the legitimate interests of minorities in their identity and culture without eroding core liberal-democratic values” (p. 7). As one “multiculturalist” mechanism to accommodate the distinct needs of minority ethno-cultural groups within these English-language dominant states, and to redress historically situated power imbalances, governments have introduced various linguistic policy accommodations.

For example, both the Canadian and American federal governments provide voter information for state elections in 31 and 11 languages, respectively, although English (and in Canada also French) is the dominant and/or official language (Elections Canada, 2015; U.S. Election Assistance Commission, 2015). Some Canadian and U.S. jurisdictions similarly permit those applying for drivers’ licenses to complete knowledge tests in a range of languages (New York Department of Motor Vehicles, 2016; Welcome, 2015). The Australian government likewise provides translations of an extensive array of informative materials in “over 60 languages” (Australian Government Department of Human Services, 2016, p. 1).

Multilingualism in Pluralistic Health Care Context

In recent decades, state-funded medical services across many industrialized countries have been increasingly provided in multiple languages as part of a broader trend toward delivery of “culturally competent” and “linguistically-concordant” health care (Anderson et al., 2003; Weech-Maldonado et al., 2012). Non-English-language interpreter services have, for example, been made widely available for 911 emergency call services in both Canada (E-Comm 9-1-1, 2011; Ontario Council of Agencies Serving Immigrants, 2015) and the United States (Northwest News Network, 2014; Raymond, 2014), and for the “Triple Zero” emergency call service in Australia (Triple Zero, 2016). All American hospitals are now required to make clear records documenting their patients’ linguistic communication needs (Mui, Kang, Kang, & Domanski, 2007). As Clifford, McCalman, Bainbridge, and Tsey (2015, p. 90) have noted with reference to these three multiculturalist states, the principles of “cultural competence ha[ve] been increasingly incorporated into health policy documents and professional accreditation standards.” Regardless, Indigenous and ethno-racial minority groups continue to face considerable health inequities (Anderson et al., 2003; Weech-Maldonado et al., 2012), some language-related.

“Language difficulties and cultural barriers” have, for instance, been identified as a contributing factor to ethnic minority Asian Americans’ disproportionate rates of many diseases (Mui et al., 2007, p. 119), and low English-language proficiency has been identified as one significant barrier to East Asian immigrants accessing health services in both North America and the United Kingdom (Mui et al., 2007; Sproston, Pitson, Whitfield, & Walker, 2000). A study of “Chinese and Korean immigrant elders’ poor health status” in the United Kingdom has similarly characterized “inability to speak English” as a key exacerbating factor (along with “prejudice, micro-aggression, overt racism, and discrimination”; Mui et al., 2007, p. 125).

In addition to the role of linguistic barriers (Chappell & Lai, 1998; Han, 2000; Ma, 2000; Rochelle & Marks, 2011), East Asian immigrants’ usage of state medical services is known to increase when their ethnic identities are reflected in the provision of care (Han, 2000). Furthermore, a significant preference for traditional East Asian medicine over biomedicine has been demonstrated both among East Asian immigrants with low English-language proficiency (Sproston et al., 2000) and those “speaking Chinese as a first language” (Rochelle & Marks, 2011, p. 402) in the United Kingdom.

“Post-Multiculturalism” and Immigrant Language Policy

Over the last few decades, state multiculturalism policies have been critiqued, on one hand, as contributing to the further “marginalisation of minorities by keeping them off serious government policy agendas” (Vertovec, 2010, p. 85) and, conversely, as “prioritizing the maintenance of culture at the cost of strong national identity” (Gozdecka et al., 2014, p. 52). Reflecting the latter critique, a “post-multicultural” political trend (Kymlicka, 2010; Vertovec, 2010) has recently emerged in multiculturalist states, with the introduction of policies that “seek to foster both the recognition of diversity and the maintenance of collective national identities” (Vertovec, 2010, p. 83). A key exemplar of this trend involves mandatory “citizenship and/or language tests” (Gozdecka et al., 2014, p. 53) for those seeking immigration in these countries.

Such tests have been implemented in Canada, Australia, as well as the United States. They require that prospective citizens demonstrate a rudimentary, or in some cases vocational level of proficiency in the jurisdiction’s official or dominant language. Several critics have contested the ethical and political basis of citizenship/language tests (see Cooke, 2009; McNamara & Ryan, 2011; Shohamy & McNamara, 2009; Winter, 2014), characterizing their “gatekeeping” function as keeping members of particular ethnic or religious groups—often “those perceived as being culturally very different to the host population” (Cooke, 2009, p. 71)—from migrating to a particular country. Notably, exemptions to citizenship-related linguistic proficiency requirements have been implemented on the basis of advanced age in all three countries (Government of Australia, 2016; Government of Canada, 2015; Starr, 2016; U.S. Citizenship and Immigration Services, 2015).

As this paper highlights, the question of linguistic regulatory policies for traditional acupuncture practitioners in English-dominant jurisdictions addresses key issues around the professional regulation of TM systems in culturally pluralistic societies. Some share features with other linguistic policy questions in multiculturalist states, which—as noted—have been extensively addressed in the literature to date. Other issues we raise in this work are unique to the field of TM regulation, in which clinical and cultural considerations intersect, and which very little research has to date addressed. This paper aims to begin filling this key gap in the literature. We turn now to our study methods.

Methods

Data Collection

Data collection in this study was twofold, consisting of (a) the compilation of public documents and (b) qualitative, semistructured interviews.

Our study spans Canada, the United States, and Australia, the three English-dominant nations where traditional acupuncture practitioners are currently subject to statutory regulations. We collected a wide range of Canadian, American, and Australian public documents related to linguistic regulatory policies for traditional acupuncturists across these jurisdictions, including the following: policy and informational documents from regulators and certification agencies; minutes of the same bodies’ public meetings; media reports; court transcripts; letters from and statements by public officials; and public petitions. In compiling these documents, we focused on those jurisdictions where there have been recent controversies around the policies under study while seeking to gather policy-related details from across the three countries more broadly.

We also conducted 28 qualitative interviews with a range of stakeholders involved in one specific policy controversy under study. These interviews were conducted as part of the first author’s doctoral dissertation work, which involved a case study of Chinese medicine and acupuncture’s statutory regulation in the province of Ontario, Canada. Approval to conduct the interviews was secured from the University of Toronto’s Research Ethics Board. Using an informed consent process, and a semistructured interview guide that included questions about regulatory language considerations, the first author interviewed participants for 60 to 90 min. Digital audio recordings were subsequently transcribed for analysis.

Interview participants included Ontario government regulators and other staff (n = 6) as well as acupuncture practitioners (n = 17) involved in the 2013 regulation of traditional Chinese medicine in the province. Nine of the Ontario practitioners interviewed identified as male, and eight as female. A total of 12 practitioners were between the ages of 25 and 55, and five were over age 55. Approximately one-half of the acupuncture practitioners interviewed were East Asian immigrants to Canada; three among them (two of who were over age 55) were interviewed with the assistance of a Chinese-language interpreter. We also interviewed five study participants (practitioners [n = 2] and regulators [n = 3]) who had been actively involved in acupuncture-related linguistic controversies in other Canadian and American jurisdictions. These particular participants were included in the study as their particular involvement in these language controversies had indirectly or directly influenced Ontario’s Chinese medicine policy process.

Data Analysis

Study findings were analytically generated in iterative stages, reflecting the three articulated study aims, and presented in three parts in what follows.

For Parts A and B of our study, in which we describe the range of linguistic regulatory policies used by traditional acupuncture regulators in Canada, the United States, and Australia, and document recent related controversies, we applied descriptive content analytic methods to the set of public documents collected. As a relatively “uncritical” qualitative method, descriptive content analysis is concerned with presenting a ‘fact’-based narrative, without engaging in significant interpretive or theoretical analysis (Vaismoradi, Turunen, & Bondas, 2013). Parts A and B provide important contextual information needed for the more critical/interpretive work undertaken for Part C.

The work conducted for Part C of our study, which characterizes and analyzes the competing linguistic policy discourses underpinning the controversies described earlier on as study aim (b) took place in two steps. First (Part C[a]), we conducted a thematic analysis of linguistic policy-related rationale and argumentation articulated across the study documents as well as in our interview transcripts. Thematic analysis, as described by Braun and Clarke (2006), is a multistep qualitative analytic process, in which data are repeatedly reviewed and coded to characterize recurrent features across the texts under study. Supported by illustrative textual excerpts, data-driven themes are iteratively refined to provide an account of focal concerns within the data. In this case, we aimed to identify the primary arguments used to support or contest particular linguistic policy approaches across the texts being analyzed.

Next (Part C[b]), having completed this thematic analysis, we used an theoretical stance underpinned by the concept of equity, as elaborated earlier on in this work, to evaluate the policy-related discourses uncovered in our thematic analysis. To this end, we applied critical discursive analytic methods. Bacchi’s (2009) policy-focused methodology in this regard seeks to interpret the way in which a particular “policy problem” is implicitly or explicitly represented in discourse, giving careful consideration to historical and contextual undercurrents, and to the policy’s potential to exert broader sociocultural or political impacts.

In what follows, we present out study results in three parts, corresponding to our articulated study aims.

Results

Part A: Policy Overview

As seen in Table 1, regulators in Canada, the United States, and Australia have adopted a range of regulatory approaches to English-language proficiency in their traditional acupuncture practitioner regulations. Whereas some jurisdictions require English-language proficiency of all new registrants, others have temporarily provided transitional (e.g., Ontario, Canada) or permanent (Australia) exemptions to such requirements for a subgroup of non-native English speakers who practice in an East Asian language. Yet elsewhere, no language proficiency requirements are articulated. Across jurisdictions where English proficiency is a requirement, the mechanisms in place for demonstrating such proficiency include English-only registration exams, demonstration of English-language education, and completion of standardized English-language proficiency tests.

Table 1.

Regulatory Language Proficiency Requirements for Traditional Acupuncturists’ Professional Entry in the United States, Canada, and Australia.

	English proficiency required	English proficiency not required
Australia	Entire country; exemption for grand-parented registrants
Canada	Ontario (temporary exemption for grand-parented registrants); Alberta, Quebec (French, not English)	British Columbia, Newfoundland/Labrador (conditional/restricted registration for registrants not proficient in English)
United States	Delaware, District of Columbia, Florida, Iowa, Maryland, Massachusetts, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Texas, Virginia, Washington	Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Georgia, Hawaii, Idaho, Illinois, Indiana, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, North Carolina, Ohio, South Carolina, Tennessee, Utah, Vermont, West Virginia, Wisconsin

Source. U.S. data adapted from National Certification Commission for Acupuncture and Oriental Medicine (2012).

Multilingual registration examinations (i.e., both in English and at least in one East Asian language) are currently made available across most of the United States, and in the Canadian province of British Columbia. In Australia, no registration examinations are currently required for traditional acupuncturists. With regard to patient records, linguistic policy approaches range from none stipulated (e.g., California and British Columbia) to English-only (e.g., Ontario, Alberta, Texas, Arizona). Several American jurisdictions and Canada’s province of Newfoundland/Labrador instead require that practitioners make records available in English on an as-needed basis. In Australia, a patient’s identifying details and emergency contact information must be kept in English, and although the regulator has expressed “a preference that records be kept in English” (Chinese Medicine Board of Australia [CMBA], 2012, p. 4), permanent exceptions have been made for long-standing East Asian immigrant practitioners.

Part B: The Acupuncture Linguistic Regulatory Controversy

Our analysis of public documents has revealed a trend in recent years across several English-dominant jurisdictions, to further standardize English-language requirements for traditional acupuncturists, with respect to language proficiency, examination language, and patient records. Five notable controversies took place between 2011 and 2014: two in the United States (in 2012), two in Canada (in 2011-2012 and 2013-2014, respectively), and another in Australia (2012-2013). The descriptive account provided below provides important context for our discussion of the policy themes and discourses at play across these controversies in Parts C and D.

United States

Case 1: National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)

Language proficiency requirements for traditional acupuncturists in the United States are stipulated at the state level, but most American states have adopted a common certification standard set by the NCCAOM. The NCCAOM has long offered its certification examinations in the English, Chinese, and Korean languages, but in 2012 appointed a panel to study whether these should be discontinued. In 2013, the NCCAOM proposed to “phase out” multilingual examinations and to “require documentation of English language proficiency” for all successful applicants (NCCAOM, 2013, p. 1). However, in light of practitioner feedback, the NCCAOM withdrew these proposals; multilingual examinations continue to be offered.

Case 2: California Acupuncture Board

In California, where the NCCAOM exams are not used, the state acupuncture Board similarly proposed, in 2012, to abandon its decades-long practice of offering multilingual examinations. The proposal proved contentious within the Board itself, produced vocal objections from within the broader community of traditional acupuncturists and patients, and gave rise to a letter of reprimand from the California State Senate. Today, California continues to offer acupuncture licensing examinations in the English, Chinese, and Korean languages, contingent on 5% demand from within the applicant pool.

Canada

Case 3: College of Traditional Chinese Medicine Practitioners of British Columbia (CTCMA)

In 2011, British Columbia’s regulatory body for traditional acupuncturists, the CTCMA, passed a bylaw requiring that all patient records be kept in English. Since its inception in 2002, no linguistic requirements had been stipulated for practitioners, and registration examinations had been offered in both English and Chinese. The new record-keeping bylaw proved deeply controversial both within the CTCMA executive and its professional membership and was abandoned under significant pressure from practitioners.

Case 4: College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO)

In 2013, the province of Ontario introduced regulations governing traditional Chinese medicine practitioners, in which patient records were required to be kept in English and registration examinations were offered in English only. Although temporary linguistic accommodations were made for entry examinations, and a temporary registration class was introduced to permit practitioners without English fluency to continue practicing until 2018, English-language proficiency would ultimately be required of all practitioners. A subgroup of long-standing practitioners undertook court proceedings, claiming that these linguistic regulatory were discriminatory; their case was unsuccessful and the policy remains intact.

Australia

Case 5: CMBA

In 2012, the CMBA made English proficiency a normative requirement across Australia’s newly regulated Chinese medicine profession while permitting a subgroup of grand-parented registrants to indefinitely work alongside an on-site interpreter and keep patient records in a language other than English. Australia’s professional association of medical doctors expressed strong objections to the latter portion of the policy, but the CMBA remained firm in its policy approach. In 2013, during public consultations preceding further tightening of the regulator’s English-proficiency standards, two of Australia’s three largest Chinese medicine practitioner organizations objected vocally to these requirements, arguing they were producing a “tremendous [negative] impact within the Chinese eth[n]ic practitioners’ community” (Federation of Chinese Medicine & Acupuncture Societies of Australia Ltd, 2013, p. 3); the policy was nevertheless implemented.

Part C(a): Thematic Analysis of Competing Policy Discourses

Our overview of linguistic regulatory approaches implemented for traditional acupuncturists across Canada, the United States, and Australia makes clear that no consensus exists across jurisdictions as to the most appropriate policy approach. Indeed, policies vary considerably as to English-language proficiency requirements and record-keeping frameworks; and whereas many North American jurisdictions make available professional entry examinations in East Asian languages, others provide them exclusively in English. Our thematic analysis of policy-related documents, as well as of interview transcripts from the Ontario (Canada) context, illustrates this lack of consensus, exposing starkly contrasting policy discourses between those who support English-only versus multilingual regulatory strategies. Several subthemes are evident in this debate, as summarized in what follows.

Notably, we found a high degree of discursive congruence across jurisdictions in the arguments made on each side of the debate, affirming that the policy controversies at play across all three countries are substantially similar. In our document and interview analysis, we found both practitioners and state actors holding views on either side of the debate. That said, community-based groups who expressed opposition to English-only policies appeared in all cases to have been led by East Asian immigrant practitioners and patients. Across our interview sample, we found over two-thirds of practitioners to be opposed to English-only policies, representing both immigrant East Asian and North American–born practitioners. However, the majority of practitioners who supported English-only policies were not of East Asian ethnicity. In what follows, we detail our study themes, also summarized in Table 2.

Table 2.

Competing Discourses on English-Only Regulatory Policies for Traditional Acupuncturists.

Primary themes	Favoring English-only policies	Opposing English-only policies
1. Patient safety	Non-English proficient practitioners create unnecessary patient risks	English-only policies create more significant risks by driving practitioners underground
2. Standardized, integrated health care systems	Traditional acupuncturists should “integrate” into English-dominant, biomedical culture	Prospect of “integration” raises complex issues of powerLevel of required fluency should reflect context of practice
3. Economic considerations	Provision of multilingual services is too costly	Economic concerns should not supercede fair regulationsEnglish-only policies economically disadvantage practitioners working in East Asian languages
4. Preservation of traditional knowledge	Advantages of English-only approach outweigh disadvantages	Regulations should respect traditional acupuncture’s linguistic and cultural underpinningsLanguage requirements produce discriminatory barriers to professional entry and practice
5. Provision of culturally inclusive health care	Recognition that English-only approach may have addressable shortcomings	Multilingual policy approach is vital to foster inclusion of East Asian language practitioners who provide important ethno-specific health services

Theme 1: Patient safety

Practitioners and state actors who supported English-only policies generally emphasized public safety as their primary concern. They tended to argue that poor English-language skills could produce a significant risk to patients, particularly in emergency situations:

If you have someone in your office and they’re experiencing cardiac arrest, and you don’t have the language skills to call 911, what are you going to do? (Canadian regulator)

They commonly situated their safety concerns within the context of interprofessional communication (a point to which we will return further on):

We must take action that would increase patient safety by ensuring that all graduates taking the CALE [California Acupuncture Licensing Examination] are prepared to communicate with all other healthcare professions. (California Acupuncture Board, 2012, p. 6)

[With a] practitioner who does not keep records in English, at a time of patient crisis or emergency . . . [where] a patient has to be rushed to ER [emergency room] after just seeing their [traditional acupuncture] practitioner, the patient records, if they’re not able to translate them appropriately, aren’t going to mean anything to the emergency medical practitioners who might need to save this patient’s life. (Acupuncturist, non-East Asian, nonimmigrant)

English-only policy opponents did not deny, but tended to minimize the potential risk to patients associated with some practitioners’ low English proficiency. Traditional acupuncturists practicing exclusively in East Asian languages were, they argued, some of the most experienced within the profession, with a long history of safe practice:

We’ve been practicing, more senior traditional Chinese medicine practitioners, twenty years, thirty years they’ve been practicing this profession for so long, and never anything wrong happening. (Acupuncturist, East Asian immigrant)

By requiring English-language proficiency, they asserted, regulators would magnify the small existing language-related risk for patients, by removing statutory accountability and recourse mechanisms for patients who might otherwise be harmed:

The risk [associated with practitioners who are not fluent in English] is minimal and controllable. Manageable. We don’t need [a] policy to deal with this minimal risk, it creates a bigger risk. You know the bigger risk is that you create a category of illegal practitioners. If those doctors puncture a patient and hurt them, what would happen? If they’re licensed, they can get malpractice insurance. (Acupuncturist, non-East Asian, nonimmigrant)

Some also argued that English-only registration policies might compromise delivery of safe care for East Asian immigrant patients lacking English fluency:

What about the public safety for those patients that can only speak Chinese or Korean? What if the patient has to go to a practitioner that can only speak English? (California Acupuncture Board, 2012, p. 6)

There’s less risk in my perspective and in terms of safety in communication, there’s much less risk of miscommunication when you have Chinese-speaking people seeing practitioners who speak their native tongue. (Canadian regulator)

Theme 2: Standardized, integrated health care systems

English-only regulatory supporters commonly advocated for the standardization of linguistic entry requirements across health care professions. For instance, the Australian Medical Association—objecting to the transitional linguistic accommodations for long-standing immigrant practitioners proposed by that country’s Chinese medicine regulator—argued,

All health professions registered under the National Law have registrants who are from diverse cultural backgrounds. All these registrants are required to meet high standards of proficiency in the English language. (Hambleton, 2011, p. 2)

English-only policy proponents furthermore argued that English proficiency was necessary for traditional acupuncturists’ integration into existing (biomedical) health care systems:

If you’re going to be working with the public you need to be able to communicate with the public. You need to be able to interface. So as a practitioner who perhaps doesn’t have English language fluency, and a doctor wants to send you a patient’s medical test report, what are you going to say, send it to me in Chinese because I don’t speak English? You have to integrate them. They have to integrate themselves into the mainstream. (Acupuncturist, non-East Asian, nonimmigrant)

The official language is English. Especially if we want to integrate [traditional acupuncture] into our health care system, English is a must. If you don’t know English, I would say, you must. (Acupuncturist, East Asian immigrant)

Those opposing English-only policies asserted, by contrast, that the integration of traditional acupuncturists into mainstream health care was a complex undertaking that could not be achieved simply by enforcing language proficiency requirements. They characterized two sets of socio-political barriers as impeding such goals: (a) the relative marginality of TM practitioners in relation to dominant biomedicine and (b) the ethno-linguistically disadvantaged position of East Asian immigrant practitioners:

Of course we appreciate about so-called collaboration with other regulated health professionals. But if I tell another health professional about deficiency fire, will they understand what I am saying? This is a diagnosis from traditional Chinese medicine, this is the professional language of our medicine. Don’t tell me you don’t understand and want me to translate it into English. This is already the English translation, but they don’t know our medicine. (Acupuncturist, East Asian immigrant)

I think for people who are trained here, speak English, possibly are white, it’s easier to envision just fitting into the mainstream health and being accepted by the mainstream health care system. . . they can just picture being integrated much more easily than I think a practitioner who has immigrated here, still doesn’t speak a whole lot of English, or speaks with an accent, you know, works out of China town, and is still pretty marginal, has no prospect maybe of being integrated into that system as much. (Acupuncturist, East Asian nonimmigrant)

Notably, some respondents who opposed English-only policies within the context of private clinical practice conceded that English fluency, and a requirement to keep English-language patient records, might be reasonable within the context of state-funded health care:

If it was integrated, and there was acupuncture and herbs in hospital settings, yeah, well then yeah. Then I think that those acupuncturists would have to be writing notes in English. I think that would be fair, it’s an English speaking hospital, whatever. Private? No, I don’t think so. (Acupuncturist, non-East Asian)

Theme 3: Economic considerations

Some advocates of English-only policies—such as one participant at a California acupuncture regulatory board meeting—argued that the provision of multilingual regulatory examinations was too costly:

This Board spends more money on examination than in enforcement. I would suggest that the English-only test is an easy fix for this. . . If you are no longer paying for translation services for forms of the test, presumably that saves money that could go to enforcement. (California Acupuncture Board, 2012, p. 7)

The substantial cost associated with provision of multilingual examinations was affirmed by study participants involved in the delivery of certification examinations in other North American jurisdictions:

It’s respect we do for our elders, but it’s not a profitable thing. As you can well imagine there’s a lot of cost to provide the [multilingual] exam. (American regulator)

Regardless, those favoring multilingual policy approaches argued that this was money well spent:

Budget cost should not be a reason why we do an English-only exam. (Acupuncturist, non-East Asian, nonimmigrant)

English-only policy opponents furthermore tended to characterize these policies as having the potential to produce detrimental economic impacts on East Asian immigrant practitioners lacking English fluency. In a letter from California’s State Senate to its acupuncture regulator, potential income losses are highlighted:

English proficiency is not a necessary precursor to becoming a contributing citizen in California’s economy and should not be used by the Board to discriminate against talented and skilled individuals who seek to provide high-quality acupuncture services in California. (Steinberg & Price, 2013, p. 1)

Others emphasized the high costs associated with translating patient records into English as a disproportionate burden placed on clinicians working in East Asian languages:

Seriously, that would put me out of business. We’re talking about translators with very specific knowledge. Full stop. There’s no way any of us can afford that. That’s just ridiculous. You do not know medical language in two languages unless you have a lot of study. Those people, do you know what they cost per hour? (Acupuncturist, non-East Asian, nonimmigrant)

Theme 4: Preservation of traditional knowledge

Those opposing English-only policies typically characterized traditional acupuncture as a unique profession that requires unique regulatory consideration to preserve the profession’s associated traditional knowledge base. They consistently emphasized the historical and cultural importance of East Asian languages to the profession’s clinical work. A practitioner organization in Australia explained its position in this respect as follows:

[The] Chinese Medicine Board of Australia should also consider to have an English language standard different to other 12 National Boards in consideration of the unique cultural and historic background of Chinese medicine professional[s]. . . to better refle[ct] the specific nature of practice of the Chinese Medicine profession. . . . [The] Mandarin [language] in Chinese Medicine is not only the art, it is also the culture and philosophy of Chinese Medicine. (Chinese Medicine and Acupuncture Society of Australia, 2013, pp. 6-7)

The vital role of senior practitioners (who commonly conduct their clinical practices in an East Asian language) in continuing to transmit traditional knowledge to junior practitioners was further emphasized by those favoring multilingual regulatory policies:

By saying that they can’t continue to write in Chinese is just like, that’s something that is to me so inverted. . . . That’s something that should be cherished and we should be proud of them for keeping [traditional medicine] alive. . . All the best doctors are now in their 60s, 65 and 70s, and in the next 15, 20 years it’s over. . . I think while we have these things they should be honoured. (Acupuncturist, non-East Asian, nonimmigrant)

English-only policies, in this light, were repeatedly characterized as threatening the inclusion of such senior mentors within the regulated profession:

Almost all of the teachers of the people that are doing [traditional acupuncture] now were not speaking English confidently, a lot of them were not competent enough to write medical notes in English. The older practitioners that are not native English speaking, you know, to eliminate them from the profession, is a disservice to the profession itself. (Acupuncturist, East Asian, nonimmigrant)

Although some English-only policy advocates recognized that some senior practitioners might be excluded as a result of these regulatory parameters, they tended to minimize these impacts as an inevitable “cost of regulation” (Acupuncturist), outweighed by the policy’s other apparent advantages:

[For] some of the older [practitioners], it’s really hard to have them upgrade to that level [of English], but . . . how many past practitioners are there? They’re all probably near retirement or stop[ping] practice already. I don’t have too much concern about that. If they’re 75 or over 70 years old and so on, that’s okay. (Acupuncturist, East Asian immigrant)

If it’s a Chinese practitioner treating a Chinese patient and maybe has a Chinese-speaking physician, well then in that case English might actually be a liability, so there’s no good answer to it. I don’t know the solution. I don’t know how to make it better. It just goes back to my opinion that standardized record keeping in English is only going to help improve patient safety. (Canadian regulator)

Theme 5: Provision of culturally inclusive health care

Those opposing English-only policies and advocating multilingual policy models for traditional acupuncturist regulation repeatedly cautioned that English-only approaches might compromise delivery of culturally appropriate TM care for and by East Asian immigrants. A patient petition, for instance, characterized the prospect of an English-only policy in California as follows:

This proposal would deny all Chinese and Korean speaking people the privilege and right to be consumers and practitioners of their native medicine, alienating large numbers of immigrant, elderly and low-income communities of healthcare. (Qi, 2013, p. 2)

Others explained that practitioners working in languages other than English would commonly provide care to members of their specific ethno-linguistic communities. Such practitioners, they argued, did not generally require high levels of English-language proficiency to serve the patients who would seek them out, but provided an important, culturally specific health care service which should be given regulatory sanction:

What about people that are only treating people from their community? They only treat Chinese people, why do they need to speak English? I don’t know that they do. (Acupuncturist, non-East Asian, nonimmigrant)

When the [Chinese medicine] doctors don’t speak good English they take care of Chinese speaking patients. They don’t take care of English speaking patients. There are many practitioners available that speak very good English so they don’t have to go to a Chinese-speaking doctor. They have so much choice for that. . . . The patients are smart. They don’t choose people who don’t understand them. I speak Mandarin. Even Cantonese-speaking patients who are Chinese, they don’t come to see me. I don’t understand them. There are so many practitioners who speak fluent Cantonese, why would they come here and see me? No way. (Acupuncturist, East Asian immigrant)

Part C(b): Critical Discourse Analysis of Thematic Findings

As our thematic findings illustrate, there are both state actors and practitioners of diverse demographic makeup on either side of the polarized debate around linguistic regulatory policies for traditional acupuncturists working in English-dominant diaspora jurisdictions. In what follows, we interpret the discourses on both sides of the debate with a view to demographic features, political philosophy, and alignment with similar linguistic policy debates.

The preponderance of non-East Asian immigrant interviewees among those favoring English-only policies in our study is, we suggest, not indicative of a strong ethno-specific polarization around this policy issue. In addition, we found in our analysis of the interview narratives of those practitioners of non-East Asian ethnicity who opposed English-only policies that they were more likely to make explicit their reverence for and allegiance toward their East Asian immigrant teachers and clinical mentors than did those who supported English-only policies. Put another way, opposition to English-only policies appeared to accompany a broader narrative that gave concurrent importance to the cultural and clinical aspects of traditional acupuncture as a system of therapy, and it was East Asian participants who appeared somewhat more likely to do so. In addition, we found—across both interviews and documents—an important philosophical difference underpinning the policy-related discourses of English-only policy supporters and opponents, pointing to a contrasting (though not always explicit) engagement with the principles of regulatory equality and equity, respectively.

Those advocating for English-only policies for traditional acupuncturists regulated in English-dominant diaspora regions rely implicitly on the notion of “equality” to shape their policy-related discourses. English-language proficiency, registration examinations, and patient records, they assert, have been implemented for all other regulated health professionals and the principle of equality calls for regulatory standardization. All traditional acupuncturists, they argue, must be able to equally serve “the public,” which they singularly conceptualize as English speaking. Safety and access to care for this English-speaking “public” are, they suggest, of utmost concern, overriding other considerations. Although English-only proponents tend to recognize some detrimental impacts as potentially arising from the policies they advocate, these are normalized as inevitable consequences of statutory regulation: unfortunate, but acceptable. Any accommodations proposed by regulators to alleviate such impacts should therefore be seen as generous, rather than necessary, and dispensable, if costs prove too high.

Opponents of English-only policies, by contrast, predicate their arguments upon the notion of regulatory equity, emphasizing fair outcomes (rather than equivalent treatment). They underscore a range of factors that differentiate the traditional acupuncture profession from biomedical health professions, arguing for a set of unique linguistic regulatory parameters in response. Such parameters include consideration for the historical importance of East Asian languages in the traditional acupuncture profession, the systemic subordination of nonbiomedical forms of health care and socio-cultural subordination of immigrant professionals, the traditional medical expertise of senior practitioners lacking English fluency, and the ways in which linguistically concordant traditional acupuncture care addresses the culturally specific needs of East Asian immigrant patients. Minimizing safety-related concerns, those favoring multilingual policies ultimately characterize English-only policies as inequitably discriminating against and rendering professional licensure and disproportionately difficult and costly for senior East Asian immigrant practitioners. Conceptualizing the public of traditional acupuncture patients as diverse rather than singular, they assert that linguistic diversity within the profession should be honored, in policy, as an asset.

In addition to these equality- and equity-discourse observations, we suggest that the recent trend toward more widespread mandatory English-language requirements for regulated traditional acupuncturists may roughly correspond—not only temporally but discursively—to the “post-multiculturalist” trend (see Gozdecka et al., 2014) toward linguistic citizenship testing requirements in several culturally pluralistic, industrialized states. Indeed, as we now illustrate, discourses on both sides of the acupuncture language debate appear to parallel the political narratives of those favoring and opposing language proficiency tests for aspiring citizens in a number of Western world jurisdictions.

For example, where supporters of English-only traditional acupuncture regulatory requirements cite interprofessional collaboration and transprofessional standardization as key imperatives, proponents of linguistic citizenship requirements argue that such will position immigrants on a more “level (i.e., standardized) playing field” within which to better “integrate” (i.e., collaborate) into the dominant culture (Cooke, 2009; Vertovec, 2010). Opponents of English-only linguistic policies for traditional acupuncturists by contrast—in parallel with those opposing linguistic citizenship tests (Cooke, 2009; McNamara & Ryan, 2011)—characterize such as discriminatory gatekeeping mechanisms which unjustly exclude particular groups from the domains in question. Whereas citizenship tests are frequently justified as mechanisms to preserve national security (Cooke, 2009; McNamara & Ryan, 2011; Vertovec, 2010), “patient safety” is commonly invoked by English-only policy supporters in our analysis. Those lacking dominant-language proficiency are in both debates furthermore characterized as posing an economic burden upon the statutory infrastructure (Vertovec, 2010).

Taken as a whole, our findings highlight the conceptual overlap between the linguistic policy controversy involving traditional acupuncture regulations, and other language-related policy controversies in which marginalized or minority ethnic groups struggle for equitable treatment under the law. Despite our explicit commitment to equity-informed scholarship and policy, we do not suggest that the discursive claims of English-only policy opponents be adopted wholesale simply because their arguments take the notion of equity as axiomatic. Rather, with a view to recommending equitable policy frameworks for such cases, we further discuss, below, the claims put forward on either side of the debate.

Discussion, Implications, and Conclusions

Hill, Ross, Serafine, and Levy (2008, p. 671) have characterized the long-standing debate over English-only workplace policies in the United States as reflecting “a tension between demands for assimilation and respect for cultural differences.” Young, Ingram, Liu, and MacIntosh (1995, p. 511) similarly describe the primary tension or “dilemma” surrounding medical pluralism and statutory regulation in global context as follows:

[H]ow to balance the demands of minority groups who wish to practise their own healing traditions (as well as individuals to have the freedom to choose their own healers) with the desire of central governments to promote the interests of the nation-state and set general standards of health care for everyone.

However, the issue of regulatory linguistic requirements for traditional acupuncturists is in several ways distinct from other language policy questions.

In contrast, for example, to other regulated health professions for which English-language proficiency requirements have been implemented, the services of traditional acupuncture practitioners are not generally funded by the state. Moreover, the proportion of immigrant members of the traditional acupuncture profession in English-language dominant jurisdictions may at present be higher than for other health professions. Finally, in contrast to biomedical health professions (which, despite their cultural roots in the European scientific revolution [Harding, 1998], are today not strongly aligned with particular linguistic or ethnic communities), the traditional acupuncture profession today remains integrally linked to its East Asian epistemic, cultural and linguistic origins. As elsewhere argued (Ijaz et al., 2016), these (and other) factors require that the statutory regulation of TM practitioners—whether in diaspora or not—be considered as a unique policy issue requiring careful contextual consideration.

In our analysis, we found that safety, an important public interest consideration in regulating health care professionals across many jurisdictions (Baggott, 2002; Saks, 1995), was repeatedly invoked by English-only policy supporters as the primary rationale behind their support for English-language proficiency requirements, registration examinations, and patient records in the traditional acupuncture profession. As noted earlier, multilingual interpreters are now widely available in 911 emergency call centers across the nations under study. As such, it is unlikely that practitioners’ low English fluency would impede emergency care delivery for a patient. It is furthermore difficult to imagine how traditional acupuncturists’ patient records might prove urgently useful to emergency medical workers even if they were composed in English. Traditional acupuncturists commonly use specialized East Asian medical terminology to describe their diagnoses (e.g., “Liver Qi Stagnation” or “Damp Heat in the Lower Burner”) and the locations of the acupuncture points they select for needling (e.g., Stomach 36, or Kidney 3; Maciocia, 1989). This is terminology that would be difficult for most biomedical professionals to decipher.

That having been said, it is certainly conceivable that lack of practitioner proficiency in a jurisdiction’s dominant language—English, in the cases studied—might result in clinical miscommunications, or worse, harmful errors. Across the extensive document review and set of interviews that inform this study, we encountered just one account of patient harm associated with a traditional acupuncturist’s low English proficiency (Wells, 2014, p. 1). Although our document review was not designed to systematically collect reports of language-related clinical errors across the jurisdictions under study, the fact that few such cases were made public amid considerable policy controversy suggests, as some study participants asserted, that such cases are quite rare. Thus, although safety concerns may not be a major consideration in this context, we suggest that the potential for linguistic miscommunications between practitioner and patient produces a risk of harm that policy makers should not altogether ignore.

Aside from safety-based arguments focused on English-speaking patients, some of our study participants emphasized that access to safe, culturally appropriate care for some East Asian immigrant patients who themselves lack English proficiency might be compromised should a subgroup of non-English proficient practitioners be barred from practice. Moreover, a new set of safety considerations might arise should such practitioners continue practice, illegally, to subsist in their occupation while meeting patient care demands from within their ethno-linguistic communities. Indeed, patients potentially harmed within the context of such illegal care would have difficulty securing legal recourse for physical or psychosocial injuries incurred.

In our study, English-only policy opponents emphasized East Asian languages’ historical and cultural importance to the traditional acupuncture profession, notably echoing United Nations policy imperatives on such matters. For example, a 2013 report co-authored by the WHO, World Trade Organization, and World Intellectual Property Organization (2013), advised regulators to place focus on “preserving the living cultural and social context of TK (traditional knowledge) and maintaining the customary framework for developing, passing on, and governing access to TK” (p. 92), including in health care context. Multilingual policy advocates repeatedly expressed concern that senior practitioners with low English proficiency might be excluded from professional entry under English-only regulatory requirements, thus potentially compromising the continued transmission of traditional East Asian medical knowledge. In the same way that prevention of clinical harms to patients must be considered a public interest imperative, we argue that regulatory inclusion of practitioners who act as repositories of traditional medical knowledge should be prioritized.

We suggest that two other discursive themes identified in our study—standardized, integrated health care systems, and the provision of culturally inclusive health care—pertain more broadly to the principle of accessible health care delivery. In line with our explicit stance that TM regulation be conceptualized as an equity-informed project, we reject outright the suggestion—typified in English-only policy advocates’ discourse—that English-language proficiency, examination and record-keeping requirements should be required of traditional acupuncturists simply because these are normative requirements across other, biomedical health care professions. Instead, we contend, each of these policy considerations should be examined for its own merits as it pertains specifically to the regulation of traditional acupuncturists.

Across Canada, the United States, and Australia, traditional acupuncture care is currently delivered primarily within the context of private clinical enterprises. That is, they are outside of state-funded health care institutions and are typically paid for by the patient (and/or a privately held insurance company) rather than reimbursed within public health care systems. Within the context of private clinical practice, we see no pressing public interest as being served by requiring that patient records be kept in English, nor that the practitioner demonstrate high-level English proficiency—as long as the patient has consented to receiving care without an expectation of English-language care or documentation. Within a state-funded context (e.g., a hospital), by contrast, where health care providers are expected to interface seamlessly with one another in the jurisdiction’s dominant/official language, it may be reasonable to expect that practitioners both demonstrate high-level proficiency and keep patient records in that language.

We furthermore see no clear reason why all privately operating traditional acupuncturists in a particular English-dominant jurisdiction should be required to be available for serving patients in the English language. Demographic data characterizing traditional acupuncture practitioners in the jurisdictions under study suggest that it is a small proportion of East Asian immigrant practitioners who self-identify as having minimal English fluency. It is, therefore, the vast majority of practitioners who are available to serve patients seeking English-language care, suggesting no accessibility concerns for this particular “public.”

That said, senior practitioners offering traditional acupuncture services in East Asian languages may be seen as providing skilled, culturally appropriate and linguistically concordant TM care for members of an ethno-linguistic minority “public” known to be underserved by mainstream biomedical health care systems. A regulatory approach that threatens to exclude such practitioners may thus significantly compromise health care accessibility (while reinforcing systemic barriers to immigrant professional entry that have been extensively documented). As such, an equitable regulatory linguistic approach for traditional acupuncture practitioners working in English-dominant diaspora jurisdictions should (a) be predicated upon a conception of the “public” that is multiple and diversified rather than singular and monolithic and (b) attend specifically to the distinct needs of both majority and marginal publics.

Although we have made some broad policy recommendations here, it is evident that additional work will be needed to further establish the specifics of such an equitable linguistic policy approach. Economic considerations—raised by stakeholders on both sides of the traditional acupuncture language debate—will, for instance, need to be evaluated, perhaps on a jurisdiction-specific basis. The degree of English-language proficiency needed to ensure patient safety within private policy mechanisms may best enable a subgroup of practitioners lacking English proficiency to continue their clinical work within their language communities should be furthermore examined. Also warranting closer scrutiny is whether linguistic policy strategies applied in other contexts—such age-based exemptions used in federal immigration tests—might prove relevant to this particular policy area. Our analysis to this point has been largely conceptual and, while theoretically valuable, would ideally be complemented with research documenting the lived impacts to patients and practitioners—whether with respect to safety, traditional knowledge protection, or accessibility—of specific policy approaches implemented across the jurisdictions under study.

As states continue to regulate TM practitioners across the globe, both in their indigenous geographies and in diaspora, innovative policy approaches will become increasingly important, in pursuit of a more equitable medical pluralism. We emphasize that TM professional regulations should not necessarily be modeled to mirror those created for biomedical professionals; nor should they serve to further disenfranchise ethnic minority practitioners who steward these systems’ longevity. Rather, policy approaches should be flexible enough to meet the needs of multiple publics, attend to the health care requirements of ethnic minority patients, redress historical inequities, and accommodate TM professions’ culturally situated features. To better enable critical examination of such emerging regulatory models, we strongly affirm Marian’s (2007a, 2007b) call for regulatory transparency and accountability in such policy projects, particularly when issues of social justice are at stake.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nadine Ijaz

Author Biographies

Nadine Ijaz is a health policy/services scholar, whose research focuses on regulatory and epistemic issues surrounding traditional, complementary and integrative medicine. She is currently a postdoctoral fellow at the University of Toronto’s Leslie Dan faculty of Pharmacy.

Heather Boon is professor and dean at the Leslie Dan faculty of Pharmacy, University of Toronto. Her research focuses on the safety, efficacy and regulation of natural health products and traditional medicines as well as questions regarding how these products and therapies are included (or not) in health care systems.

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Medical Pluralism and the State: Regulatory Language Requirements for Traditional Acupuncturists in English-Dominant Diaspora Jurisdictions

Abstract

Keywords

Introduction

Professional Entry and Language Requirements

Linguistic Regulatory Requirements for Immigrant TM Practitioners

Cultural Pluralism, Multiculturalism, and Language Policy

Multilingualism in Pluralistic Health Care Context

“Post-Multiculturalism” and Immigrant Language Policy

Methods

Data Collection

Data Analysis

Results

Part A: Policy Overview

Part B: The Acupuncture Linguistic Regulatory Controversy

United States

Case 1: National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)

Case 2: California Acupuncture Board

Canada

Case 3: College of Traditional Chinese Medicine Practitioners of British Columbia (CTCMA)

Case 4: College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO)

Australia

Case 5: CMBA

Part C(a): Thematic Analysis of Competing Policy Discourses

Theme 1: Patient safety

Theme 2: Standardized, integrated health care systems

Theme 3: Economic considerations

Theme 4: Preservation of traditional knowledge

Theme 5: Provision of culturally inclusive health care

Part C(b): Critical Discourse Analysis of Thematic Findings

Discussion, Implications, and Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Author Biographies

References