What is Traditional,Complementary,and Integrative Medicine: An Operational Typology (Part I,Conceptual Foundations)

Abstract

Background:

This work, the first in a series of four linked articles, presents the conceptual foundations of an operational typology of the field of Traditional, Complementary, and Integrative Medicine (TCIM). While the TCIM field is very broad, encompassing a large and disparate range of therapeutic systems, knowledges, practices, products and devices not currently falling within biomedicine’s standard of care—no international standard currently exists for classifying these health care approaches.

Methods:

Operational typologies are theoretically informed classification tools that subdivide larger constructs (in this case, TCIM) into meaningful subcategories. The typology is theoretically predicated upon a detailed analysis of the World Health Organization’s (WHO)’s definitions of traditional, complementary, and Indigenous traditional medicine. The WHO definitions are widely cited, have global applicability, and are inclusive enough to account for a wide range of non-biomedical therapeutics. To further support the typology’s theoretical foundations, this article engages scholarly perspectives related to the aforementioned domains, drawn from the fields of medical sociology and anthropology.

Results:

The WHO definitions point to four key conceptual domains upon which the typology is designed: (1) historical factors; (2) paradigmatic and cultural features; (3) knowledge transmission modes; and (4) health systems contexts. Sociological and anthropological perspectives critically interrogate the TCIM construct in light of Biomedicine’s global dominance and draw attention to the paradigmatic underpinnings of diverse complex medical systems and therapeutic hybridities. More specifically, this article elaborates upon the ontological polarities of ecocentrism/anthropocentrism, vitalism/mechanism, holism/reductionism, and salutogenesis/pathogenesis, which deeply inform the typology’s design.

Conclusion:

Readers will find the typology itself presented in the second article of the series, followed by third and fourth articles discussing the typology’s applications.

An Operational Typology of TCIM: What and Why?

This work is the first in a series of four connected articles that together present an operational typology of Traditional, Complementary and Integrative Medicine (TCIM). Operational typologies are conceptually informed classification systems that help to make sense of complex domains or constructs, breaking them into smaller subunits. The TCIM field is complex and multidimensional, consisting of a wide range of often-unrelated and/or dissimilar therapeutic approaches that fall outside of the boundaries of Biomedicine ⁱ ’s standard of care. Though some TCIM approaches share underlying philosophical principles, the differences between them can also be notable, making it difficult for decision makers, researchers, practitioners, educators, and members of the public to discern their characteristic features.

For example, the field of TCIM includes Indigenous healing ceremonies, yoga and t’ai chi, massage therapy and foot reflexology, herbal teas and compresses, standardized botanical products and a range of dietary supplements, and ozone therapy devices. How do such disparate therapeutics relate to one another, if at all? What do they have in common, and how do they differ? There are also TCIM therapeutics that at first glance may appear similar but have important distinctions between them. For example, acupuncture is a practice that may be delivered with reference to a traditional Chinese, Japanese, Korean, or Vietnamese medicine diagnosis (along with moxibustion, a complex herbal formulation, and/or therapeutic massage). But, there are also styles of acupuncture that rely on biomedical diagnostic or explanatory models. In addition, TCIM therapeutics are increasingly being offered in a range of health care settings where biomedical care is also offered, sometimes resulting in new therapeutic approaches. How might these be characterized?

This operational typology presented in this four-part series is meant to help a range of knowledge users make sense of the TCIM category and its many encompassed therapeutic approaches. While reading the full four-part series will prove advantageous for anyone interested in a deep understanding of the TCIM field as a whole, each of the four articles may also stand alone for the reader who prefers to engage with specific dimensions of the work. The current article, the first in the series, presents in detail the typology’s conceptual and contextual foundations, attending to important historical, paradigmatic, and power-related complexities. The second article ¹ builds upon those foundations to present the TCIM typology itself. The next, third article ² provides more detailed examples and explanations for how particular TCIM approaches might be appropriately classified. Finally, article four ³ fleshes out the ways in which these therapeutic approaches may come to interface with one another and with Biomedicine.

Rigorously developed scholarly typologies: (a) subdivide a larger construct—in this case, TCIM—into smaller subunits for classification purposes; and, (b) have a strong theoretical or conceptual basis (rather than being developed, as are taxonomies, ⁴ on the basis of empirical research datasets). As such, this work must begin by elaborating the conceptual basis upon which the operational typology will be elaborated. The parameters laid out by the World Health Organization (WHO) in its definitions of traditional and complementary medicine, as well as Indigenous traditional medicine, provide an important foundation in this regard.

The WHO’s definitions have four primary advantages as the basis for such a project: (a) they are well-known to and widely cited by a large range of interest holders worldwide; (b) they have clear global applicability, rather than being limited to a particular region or context; (c) they are inclusive enough to account for a wide range of therapeutic approaches that fall outside of Biomedicine’s standard of care; and (d) they are conceptually rich—attending explicitly to the historical, cultural, paradigmatic, and health systems considerations at play in the TCIM field. As such, they offer a meaningful and broadly applicable set of indications as to how the complex TCIM construct might be fruitfully understood and operationalized across contexts.

Conceptual Foundations

The WHO has called upon governments worldwide to incorporate into national health systems a wide range of “traditional and complementary medicine” (T&CM) practitioners, practices, and products “not fully integrated into the dominant health care system.” In its Traditional Medicine Strategy (2014–2023), the WHO provides the following definition of T&CM: ⁵

Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement, or treatment of physical and mental illness.

The terms ‘complementary medicine’ or ‘alternative medicine’ refer to a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health care system. They are used interchangeably with traditional medicine in some countries.

Conceptually speaking, the WHO definition may be considered a “theoretical definition.” Theoretical definitions characterize “the fundamental nature of a construct,” in contrast to operational definitions, which determine “whether a specific instance is or is not a member of the construct through a series of criteria.” ⁶ Beyond the WHO’s T&CM definition, there have been a wide range of TCIM-related definitions, both theoretical and operational, proposed by governments, scholars, and organizations worldwide. Such definitions have addressed constructs like “complementary and alternative medicine,” “integrative medicine and health,” among others.^6–16 While an exhaustive account is beyond this work’s scope, it warrants note that there currently exists “no international standard for categorizing… [non-biomedical] therapies.” ⁸

Furthermore, as Ng et al. have shown—and while the WHO definition is an outlier in this regard—there is a widespread trend in the scholarly literature to constitute TCIM-related constructs in terms of “what they are not” (i.e., “not” Biomedicine), rather than with reference to their own distinctive characteristics. ¹⁷ For example, the theoretical definition of “complementary, alternative, and integrative medicine/health” proposed by the U.S. government’s National Center for Complementary and Integrative Health (NCCIH) defines “complementary” and “alternative” medicine as “non-mainstream approach[es]…that are not typically part of conventional medical care or that may have origins outside of usual Western practice.” ⁷

Such catch-all “what is not” definitions have also been termed “residual categories” in the science and technology studies literature. ¹⁸ As Starr and Bowker have observed, use of residual categories has the potential to inadvertently erase or dismiss many layers of complexity held beneath the surface, in particular in situations where there are complex power dynamics involved. As such, using a “what is not” theoretical definition as the basis for a TCIM typology risks an operational outcome in which the typology’s categories might be arbitrary, relying on unarticulated premises.

Classification models based on inadequately theorized definitions (such as residual categories) may also fall short in their applicability. The NCCIH has, for example, proposed a fourfold typology based on its aforementioned definition, which classifies TCIM therapies according to their “primary therapeutic input”: nutritional (including “special diets, dietary supplements, herbs, and probiotics”); psychological (e.g., “mindfulness and spiritual practices”); physical (“e.g., massage, spinal manipulation”); or combinations (e.g., yoga, t’ai chi as psychological and physical combined). ⁷ While these categories hold some descriptive value, NCCIH itself notes that “the practices of traditional healers, Ayurvedic medicine, traditional Chinese medicine, homeopathy, naturopathy, and functional medicine” do “not neatly fit” into any of its categories. Indeed, that model’s omission of such ethnomedical and non-ethnomedical therapeutic systems signals the NCCIH typology’s limited scope in describing or differentiating the diverse world of non-biomedical therapeutics.

An additional shortfall of residual categories relates to issues of power, an important consideration since TCIM therapeutics are widely subordinated, politically speaking, to Biomedicine across global contexts.^19–21 As historians and social scientists have carefully documented, Biomedicine’s hegemonic political dominance worldwide stems at least partly from its extended deployment as a tool of empire within the European colonial (and neocolonial) project.^21–25 Returning to residual categories, medical sociologist Gale has noted that definitions of “complementary” and “alternative” medicine that center Biomedicine as their reference point may enact “symbolic violence” by falsely constructing the widespread relations of therapeutic domination and subordination between Biomedicine and TCIM as “natural and inevitable.” ²⁶ The sociological concept of symbolic violence may also be understood as a form of “epistemic injustice.” ²⁸ In a recent World Health Organization meeting report, the advancement of “knowledge diversity” and “epistemic justice” ⁱⁱ was identified as a priority with respect to the evidence-informed integration of TCIM across global health care systems. In this light, it would not be prudent to risk basing a globally relevant operational typology of TCIM on definitions of the field that rely on residual or incomplete constructions.

As noted, the typology presented in this series of articles is foundationally based on an analysis of the WHO’s TCIM-related theoretical definitions. In light of that analysis (presented in Section “Unpacking the WHO Definition”), the typology’s design also draws on conceptual insights from the fields of critical medical anthropology and sociology (Section “Critical Scholarly Perspectives”).

Unpacking the WHO Definition

Since operational typologies are built upon theoretical foundations, it is necessary to begin with a careful examination of the WHO’s T&CM definition, which forms the primary basis of the TCIM typology presented in this series of articles. As elaborated below, the WHO’s definition (provided at the beginning of Section “Conceptual Foundations”) has several salient theoretical elements.

Centralizes traditional medicine as the primary construct, with complementary medicine as secondary

The most prominent theoretical feature of the WHO’s T&CM definition is that it positions traditional medicine as its primary conceptual construct, essentially nesting the secondary construct of complementary (and alternative) medicine, as well as the concept of “integration,” with reference to “traditional medicine.” These definitional moves are important because they explicitly signal an historicized recognition of the Indigenous and ethnomedical ⁱⁱⁱ roots of a wide range of non-biomedical therapeutic approaches, including those transplanted beyond their lands, communities, and knowledge systems of origin. Traditional medicine’s centrality in the WHO definition is also unusual, globally speaking, since many widely used definitions (e.g., of complementary medicine; complementary and alternative medicine; and complementary, alternative, and integrative medicine and health)^6,8,17 overlook the “traditional” medicine construct entirely, implicitly erasing the historical, cultural, and paradigmatic roots of many non-biomedical therapeutic approaches.

Emphasizes historical and cultural considerations

Closely related to the first point, the WHO definition explicitly emphasizes the historical and cultural contexts surrounding T&CM therapeutics. The definition’s first sentence (“Traditional medicine has a long history”) clearly draws attention to historical contexts, which—as the WHO observes in its 2014–2023 Traditional Medicine Strategy—include a “long history of use in health maintenance and in disease prevention and treatment, particularly for chronic disease.” ⁵ The second sentence, which refers to the “sum total” of therapeutic epistemologies and practices “indigenous to different cultures,” underscores the culturally situated character of such therapeutics.

Notably, the WHO definition appears to engage the term “indigenous” as a generality, with reference to the broad category of ethnomedicine, rather than with exclusive reference to Indigenous peoples as constituted in other United Nations documents such as the 2007 Declaration on the Rights of Indigenous Peoples. ²⁶⁸ As the 2014 Strategy observes, “many countries” have traditional medicine approaches that are “firmly rooted in their culture and history” ⁵ —and need not be necessarily affiliated with Indigenous communities per se. This interpretation may be further secured by observing that the WHO’s Traditional Medicine Strategies (both in 2002 and in 2014) refer repeatedly to such ethnomedical systems as traditional Chinese medicine, Unani, and Ayurvedic medicine as traditional medicine exemplars, despite these not being historically affiliated with particular communities of Indigenous Peoples.^5,29

In the 2014 Strategy, the WHO also makes explicit the kinds of issues that may arise in relation to the cultural and historical contexts of traditional medicine. For example, the Strategy identifies a “need to protect the intellectual property rights of [I]ndigenous peoples and local communities and their health care heritage while ensuring access to T&CM and fostering research, development, and innovation.” ⁵ Such considerations, as elsewhere observed,^19,21 are inextricably linked to the historical and ongoing marginalization, co-optation, and misappropriation of Indigenous and other ethnomedical knowledges and therapeutic practices as part of the European colonial encounter and its neocolonial sequelae, whose impacts should not be overlooked in any rigorous account of TCIM across global contexts today.

Recognizes Biomedicine’s globalized dominance

By explicitly highlighting the “dominant health care system[s]” health systems contexts into which T&CM “are not fully integrated,” ⁵ the definition clearly acknowledges that T&CM systems of knowledge and practice are significantly subordinated (to Biomedicine) across many health systems worldwide, signaling the WHO’s attention to the complex power relationships at play in this regard.

Emphasizes therapeutic knowledges as well as practices

In the first section of its definition, focused on the traditional medicine construct, the WHO clearly recognizes a wide range of ethnomedical epistemologies (“knowledge, skill…theories, beliefs and experiences indigenous to different cultures”) rather than therapeutic modalities (“practices”) alone. This dual recognition of therapeutic knowledges and practices is consistent with related messaging evident in other WHO documents (and illustrative of the definition’s implicit call for epistemic justice). For example, the WHO’s 2018 Declaration of Astana, focused on strengthening primary health care worldwide, calls not only for the inclusion of “traditional medicines” (i.e., therapeutic modalities) within national health systems but also for the inclusion of “scientific as well as traditional knowledge” (i.e., non-biomedical therapeutic epistemologies) within related efforts. ³⁰ Furthermore, the WHO’s definitional construction of traditional medicine as “the sum total” of diverse ethnomedical knowledges and practices clearly indicates that in operationalizing the T&CM definition, both of these dimensions would best be concurrently considered.

Includes “expert” as well as “community-based” knowledges

It is noteworthy that the WHO definition uses multiple terms (“knowledge, skill,… theories, beliefs and experiences”) to characterize ethnomedical therapeutics. In doing so, the definition implicitly alludes to the various means and contexts wherein non-biomedical therapeutic paradigms may be expressed or enacted, whether as formal, so-called expert knowledge (“knowledge”), as tangible practice (“skill”), or as community-based “lay” knowledge and usage (“beliefs and experiences”). This inferred range of meanings may be confirmed with reference to the WHO’s Traditional Medicine Strategy (2014–2023), which not only recommends that governments regulate qualified T&CM practitioners but also discusses at length the importance of government initiatives to advance safe, T&CM-related “self-health care” that is, community-based usage by lay people. Such self-care is explicitly constituted in the Strategy as a means to “support disease prevention or treatment, health maintenance and health promotion…in line with patient choice and expectations.” ⁵

Extends the traditional medicine construct beyond ethnomedical therapeutic knowledges and practices

Notably, in the definition’s second section, focused on “complementary” and “alternative” medicine, the WHO discursively extends the meaning of the traditional medicine construct to include therapeutic approaches that are “not part of…conventional medicine and are not fully integrated into the dominant health care system.” In other words, within the parameters of the overarching traditional medicine construct initially specified with reference to ethnomedical knowledges and practices, WHO now also incorporates a wide range of politically marginalized, non-ethnomedical therapeutic knowledges and practices (e.g., homeopathy, naturopathy, osteopathy, and nutritional supplements).

That the traditional medicine construct is intended to signify what is increasingly referred to as “TCIM” is also made evident in other WHO documents. For example, in a published agenda for the WHO’s first Traditional Medicine Global Summit, held in 2023 in India, a footnote indicates that “in this document, [the] term ‘traditional medicine’ refers to traditional, complementary, integrative medicine/health and well-being services.” ³¹

Advances an equitable construct of integration

The concept of T&CM’s “integration” within health systems is addressed just briefly in the WHO definition but warrants analytic attention in light of recent indications that this concept, along with the related notion of “integrative medicine,” is of increasing importance to the WHO’s work in this area. Indeed, “[i]n mid-2017, WHO’s Traditional and Complementary Medicine unit was renamed” to “Traditional, Complementary and Integrative Medicine.” ³² The WHO further indicated, in 2019, that a “project is underway to define and understand the concepts of T&CM’s health systems ‘integration as well as integrative medicine’.” ³²

The WHO definition characterizes T&CM approaches as those “not fully integrated into the dominant health care system,” requiring some interpretation. Rhetorically speaking, the “integrated into” phrasing might, if interpreted without context, appear to constitute “integration” as a “biomedicalizing” process, that is, as a unidirectional assimilative process of incorporating non-biomedical practices (separated from their concomitant knowledges) “into” existing biomedically dominant health systems. Conceptually speaking, however, such an interpretation would be at odds with the WHO’s repeatedly articulated commitment to preserving and honoring traditional ethnomedical knowledges and practices. Furthermore, such a biomedicalizing interpretation diverges from indications provided by former WHO Director-General Margaret Chan, which appear to align with the equity-based principles of “interculturality” and “cultural safety” (as opposed to assimilation).

Interculturality—from a definition advanced by the United Nations Educational, Scientific and Cultural Organization—refers to “the existence and equitable interaction of diverse cultures and the possibility of generating shared cultural expressions through dialogue and mutual respect.” ³³ Aligned with this principle, Chan indicates, with respect to “appropriate integration” in the context of T&CM:

The two systems of traditional and Western medicine need not clash. Within the context of primary health care, they can blend together in a beneficial harmony, using the best features of each system and compensating for certain weaknesses in each. ⁵

Chan further indicates that T&CM is “care that is close to homes, accessible, and affordable” as we well as “culturally acceptable and trusted by large numbers of people.” T&CM’s integration within health systems, then, may be understood as an imperative toward “cultural safety.” Cultural safety refers to culturally appropriate health care that is “[d]etermined from the patient/community’s perspective” ³⁴ and “strives to address the power imbalances inherent in the health care system [including] current and historical and colonial impact and…structural racism and discrimination.” ³⁵

In 2022, in his opening remarks at the WHO’s First Traditional Medicine Global Summit, current WHO Director General, Tedros Adhanom Ghebreyesus, emphasized “equity, and the importance of respecting local resources and rights,” as well as the delivery of “culturally and environmentally sensitive primary health care” as priorities with respect to T&CM’s integration within “modern health systems.” ³⁶ This approach echoes Chan’s earlier narratives.

As such, and in the absence of formal WHO definitions for “integration” or “integrative medicine,” it may be inferred that the WHO’s T&CM definition implicitly advances the construct of integration as an equitable, intercultural form of culturally safe synergy between distinct therapeutic systems of knowledge and practice, rather than an assimilative, biomedicalizing approach.

Specifies definitional parameters for Indigenous traditional medicine

In 2019, the WHO advanced a secondary definition for “Indigenous Traditional Medicine” that partially operationalizes its primary T&CM definition by specifying a key sub-element within it. ³² This secondary definition, shown below, appears to refer more specifically (though not exclusively) to those ethnomedical knowledges and practices affiliated with Indigenous peoples. Further, this definition echoes the WHO’s primary T&CM definition both structurally and theoretically (including some identical text), while drawing attention to additional elements:

Indigenous traditional medicine is defined as the sum total of knowledge and practices, whether explicable or not, used in diagnosing, preventing or eliminating physical, mental, and social diseases. This knowledge or practice may rely exclusively on past experience and observation handed down orally or in writing from generation to generation. These practices are native to the country in which they are practised. The majority of [I]ndigenous traditional medicine has been practised at the primary health care level.

Like the WHO’s primary definition of T&CM, this secondary definition attends to both “knowledge and practices” while including additional considerations that further indicate how the primary definition might be operationalized. More specifically, the Indigenous traditional medicine definition highlights particular modes of knowledge and practice transmission (“handed down orally or in writing from generation to generation”), geographic origins and land-based sites of practice (“native to the country in which they are practiced”), and health systems contexts of Indigenous traditional medicine practice (“at the primary health care level”). Importantly, by omitting to specify that Indigenous traditional medicine is based primarily on the knowledge and practices of Indigenous peoples, instead locating such therapeutics as “native to the country where they are practised,” this WHO definition appears to include a range of ethnomedical practices transmitted orally or intergenerationally at the community level (rather than primarily through textual codification or institutional transmission).

Analytic summary

The preceding sections have presented an analytic overview of eight key theoretical elements of the WHO’s TCIM-related definitional work, which together address a range of issues at play in the TCIM field. Overall, these issues may be synthetically understood as falling within four primary (but interlinked) conceptual domains: (1) historical factors; (2) paradigmatic and cultural features; (3) knowledge transmission modes; and (4) health systems contexts. To maintain conceptual fidelity with the WHO’s indications, an operational typology of TCIM based thereupon must have the capacity to negotiate this complex range of overlapping considerations. While the WHO definitions themselves, and the preceding analyses thereof, are of foundational utility in this regard, the issues they raise require additional conceptual elaboration to provide a strong basis for the typology itself. To this end, the sections that follow, underpinned by critical scholarly perspectives from anthropological and sociological literature, provide additional theoretical insights that support the typology’s design.

Critical Scholarly Perspectives

What is Biomedicine?

The operational typology to be presented in this work is predicated on the question, “What is Traditional, Complementary and Integrative Medicine?” In the pages and articles that follow, considerable space will be devoted to answering this question in ways that move beyond false binaries (Biomedicine vs. non-Biomedicine). A central premise of this work is that TCIM be defined in terms of “what it is,” rather than “what it is not.” To do justice to the diversity of therapeutic approaches included within the TCIM construct, the typology presented in the second article of this series details six distinct TCIM “types,” each with its own affiliated “sub-types.” Nevertheless, within a global context wherein Biomedicine remains politically dominant, it is unescapable that the TCIM construct essentially represents those therapeutic approaches that fall outside of Biomedicine’s boundaries. As such, this work would be remiss not to offer a brief definition of Biomedicine, informed by critical scholarship.

Biomedicine is a system of therapeutics ²¹ historically described by Dorland (1923) as a form of “clinical medicine based on the principles of physiology and biochemistry.” ³⁷ Biomedicine, a system that is today politically dominant across the globe, conceptualizes “the body” as falling “fully into the domain of the natural sciences” and as “subject to biological laws.” ³⁸ In Biomedicine, “the focus…[is] on the material body, the assumption of a universal body, and the associated idea that illness is deviation about a standardized norm.” ³⁸ Although Biomedicine is widely represented as an acultural, universal, and value-neutral therapeutic system, this is not the case. ²⁰ This representation, rather, reflects the disproportionate social, economic, and political power attributed to Biomedicine at this historical moment and may be made more visible by examining Biomedicine’s cultural and epistemic features.

As one among many therapeutic systems around the world, Biomedicine is culturally rooted in the 19^th-century “European scientific revolution and the linear reductionism of Rene Descartes and his contemporaries.” ¹⁹ Like all therapeutic systems, BBiomedicine has its own paradigmatic elements (see “Ecocentrism and Anthropocentrism” to “Holism and Salutogenesis”), in this case rooted in a mechanistically inclined worldview of “technoscientific rationality.” ³⁹ Biomedicine’s characteristic diagnostic approaches aim at “objective measurement” of material biological markers, and its primary treatment approaches include use of synthetic pharmaceutical medicines and surgery). Also akin to other therapeutic systems, Biomedicine is internally diverse, includes many subcommunities of knowledge and practice, and continues to evolve.^40,41 This evolution includes the addition of new therapeutic elements (e.g., some derived, co-opted or adapted from T&CM systems and some new innovations), as well as transformed paradigmatic elements (e.g., the “biopsychosocial” paradigm, which increasingly attends to psychological and social factors in addition to biological considerations. ⁴² As a living therapeutic system, Biomedicine will take different forms in different contexts; and the political capital associated with its affiliated paradigm may be lesser or greater in different countries.

Having established a definitional basis for “what TCIM is not,” let us undertake a critical inquiry into what it indeed may be.

Problematizing “traditional, complementary and integrative medicine”

The TCIM construct, while useful and widely recognized, has some problematic conceptual elements that warrant unpacking. One such problem is that it may convey the impression that biomedical and TCIM approaches have some absolute, or essential, traits that differentiate them from one another. As will be discussed in the Sections entitled “Ecocentrism and anthropocentrism” through “Holism and salutogenesis”, it is true that many biomedical therapeutic approaches are based on paradigmatic tenets that differ dramatically from many so-called TCIM therapeutics. However, it is more fundamentally the historically situated, hierarchical power relations between Biomedicine, and the wide range of therapeutic approaches subordinated to that system across global contexts that the TCIM construct signifies. In other words, the TCIM construct is perhaps most essentially a signifier of sociopolitical marginalization. In fact, the TCIM construct might be reasonably critiqued for concealing those relations of power, as compared with the related constructs of “heterodox” ⁴³ or “unconventional” ⁴⁴ medicine, which, in contrast to their dominance-indicating counterparts (“orthodox” or “conventional” medicine), makes these relations more explicit. Nevertheless, TCIM is also a globally recognized category that holds special political meaning owing in part to the WHO’s ongoing engagement with it.

In Section “Advances an Equitable Construct of ‘Integration’” above, some critical considerations with respect to the “integrative medicine” construct, which addresses the interface between dominant Biomedicine and T&CM therapeutics, have already been laid out. These will not be repeated here but will form the basis for key elements of the typology’s design (article 2 ¹ in this series) and application (articles 3 ² and 4 ³ in this series) further on. In what follows, the concepts of “traditional,” “complementary,” and “medicine” will be further unpacked.

As Carlessi and Ayres (a medical anthropologist and biomedical physician–researcher) observe, the WHO’s “interest in rebuilding universal health systems through the recognition of culturally distinct knowledge”—that is, with respect to TCIM– is both “well-intentioned” and laudable. ³⁹ However, these scholars also characterize a “contradiction of the WHO’s proposal” with respect to “the term traditional,” which seems to merely qualify medicine without considering the political baggage that these terms carry.” ³⁹

Prior critiques of the term “traditional” (in the context of traditional medicine) highlight how this construct may inappropriately romanticize and essentialize ethnomedical therapeutic knowledges and practices (and their variations) either: (a) static artifacts arising from a nebulous ancient history that are “crystallized in time and space”; ³⁹ and/or (b) the result of singular, continuous lineages of community-based transmission.^45–50 In fact, most therapeutic approaches with ethnospecific, non-biomedical roots are distinctly modern(ized), internally plural, and often hybridized with other therapeutic systems (biomedical or otherwise).^47,48,51 In addition, many ethnomedical therapeutic approaches have been contemporarily reconstructed with reference to fragmented oral and/or textual lineages, following pauses in transmission resulting from a range of historical and political factors, including European colonization.^47,52,53

Moreover, as Martin-Hill, a cultural anthropologist and Indigenous scholar, observes, “the term ‘traditional’” is “disliked by many Indigenous groups,” who understand it as “a British colonial concept” that separates “discussion of medical practices into two time periods, pre- and post-contact.” ⁵² This separation, while conceptually useful (as it may helpfully draw attention to Biomedicine’s deployment as a tool of imperial domination,^21,22) also fundamentally constitutes long-rooted ethnomedical systems and practices with reference to European colonial powers, rather than in their own right. Related (and as briefly indicated earlier), the construct of “complementary” medicine is predicated on the implicit notion that “a practice must be…complementary to something.” ²⁶ As medical sociologist Gale further elaborates, the “absent presence here is, of course biomedicine,” a construction that quietly and inappropriately holds the potential to reinforce “biomedical dominance” as a state of affairs considered “natural and inevitable.” ²⁶

Further, the term “medicine” carries its own conceptual baggage, owing to its implicit association with pharmaceutical Biomedicine: a hegemonic system^46,54 situated within a context of globalized capitalism and predicated on an ontology of “technoscientific rationality” ³⁹ that emphasizes a “dichotomous dualit[y]” between mind and body, health and ill-health. ⁵⁵ Conversely, many Indigenous, ethnomedical, and otherwise non-biomedical therapeutic ontologies constitute “health and illness as…parts of the same continuum,” and holistically constitute “environmental equilibrium” and “spirituality” as key elements of health. ⁵⁵ Related critiques have arisen within the movement for “integrative health care” (sometimes termed “integrative medicine” or “integrative medicine and health”) in several high-income countries. ⁵⁶ There, it has been repeatedly suggested a lesser focus on the term “medicine” (and a greater emphasis on “health”) would better recognize a broad range of health-related determinants as well as therapeutic ontologies and epistemologies.^56–58

While the WHO has not explicitly defined “medicine,” its definition of “health”—a construct in relation to which “medicine” is presumably constituted—has been both praised and critiqued. The WHO defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” ⁵⁹ This definition has been applauded for its holistic inclusion of not only physical but also mental well-being, its attention to health’s broader social and structural determinants, including community health (“social well-being”), and its broad generality, which allows for the definition’s contextual applicability across a range of cultural settings. ⁶⁰ However, critics from across multiple disciplines have observed that the definition falls short in its “utopian rather than pragmatic” ⁶¹ call for complete well-being, which is generally seen as unattainable,^60–62 and thus “contributes to the medicalisation of society.” ⁶² Proposals have been made for the WHO to reconstitute the concept of health with reference to “the ability to adapt”;^60–62 and to give attention to “environmental equilibrium” and “spirituality” as key elements, ⁶¹ thus better reflecting globally diverse understandings of health and well-being. Such definitional shifts, it has been, furthermore, suggested, would make “it easier to assume a complementary cooperation between traditional medicine and Biomedicine” ⁵⁵ as distinct complex medical systems—that is, therapeutic paradigms—in their own right.

Therapeutic paradigms

As observed by Thomas Kuhn, paradigms refer to “the entire constellation of beliefs, values, techniques, and so on shared by the members of a given community.” ⁶³ Paradigms, including therapeutic paradigms, include three key elements: ontology (ways of “being,” i.e., how the world/reality is constituted), epistemology (ways of “knowing,” i.e., investigating the world/reality) and praxis (ways of “doing,” i.e., techniques and methodologies that reflect specific ontologies and epistemologies). ⁶⁴ As elsewhere proposed. ⁶⁴ the “medical rationalities” framework of Brazilian scholar Madel Luz,^65–67 elaborates upon the essential features of “complex medical systems,” offers conceptual parameters for understanding therapeutic paradigms. Like Biomedicine, many TCIM therapeutic approaches may be characterized as complex medical systems with reference to Luz’s medical rationalities framework. Luz’s original work uses the cases of Biomedicine, traditional Chinese medicine, Ayurvedic medicine, and homeopathic medicine to delineate six key elements that characterize complex medical systems. ⁶⁶ These six elements map clearly onto the threefold concept of a therapeutic paradigm elaborated above, as follows.

In terms of ontology, the first element of therapeutic paradigms, Luz’s model observes that complex medical systems have distinct cosmologies, that is, ways of understandings the world and its origins, elements, and fundamental governing principles. With regard to the second element, complex medical systems also have unique epistemological elements such as morphology (characterizing the human organism’s organizational form and structure, e.g., “anatomy” within Biomedicine); physiology, or “vital dynamics” (i.e., an explanatory model for the processes whereby balance or imbalance may be made manifest within the organism); and a diagnostic system that underpins characterizations of and differentiation between defined health conditions (including their causal trajectory or etiology, severity, and possible prognoses). Finally, in terms of praxis, the third element of therapeutic paradigms, Luz observes that complex medical systems have distinct systems of therapeutics (wherein appropriate therapeutic interventions are determined with reference to the established diagnoses).

The six elements of Luz’s model differentiate complex medical systems not only from standalone therapeutic “modalities” but also, arguably, from “microsystems” that may have some of the aforementioned characteristics but do not offer a comprehensive framework for understanding and addressing a wide range of health-related scenarios. In addition to these characteristics, it should be noted that all therapeutic paradigms are historically and culturally situated in terms of their origins and expressed features. A closer examination of some ontological principles that underpin various therapeutic paradigms provides useful conceptual insights that underpin this work’s typology. But three issues drawn from the discipline of philosophy must first be addressed to set the stage for the typology’s construction in the next article.

It should first be recognized that despite “historic Western attempts to impose a bounded way of understanding the world,” ontologies—and in particular, ontologies of the body—are “never singular.” ⁶⁸ In other words, multiple ways of understanding reality (and health/ill health) often coexist concurrently in a single context or paradigm, at times with internal contradictions or inconsistencies. While some cultures and paradigmatic communities may “feel compelled to insist on ontological uniformity” to a greater degree than others, seemingly distinct ontologies (like the “ideal types” in the present work’s typology) may be fundamentally understood as “heterogeneous and open,” with “blurred boundaries between” them. Second, and related, a paradigm may be structurally characterized by an “ontological hierarchy” (in which some ontological modes are subordinated to a primary one) or an “ontological heterarchy” (wherein different ontological elements are not ranked but coexist more permeably, in parallel or in various forms of synergy). ⁶⁸

Finally, in characterizing ontological elements, it can be useful to use sets of binary comparators “involving two terms, concepts, or thoughts with contrasting meanings,” to draw attention to different ontologies’ distinguishing features. ⁶⁹ However, despite a “Western propensity” to view such binaries as mutually exclusive and fundamentally separate, a seemingly singular construct can at times contain within it what would initially appear to be its opposite. This “dialectical” insight, which allows for a relational “synthesis” to take place between seemingly opposite perspectives, ⁶⁹ is evident in many ethnomedical cosmologies, such as the Taoist construction of yin and yang as a binary pair. There, both yin and yang categories are understood as dynamically interdependent, and inclusive of their apparent opposites. ⁷⁰

In what follows, four sets of ontological binaries with relevance to therapeutic paradigms—ecocentrism/anthropocentrism; vitalism/mechanism; holism/reductionism; and salutogenesis/pathogenesis—are briefly elaborated in this light. Conceptually, the first item in each of the aforementioned binary pairs may be understood as a “larger” category with the capacity to “contain” its apparent opposite, but the inverse is not the case. Ultimately, most non-biomedical paradigms may be understood as ontological heterarchies predominantly comprised in varying degrees by the first items in each pair (along, typically, with other paradigm specific elements). Conversely, much (though not all forms) of Biomedicine are predominantly underpinned by an anthropocentric ontological hierarchy with “mechanism” at the top, secondarily (but not exclusively) supported by ontologies of reductionism and pathogenesis (though at times also informed by holism and/or salutogenesis). Each of the aforementioned ontological principles is defined in the sections that follow. These conceptual elements explicitly inform the design of the typology presented in the second article in this series, where readers will also find the principles more briefly summarized.

Ecocentrism and anthropocentrism

Most ethnomedical paradigms, both Indigenous and non-Indigenous, are fundamentally cunderpinned by ecocentric (rather than anthropocentric) ontologies. Anthropocentric ontologies, which form the basis of many contemporary, globally dominant intellectual, medical, political, and economic models, ⁷¹ are based on a hierarchical view that “assumes human-centeredness and the privileged position of human beings as…the pinnacle of creation.” ⁷² There are many variants of anthropocentrism, some of which explicitly address environmental considerations. ⁷³ On the whole, however, anthropocentric ontologies privilege “humans above the rest of nature,” ⁷³ and tend to operate in terms of fixed/oppositional/static binaries. This issue is of major global importance, including for decision makers contending with how to make health systems more ecologically sustainable in the decades ahead.^74–76

Anthropocentrism has been historically tracked to Judeo-Christian traditions and the 17^th-century thinking of the French philosopher Rene Descartes, whose work strongly influenced both the industrial revolution and Biomedicine’s conceptual model.^71,72 Ecocentric ontologies, conversely, are fundamentally relational (rather than hierarchical) and represent “one of the most inclusive worldviews… recognis[ing] the whole ecosystem, including everything living and non-living.” ⁶⁹ As Redvers, an Indigenous global health researcher, explains, “ecocentric approaches to planetary health have existed for thousands of years in Indigenous communities…and embody within them protocols around reciprocity, responsibility, and respect for the planet’s wellbeing as a living entity.” ⁷⁷ In the sense that ecocentric perspectives do include humans (as one part of nature), ecocentric ontologies have the capacity to contain or include human-focused considerations without losing the larger, contextual, ecological picture of all living and nonliving relations.

Despite their global dominance, anthropocentric ontologies have been extensively critiqued as philosophically untenable—“considering that humanity is (in the end) fully dependent on nature”—and as “a significant driver of ecocide and the environmental crisis.” ⁷³ Conversely, ecocentric paradigms (including therapeutic paradigms) may offer important conceptual lenses (and practical tools) for reenvisioning more sustainable and healthy worlds. As outlined in the sections below, both anthropocentric and ecocentric ontologies have related sub-ontologies, which are particularly evident across a range of therapeutic paradigms.

Vitalism and mechanism

An ontology of “vitalism” dwells at the heart of most ethnomedical systems and some other marginalized therapeutic systems. ⁷⁸ Based on the ecocentric metaphor of “the world as a living system,” vitalistic therapeutics hold “that there is a vital force operating in the living organism and that this cannot be reduced or explained simply by physical or chemical factors.” ⁷⁸ Vitalistic therapeutics are notably diverse, both between systems and within systems, conceptualizing the “vital force” and its ramifications in diverse ways (e.g., as “the vital force” in homeopathic medicine, “qi” in East Asian medicine, “prana” in Ayurveda, as “nature’s healing power” in naturopathy, and otherwise). Overall, however, this vital force is understood as a major source of health, adaptive and regenerative capacity, and healing within the living organism, which should not only be preserved but strategically fortified to maintain and create health.

Conversely, the explanatory model of mechanism (a subset of a larger ontological framework termed “scientific materialism” ⁷⁸ ) ^iv that strongly underpins dominant Biomedicine is based upon the anthropocentric metaphor of “the world as a machine” ⁷⁸ (in a world where it is humans who build and use machines). ⁷¹ This ontology was historically “coproduced with industrial capitalism” ⁷⁹ beginning in 17^th-century Europe. ²² Extended to the domain of health and illness, mechanism aims to explain and resolve disorders constituted as dysfunctions in human biology, with reference to “physico-chemical” models predicated on material causes and effects alone. ⁷⁸ There are many branches within Biomedicine underpinned by different philosophical tenets and a wide range of clinical practice modes. On the whole, however, these variants share an underlying mechanistic, materialistic ontology. ⁷⁹

Today, Biomedicine’s materialistic, mechanistic paradigm carries significant political power worldwide, with the term “vitalism” often deployed “as a derogatory label associated with lack of intellectual rigour, anti-scientific attitudes, and superstition.” ⁸⁰ However, as philosophers explain, both mechanism and vitalism are ultimately “metaphysical doctrines… neither of [which] can be submitted to experimental control.” ⁸¹ Related debates “about the nature of life” ⁷⁸ and about “why and how” living systems operate the way they do thus remain a somewhat inconclusive prospect. ⁸² Nevertheless, it should be noted that Biomedicine’s primary ontology of materialistic mechanism excludes, by definition, vitalistic explanations of disease processes. Conversely, however, vitalistic therapeutic ontologies do not necessarily exclude mechanistic explanations of ill health, which may complement, supplement, inform, or even permeate more “energetic” understandings of health and the healing process. Regardless of one’s ontological inclinations, there is an increasing body of research evidence investigating the effectiveness of therapeutic approaches based in vitalistic therapeutic approaches (e.g., traditional Chinese medicine),^83–86 a point with ramifications for decision makers to carefully consider.

Holism and salutogenesis

There are two additional ontological principles—holism and salutogenesis—that form an integral part of most ecocentric therapeutic paradigms but which have also played a role in some strands of (mechanistic) Biomedicine and have begun to enter conventional health systems. It should be noted that the terms being used here—holism and salutogenesis—were coined in the twentieth century by scholars in industrialized countries, with reference to biomedical contexts. However, the principles they describe have long been conceptualized and applied across many ethnomedical systems, predating the aforementioned Western intellectual constructs by millennia. Because the concepts of “holism” and “salutogenesis” will be familiar to many academic readers, these terms will be adopted here, while cautiously recognizing the misrepresentation of the older concepts that this usage may problematically represent.

First introduced in the academic literature in 1926 by Smuts, a philosopher,” holism” is an ontological construct that includes but extends beyond the static truism by which it is often represented (i.e., the whole is “more than the sum of its parts”). ⁸⁷ Smuts argued that holism is a synthetic principle governing “bodies and organisms” wherein the functioning of “wholes” can only be understood by examining the “reciprocal relationship” between parts, and together with the whole. ⁸⁸ At the time, Smuts’ notion of holism was strongly at odds with the Euroscientific “tradition of reductionism” which had, over “three centuries,” ⁸⁸ sought to explain “biological phenomena using the principles of physics,” strongly complementing Biomedicine’s mechanistic ontological principles. ⁸⁹ In a reductionistic mode, disease is conceptually “separated from the sick person and scrutinized with successively finer analytic tools,” whether at the level of pathogen, organ, tissue, cell, molecule, or gene. ⁸⁹ Though reductionism remains a powerful ontological force within contemporary Biomedicine, principles of holism have become increasingly influential.^89,90 This is evident in Biomedicine’s now widely accepted biopsychosocial model (which today accounts for psychological and social factors in disease), and in such fields as epigenetics, immunology, network pharmacology, and environmental health.

Salutogenesis is another ontological principle with relevance across diverse therapeutic paradigms. Coined in the 1970s by the sociologist Antonovsky, the term “salutogenesis” characterizes a concept in counterpoint with “pathogenesis,” Biomedicine’s predominant therapeutic orientation.^91,92 While pathogenesis asks: what is the biological origin of disease, salutogenesis asks: what are the origins of health? Salutogenesis, thus, is concerned with the “creation” and “promotion” of health in its many complex dimensions, whether biological, psychosocial, historical, sociopolitical, spiritual, ecological, or otherwise. ⁹³ Salutogenesis ontologically constitutes health and illness on a continuum (rather than as a binary state of sick versus healthy) and is concerned with health and well-being of the whole person (rather than treatment of biological disease pathways alone). Salutogenic therapeutic models typically call for the application of multi-modal, multi-target, personalized, and community-engaged approaches to health and healing. They are also concerned with health’s broader determinants, whether social, structural, or planetary.

Though by other names, principles closely aligned with Antonovsky’s salutogenesis construct have long been central within many ethnomedical (and other non-biomedical) therapeutic systems.^94–96 Today, over 10,000 peer-reviewed articles about salutogenesis have been published, primarily with reference to biomedical contexts of health promotion, though the principle continues to be marginalized across global medical systems. ⁹³ Ongoing calls for the salutogenic transformation of Biomedicine’s “sick care” system^93,97 substantially echo similar long-standing calls by TCIM scholars, practitioners, and users.

Therapeutic hybridities

Therapeutic paradigms are not static. Many strands of Biomedicine—which remains a predominantly mechanistic system, with strong ontological influences of reductionism and pathogenesis—have been shifting over the last century to incorporate more holistic and salutogenic ontological perspectives. Many ethnomedical systems, while retaining heterarchical ontologies in which the principles of vitalism, holism, and salutogenesis work in tandem, have also absorbed mechanistic biomedical insights within their epistemic and therapeutic frameworks. Some complex therapeutic systems, like chiropractic, which have strong roots in vitalistic ontologies, have been gradually shifting toward more predominantly mechanistic paradigmatic positions. ⁹⁸ Historically speaking, therapeutic hybridity—the ongoing exchange of knowledge and practices between and within therapeutic systems—is the norm, not an exception. However, the dynamics of therapeutic hybridities, which take place within larger sociopolitical and historical contexts, are complex, requiring theoretical specification, since the concept of therapeutic hybridization represents an integral design element in this work’s operational typology of TCIM.

In a 2004 sociological study, Frank and Stollberg theorize four primary forms of medical hybridity between orthodox (that is, dominant) Biomedicine and heterodox (that is, non-biomedical, or otherwise marginalized) therapeutics. ⁴³ This theoretical framework offers a useful starting point around which to conceptualize therapeutic hybridities. Frank and Stollberg constitute their fourfold model with reference to two primary axes: the “degree of hybridization” between therapeutic systems (weak or strong), and the “gravitational center,” that is, which therapeutic knowledges (biomedical or non-biomedical) predominate within the new, hybridized form. “Weak” forms of medical hybridization, in this model, are those in which either biomedical or non-biomedical knowledge are retained as the “gravitational center” for clinical work, with therapeutic elements from a separate set of knowledge serving as a complement or supplement. “Strong” forms of medical hybridization, by contrast, are characterized by a greater degree of fusion between therapeutic paradigms.

Frank and Stollberg’s model indicates that in cases of strong hybridization wherein heterodox (non-biomedical) knowledges persist as the gravitational center, this “fusion” may produce new medical rationalities, which they term “meta-theories” of “medical theory and practice.” ⁴³ However, Frank and Stollberg do not theoretically elaborate why, in their model, there are no new meta-theories developed via strong hybridization that take biomedical knowledges as their gravitational center. Indeed, their model may appear to suggest that dominant Biomedicine is uniquely non-receptive to non-biomedical knowledges, in contrast to non-biomedical therapeutic paradigms, which are more permeable or flexible. But is this true? Does Biomedicine only have the capacity, metaphorically speaking, to eat non-biomedical therapeutic systems whole, swallowing certain technical “modalities” of practice, while spitting out the knowledge frameworks that underpin these practices? This question might be provisionally answered with reference to the work of other scholars.

One useful perspective, recognizing Biomedicine’s position of hegemonic global dominance, ⁹⁹ refers to Gramsci’s theorizing of co-optation.^100,101 As has been illustrated in therapeutic contexts, a hegemonic group (such as Biomedicine) may “sustain its dominance” by strategically co-opting (that is, usurping, expropriating, and/or assimilating) elements of non-hegemonic worldviews and practices into its own hegemonic framework. ⁵⁴ But this does not explain why a biomedical knowledge system might not, in principle, have the capacity to strongly interhybridize with a non-biomedical therapeutic knowledge to create a new therapeutic meta-theory.

Drawing on the work of medical anthropologists and historians, Hollenberg and Muzzin offer another perspective, indicating that “biomedicine draws on the monotheism of the West that prevents biomedicine from tolerating alternative paradigms.” ²¹ These authors question whether “there is something ‘different’ about biomedicine” that potentially renders it “epistemologically unable to equitably integrate CAM [complementary and alternative medicine]” without “co-opt[ing], marginalis[ing] and/or assimilat[ing] CAM practices.” Indeed, as noted earlier on, ecocentrism, vitalism, holism, and salutogenesis can accept anthropocentric, mechanistic, reductionistic, and pathogenesis-focused explanations, though the opposite is not the case.

Is the Biomedicine’s underlying paradigm—with its anthropocentric, mechanistic ontology—thus what the philosopher Sandra Harding has termed a “predatory conceptual framework” ²² ? Or, as Hollenberg and Muzzin ask: “Could biomedicine change such that CAM could be fairly integrated into an equitable form of IM [integrative medicine], while respecting and incorporating the fundamental aspects of CAM paradigms? ²¹ ” Coulter and colleagues pose a similar question: “Can the worldviews of vitalism, holism, and scientific materialism[,] rather than create a schism…become a collective…set of radical design tools for health creation [?] … Is there a powerful future where [mechanistic] science, empirical practice, and vitalism work together? ⁷⁸ ”

As noted in the previous sections, such ontological questions are becoming more urgent for decision makers in a pluralistic world where TCIM therapeutics remain in widespread usage and demand. In the typology that follows, and in the final articles of the series (which address the typology’s applications), readers will find indications as to how such challenges may be fruitfully addressed.

Conclusion

This article, the first in a series of four, lays the conceptual foundations for an operational typology of TCIM based on an analysis of the WHO’s related definitional work. The WHO definitions, overall, attend to conceptual matters that may be understood with reference to four primary domains: (1) Historical Factors; (2) Paradigmatic and Cultural Features; (3) Knowledge Transmission Modes; and (4) Health Systems Contexts. To maintain conceptual fidelity with the WHO’s definitional parameters while attending to the complex intersections between the aforementioned issues, the conceptual foundations presented in this article are also deeply informed by related critical social scientific scholarship. Using the concepts of therapeutic paradigms and therapeutic hybridities, this article thus provides a language through which to explore the range of issues that present across the four identified domains. This includes, notably, the power dynamics at play in the TCIM field, including its interface with Biomedicine. By expanding in scholarly nuance on the issues raised by the WHO, that conceptual language in turn provides the theoretical basis for the operational typology of TCIM presented in the next article in this series. ¹