Safety Net: The Construction of Biomedical Safety in the Global Health Discourse.

asian medicine 10 (2015) 1–31

brill.com/asme

© koninklijke brill nv, leiden, 2�16 | doi 10.1163/15734218-12341348

Safety Net—The Construction of Biomedical Safety in the Global ‘Traditional Medicine’ Discourse

Paul KadetzDepartment of Public Health, Xi’an Jiaotong-Liverpool University, China Centre for Health and Humanity/University College London

[email protected]

Abstract

This paper examines the social construction of the World Health Organization’s norma-tive discourse of the safety of ‘traditional medicines’. The findings presented are based on archival research, a review of the literature, discourse analysis of WHO documents, semi-structured interviews with pertinent stakeholders, and participant experience at the Western Pacific Region Office of the WHO. This discourse of safety can be traced to the rise and global dominance of scientific medicine over plural healthcare and the construction of biomedical expertise. This paper argues that biomedicine’s global hege-mony and construction of a dominant discourse of safety was, at least in part, influenced by the American Medical Association, The Flexner Report, The Rockefeller Foundation, the League of Nations Health Organization, the World Health Organization, and the WHO’s adoption of traditional Chinese medicine as a template for health care integra-tion. This network of stakeholders influenced the construction and dissemination of the global biomedical discourse of safety and the purported ‘safe’ control, regulation, and integration of non-biomedical practices and practitioners via biomedical expertise.

Keywords

safety – traditional medicines – World Health Organization – The Rockefeller Foundation – American Medical Association – The Flexner Report – traditional Chinese medicine

ASME_010_01-02_f2_Kadetz.indd 1 4/11/2016 5:11:06 PM

mailto:[email protected]

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Introduction

Global health discourses have been constructed by multilateral institutions, such as the technical divisions of the United Nations (UN), as well as inter-national non-governmental organisations, and powerful philanthropic foun-dations. A fundamental issue with any global discourse is the embedded assumption of universal agreement concerning basic concepts. Safety and securitisation are underlying concerns for many divisions of the UN. Safe health care is a primary concern for the World Health Organization (WHO). That we do not all share the same understanding of safe health care is obvious to any-one who has experienced health practices across different cultures. Yet the WHO discourse recognises only one standard of safe health care, namely that of biomedicine, as determined by the biomedical expert. That the majority of ‘experts’ at the WHO are biomedical physicians and scientists, even within the WHO’s Traditional Medicine Unit, may explain the reason for a single biomedi-cal standard of safety, but it does not explain how this normative standard of health care safety was constructed and came to dominate the WHO’s discourse concerning ‘traditional medicine’.1

This paper attempts to unpack the normative WHO discourse of health care safety concerning traditional medicines via an analysis of its social con-struction by various stakeholders over the past century. Research methods include a review of archival materials of The Rockefeller Foundation,2 a dis-course analysis of relevant World Health Organization documents, a review of the literature concerning the integration of traditional Chinese medicine, semi-structured interviews with pertinent stakeholders from the World Health Organization, and participant experience in the Traditional Medicine Unit of the Western Pacific Region Office of the World Health Organization. This anal-ysis attempts to identify the sociocultural and political-economic forces that have helped shape the global discourse of safety for the use of local, regional, and globalised non-biomedical practices.

1 Although the terminology ‘traditional medicine’ is a markedly problematic designation into which all non-biomedical practices and practitioners are lumped together, I employ this term here as it has been conventionally used by the WHO and in the normative discourse concerning non-biomedicines. For further discussion, see Kadetz 2011.

2 I would like to thank The Rockefeller Foundation Archive Center in New York for the use of their archives.


3Safety Net—The Construction of Biomedical Safety


Unpacking the WHO’s Current Discourse of Traditional Medicine Safety

The global discourse concerning the ‘safe’ use of non-biomedical practices has been disseminated, in particular, through the traditional medicine guidelines published by the World Health Organization. The first projects of the WHO and UNICEF to include non-biomedical practitioners began in the 1950s with train-ing for Traditional Birth Attendants.3 Yet prior to 1978, a dearth of literature can be identified that adopted a global paradigm of biomedical safety as the primary approach to non-biomedical practices and practitioners.4 The litera-ture that was available generally dismissed local practices as ‘backward’, ‘primi-tive’, ‘superstitious’, and, most importantly, ‘dangerous’. The modern scientific paradigm, particularly as adopted among the local public health elites of post-colonial states, perpetuated the belief that local health practices needed to be controlled, if not completely eradicated.

After 1978, and the introduction of the WHO’s Declaration of Alma Ata, state agendas were often superseded by the global discourse concerning the safe use of local and regional non-biomedical practices via biomedical oversight. The Declaration of Alma Ata proposes that health is a ‘fundamental human right’ and that universal health care (or ‘health for all’) can be achieved through comprehensive primary health care.5 Primary health care requires biomedi-cal practitioners, ‘as well as traditional practitioners, [who are] suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community’.6 Thereby, the Declaration of Alma Ata formally introduced the concept of integrating local practitioners and their practices into biomedical health systems into the global health discourse.

With the inclusion of the category of traditional medicine into the WHO discourse after 1978, and with the development of the Traditional Medicine Unit at the WHO, there was an exponential leap in publications concerning the safety of non-biomedical health care practices and practitioners. Subsequently, in WHO documents after 1978, whenever traditional medicine is mentioned, health care integration is almost always the recommended goal to achieve the desired outcome of safety.

3 Pillsbury 1982.4 See, for example, WHO 1975, ‘The Traditional Birth Attendant in Maternal and Child Health

and Family Planning’ and Djukanovic and Mach 1975, ‘Alternative Approaches to Meeting Basic Health Needs in Developing Countries. A Joint UNICEF/WHO study’.

5 WHO 1978a.6 Ibid., part VII 7.


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In the 2002 WHO Strategy for Traditional Medicine, the term ‘safety’ appears 74 times. In the context of the WHO discourse, safety can be understood as an outcome of the purification rituals of bioscience that include laboratory-based research, statistical analyses, technological innovation, and biomedically con-structed guidelines and regulations. The 2002 Western Pacific Region Strategy for Traditional Medicine states:

Safety is the primary concern in medical treatments—to patients and practitioners alike. Formal standards of safety for medication and non-medication treatment modalities are to be established by Ministries or Departments of Health or other governmental agencies.7

Several assumptions are embedded in this statement, including the assump-tion that the safety of local practices is a primary concern of patients, and that a biomedical construction of safety is universally shared. Particularly notewor-thy is the assumption that a treatment identified as good, that will work, and is deemed safe, cannot be determined by one’s self or community, but only by a medical expert or officer of the state health apparatus. Yet, in interviews I pre-viously conducted in the rural Philippines, community residents were not at all concerned with the safety of local practices.8 Nor did they share the WHO’s understanding of safety. But rather, local informants were mostly influenced by the perceived sincerity of a practitioner’s religious belief. Furthermore, informants sought neither the state’s nor the WHO’s oversight in their plural use of health care.9 So, if we can problematise the idea of a single universal understanding of safety,10 then we can question how biomedical safety came to dominate the WHO’s discourse of traditional medicine.

Although, we can critique any discourse that assumes the universality of a single global understanding, this analysis is primarily interested in unpack-ing the global discourse of safety regarding traditional medicine through its social construction. Focusing on the development of biomedical hegemony in the United States, this paper offers one possible explanatory thread of this construction. A construction that began with the fight for the dominance of biomedicine and biomedical physicians in nineteenth-century North America and continued with the validation and regulation of this dominance through the so-called ‘Flexner Report’. The influence of The Flexner Report was then

7 WHO 2002a, p. 20.8 Kadetz 2015, 2013, 2012, 2011.9 For further discussion, see Kadetz 2013.10 For further discussion, see Kadetz 2015.




widely disseminated via an international health épisteme of biomedical exper-tise through the international health work of The Rockefeller Foundation. Finally, Mao Zedong’s integration of ‘Traditional Chinese Medicine’ into China’s biomedical health care system was adopted by the WHO as their model of integration. Hence, this paper will illustrate how all of these developments shaped the WHO’s discourse of the safe use of traditional medicines.

The Construction of Biomedical Safety in the United States

The Standardisation of American Medical Education and the Eradication of Medical Pluralism

Before being popularised in North America, scientific (laboratory-based) bio-medicine was developed in the academies of Europe and disseminated to European colonies. As in the United States, European biomedical physicians of the eighteenth and nineteenth centuries challenged medical pluralism and the non-biomedical practices and practitioners they portrayed as ‘charlatans’ and were successful in securing the passage of laws that prohibited their competi-tors from practising. Legal prohibitions against non-biomedical practitioners were particularly successful in Germany,11 France,12 and England.13 However, the transmission of biomedical cultures from European states were predomi-nantly bilateral—i.e., from the state colonists to their colonies—rather than global. To investigate the global transfer of scientific medicine we must analyse the development of biomedical dominance in North America.

Until the twentieth century, American health care was pluralistic. Bio-medicine was neither commonly a first choice for intervention, nor was it even considered a ‘safe’ choice.14 Beginning with folk medicine in the eighteenth- century colonies and continuing until the development of biomedical pro-fessionalism in the nineteenth century, Americans had a wide assortment of professional and lay practitioners from which to choose, including ‘bota-nists, midwives, cancer doctors, bonesetters, innoculators, abortionists, sellers of nostrums and native American Indian doctors’.15 However, since the early colonial period, biomedical physicians strongly differentiated themselves from all other health practitioners. ‘In 1763, physicians in Norwich, Connecticut,

11 Neustatter 1906.12 Gelfand 1980.13 Roberts 2009; Short 1983; Macleod 1966.14 Starr 1982.15 Ibid., p. 48.


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requested their colonial legislature to distinguish between the honest and ingenious physician and the quack or empirical pretender by allowing doctors to found societies with licensing power’.16

Although these early bids for biomedical professional exclusivity were ini-tially rejected, biomedical societies were eventually formed and sought to iso-late themselves from those whom they characterised as ‘quacks’. So profound was this separation that non-biomedical practitioners were denied all consul-tation with biomedical physicians. Any physician found ‘conferring with them was subject to penalties’.17 The ideology of American individualism and free-dom fanned the flames between these warring practitioners for over 250 years. At times, ‘Knives, pistols, chisels, bludgeons, etc. were freely displayed. The battle was finally settled when one side brought a cannon’.18 However, practice transfers did occur between biomedical and non-biomedical medicine. For example, some important remedies that were used by biomedical physicians, ‘such as smallpox inoculation and quinine, were borrowed from folk cultures’.19

One of the longest battles in US medical history occurred between bio-medical physicians and homoeopaths. Homoeopaths were popular for sev-eral decades after the Civil War; especially amongst the elites of Northeastern cities.20 From the mid-nineteenth century onward, homeopathy in the Unites States appealed primarily to the upper classes. ‘It was safer than the heroics of regular medicine, and it was a sign of affluence and taste, since it was very fashionable among the European nobility and upper class who were aped by wealthy Americans’.21

In 1846, American biomedicine was professionalised through the formation of the American Medical Association (AMA). Although the AMA had not been formed with homoeopathy in mind, avoiding contact with homoeopaths ‘took on all the gravity of a pollution taboo’.22 For example, the Surgeon General of the United States was ‘denounced for having taken part in the treatment of the Secretary of State the night he was stabbed and President Lincoln was shot, because [the Secretary’s] personal physician was a homeopath’.23

16 Ibid., p. 44.17 Starr 1982.18 Ibid., p. 94.19 Ibid., p. 47.20 Ibid., p. 99.21 Brown 1979, p. 110.22 Starr 1982, p. 98.23 Ibid.




Although the AMA had been gaining power through the late nineteenth cen-tury, their ability to do away with homoeopaths and all other non-biomedical ‘sects’ was prevented by the public.24 Homoeopaths were particularly reviled as they represented a greater potential, if not actual, source of competition for biomedical physicians.25 However, some biomedical physicians were also against the removal of homoeopathy for homoeopaths served as a lucrative source of referrals.26 Slowly homoeopaths were integrated into some aspects of the biomedical health care system, such as in hospitals, in some of the larger Northeastern cities of the US.27

However, by the turn of the twentieth century, state licensing boards were dominated and controlled by members of the AMA who now ‘made reform of medical schools a top priority’.28 In 1904, the AMA established the Council on Medical Education with ‘a mandate to elevate and standardize the require-ments for medical education’.29 Standardisation of biomedicine was man-datory for the spread of biomedical hegemony within the United States and beyond. In order to promote standardisation, the AMA invited the Carnegie Foundation to generate a complete situational analysis of American medical education.

The Flexner Report and the American Construction of Biomedical Safety

Medical education reform in the United States was an outcome of the broader social changes taking place in the so-called progressive era of the late nine-teenth century. Given the rapidly expanding industrial economy, modern scien-tific education was believed to be essential ‘to provide a well-trained industrial labor force’.30 Andrew Carnegie, the steel magnate, hired Abraham Flexner to conduct the AMA’s requested comprehensive study of North American medical schools.31 Formally titled, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, the report (known more commonly as The Flexner Report) set a standard for North American medical education that resulted in the subsequent closure of

24 Berliner 1975.25 Ibid.26 Starr 1982.27 Ibid.28 Ibid., p. 117.29 Ibid.30 Hewa 2002, p. 2.31 Ibid.


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over half (84) of North American medical schools from 1919 to 1928.32 Although the AMA had already started the process of medical school closures prior to The Flexner Report,33 of the 76 schools remaining after The Flexner Report, all offered the same curriculum, set the same academic standards, and followed the same entry requirements.34

Flexner also determined where schools should be placed and how many physicians should graduate yearly according to the size of the local population.35 Such changes would inevitably render medicine as a more viable business ven-ture for new physicians seeking profit for their expertise. Flexner concludes: ‘Reorganization along rational lines involves the strengthening of democratic principle, because it tends to provide the conditions upon which well-being and effectual liberty depend’.36 Interestingly, Flexner equates medical stan-dardisation, regulation, and professional elitism and exclusivity with a pro-portional increase in the American quest for freedom and liberty. Thereby, the standardisation of medical education in North America is represented as inherently beneficent, by contributing to the moral ideals of democracy; ideals which, by their very nature, are meant to be ethically irrefutable.

The most pertinent section of The Flexner Report for the purposes of this paper is the short chapter entitled ‘The Medical Sects’. Flexner concedes: ‘Prior to the placing of medicine on a scientific basis, sectarianism was, of course, inevitable’.37 Flexner questions if ‘sectarian medicine’, which he defines as homoeopathy and osteopathy, is ‘logically defensible’ and ‘justifiable’ in the era of ‘scientific medicine’.38 He rationalises that ‘modern medicine uses knowl-edge with no preconceptions’, whereas, ‘men possessed of vague preconceived ideas are strongly disposed to force facts to fit’, interfering with ‘the free search for truth’.39 He concludes that ‘modern medicine denies outright the relevancy or value of homoeopathy’.40

32 Chapman 1974.33 The president of the AMA reported at the annual AMA meeting in 1903 that ‘the profession

was becoming overcrowded’ and to correct this required that ‘the ease and facility with which a medical degree may be secured in this country must be diminished’, Billings 1903, p. 764.

34 Chapman 1974, p. 106.35 Flexner 1910.36 Ibid., p. 155.37 Ibid., p. 156.38 Ibid.39 Ibid.40 Ibid.




Thus, herein lays a seed of both the justification for the future dominance of biomedicine as well as the invalidation of homoeopathy and thereby, poten-tially, the invalidation of all other non-biomedical health care practices; prac-tices that Flexner considers inherently unethical by virtue of their obstruction of truth. What is so powerful in Flexner’s statement is the conflation of science and ethics in the representation of the scientisation of health care as a moral democratic imperative. This logic and politics of representation foreshadows discourses embracing modernity, as far removed from Western capitalism as Castro’s in Cuba and Mao’s in China.41

What is also relevant in Flexner’s framing is the ascendancy of the bio-medical physician as the embodiment of scientific truth and, thereby, the only expert officially deserving the title of ‘healer’; to the detriment of all other practitioners. Henceforth, biomedical knowledge is rendered the sole authori-tative health care knowledge by virtue of being scientific.42 Yet Flexner does not thoroughly dismiss all non-biomedical practices, as he identifies some value in the medical education of homoeopaths, whom he forgives for being misled. ‘Science, once embraced, will conquer the whole. Homoeopathy has two options: withdraw into the isolation in which any peculiar tenet can main-tain itself [or] to put that tenet into the melting pot’.43

As illustrated in the present-day processes of integrating non-biomedicine into biomedical health care, homoeopathy could only survive by subjugating itself to biomedicine. And six decades later, the WHO claimed that traditional medicine would ‘stagnate’ without science and technology.44

Flexner’s prognosis was either prescient or a self-fulfilling prophesy as homoeopathy was co-opted by American biomedicine for a period, before completely losing public favour to biomedicine.45 The success of biomedicine was contingent on the success of its constructed validity symbolised by scien-tific expertise and realised in the person of the biomedical physician; an expert with no political boundaries. With this contingency in place, the biomedical physician was poised to become the dominant and sole expert of all health, whose paternalism was thereby justified and seemingly irrefutable.

41 See Kadetz and Perdomo 2011 for further discussion.42 According to Strong, ‘a dominant social group legitimates its power by grounding it in a

set of authoritative understandings. These understandings are taken for granted, and they permeate and structure lived experience’, Strong 1999, p. 5.

43 Flexner 1910, p. 161.44 WHO 1978b, p. 9.45 Starr 1982.


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The Flexner Report has been called ‘one of the most conspicuous early efforts of a philanthropic foundation to shape national affairs’.46 The seed of biomedical dominance and control was clearly planted by Flexner and flour-ished in North America before being disseminated beyond native soil through the work of The Rockefeller Foundation.

Foundational Knowledge: The Rockefeller Foundation

The International Dissemination of American Biomedical Expertise In the first half of the twentieth century, The Rockefeller Foundation (RF) was markedly ‘influential in shaping the discourse around global health chal-lenges and the institutional structure of global health governance’.47 The RF’s role in international health has been well-documented.48 The Foundation was involved in all aspects of public health including the formation of ‘ideas, theory, research, professional training, practice, implementation, organization and institution building’.49 However, the work of the RF is not only relevant to the normative construction of international health, but, more significantly, the Foundation exerted a primary influence on the World Health Organization in helping to secure science and technology as the dominant paradigms for the biomedical and global health discourse. ‘As the only health agency truly oper-ating internationally until the founding of the WHO in 1948, it helped to shape global public health to a greater extent than any other’.50

American philanthropic foundations of the early twentieth century pro-vided a means for business tycoons, such as John D. Rockefeller, to protect their wealth from taxation,51 as well as build prestige and political influence in domestic and world affairs.52 These foundations ‘were built on a combination of scientific principles and commercial practices, administered by paid executives

46 Baick 2004, p. 73.47 Martens and Seitz 2015, p. 23.48 See, for example, Brown 1979, Schneider 2002, Farley 2004, and Page and Valone 2007. 49 Birn 2006, p. 31f.50 Ibid. From their beginnings, ‘philanthropic foundations like the Rockefeller Foundation

have been influential actors in global development, not only through their grant- making, but also by shaping development concepts and policies, particularly in the areas of health’, Martens and Seitz 2015, p. 13.

51 After the US Supreme Court ordered dissolution of the world’s largest oil company, Standard Oil, John D. Rockefeller became the wealthiest man in the world, see Martens and Seitz 2015, p. 9.

52 Ibid.




with expertise in specific fields, [such as] law, medicine, public administra-tion, [and] education’.53 Early American philanthropic foundations embodied ‘progressive thinking with their predominant faith in experts [resulting in] the ascent of such groups as physicians and academics’.54 Education for profes-sional expertise, and the creation of elite technocrats in particular, became an imperative tool for the political-economic dissemination of American capital-ism internationally and laid an important foundation for American interna-tional dominance in trade in the early twentieth century. In this social context, The Rockefeller Foundation set about making ‘educational institutions, the agricultural economy, and the [sic] public health more supportive of the new industrial order’.55

John D. Rockefeller invited Frederick T. Gates, a Baptist minister and fund-raiser, to direct his growing philanthropy.56 Medical education reform became a central focus of the work of Gates. Like Flexner, who shortly after the com-pletion of his report for Carnegie became part of The Rockefeller Foundation team, Gates believed that medical education needed to be systematised, stan-dardised, and above all laboratory-based and scientific.57 Gates soon granted funding to those medical schools that he personally deemed worthy of being supported. The RF granted US $45,000,000 toward the reform of medical education58 and Gates was thereby able to enact many of Flexner’s wishes.59 Like Flexner, Gates’ hopes that his chosen schools would flourish coincided with his wish for numerous other allegedly ‘unscientific’ North American med-ical schools to vanish.

From 1910–35, Rockefeller philanthropies contributed ‘90–95% of all Foundation monies into American medicine’.60 The medical school of Johns Hopkins University was the first to be funded by The Rockefeller Foundation.61

53 Hewa 2002, p. 8.54 Baick 2004, pp. 60–2.55 Brown 1976, p. 899.56 Hewa 2002.57 Quite ironically, John D. Rockefeller Sr. favoured the use of homoeopathy his entire life.

‘I am a homeopathist’ Rockefeller proclaimed, ‘I desire that homeopathists [sic] should have fair, courteous, and liberal treatment extended to them from all medical institutions to which we contribute’, Brown 1979, p. 110.

58 Fleishman 2007.59 It is noteworthy that, like Flexner, Gates framed his vision of medicine and science in a

moralistic theology. He saw medical science as a modern theology. ‘In his eyes, an inti-mate relationship existed between God and physicians’. Ma 2002, p. 162.

60 Baer 1988, p. 189.61 Brown 1979.


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According to Gates, Johns Hopkins was to be the gold standard for all American medical education.62 In total, the RF contributed more than US $25 million for the development of public health schools in the US and internationally.63 The Foundation went on to fund and influence the curricula of medical and pub-lic health schools in London, Toronto, Warsaw, Prague, the Philippines, and 16 other countries.64 But The Rockefeller Foundation sought to expand its phi-lanthropy (and political influence) further on the international stage, particu-larly to China.

The Profitability of Safety: The Establishment of an International Health Épisteme

Philanthropies such as the Carnegie, Ford, and Rockefeller Foundations iden-tified that the dissemination of a particularly American political-economic ideology into low- and middle-income countries could be accomplished most directly through education.65 Thus, it can be understood that The Rockefeller Foundation established international health projects, to disseminate a partic-ular political-economic épisteme around the world.66 Brown argues that the Foundation’s public health programmes in foreign countries ‘were intended to help the U.S. develop and control the markets and resources of those nations’.67

Regardless that improvements to the population’s health in the early twenti-eth century were primarily an outcome of improvements in social conditions, the RF’s projects approached health as a technical issue requiring technical solutions.68 ‘Science-enabled innovations based on a biomedical view of pub-lic health and the embrace of new technologies were key to the Rockefeller

62 Brown 1976.63 Ibid.64 Solomon 2000; Martens and Seitz 2015, p. 24.65 Berman 1983.66 I am specifically using the term épisteme here as Foucault has defined; ‘the strategic appa-

ratus which permits of separating out from among all the statements which are possible, those that will be acceptable, which makes possible the separation, not of the true from the false, but of what may from what may not be characterised as scientific’, Foucault 1980, p. 197.

67 Brown 1976, p. 897.68 ‘The newly emergent capitalist class was faced with the dual (and often contradictory)

tasks of increasing and abetting capital accumulation and of maintaining the viability and legitimacy of the social order. The response of the capitalists, as a class, manifested itself in the transformation of social problems into technical problems. Problems whose actual basis was social and hence whose solution was political were transformed into problems of science whose solution was then technological’. Berliner 1975, p. 573.




Foundation’s approach to tackling global health problems’.69 By denying the relevance of social conditions and political-economic forces to population health outcomes, technical solutions can effectively shield governments and their elite from accountability and responsibility and thereby perpetuate the status quo of the social order and its hierarchies. Furthermore, the creation of technological need and the development of technologies to address this need were indeed quite profitable.

At the turn of the twentieth century, the first Rockefeller Foundation project for hookworm eradication in the Southern United States served as a precursor for many of the international projects that followed. From its original inten-tion ‘to integrate the backward South into the industrial economy controlled by Northern capitalists’, the Foundation identified hookworm infestation as the source of decreased productivity of workers, which ultimately affected profits.70 It was estimated that 25 per cent more labourers were needed to achieve the same output in countries with heavy hookworm infestation, com-pared to those without infestation.71 Once investing in health care was under-stood as a profitable enterprise, medicine, technology, capitalism, and safety were effectively joined.

Other early Foundation successes include the first yellow fever vaccine and the eradication of the malaria vector in Brazil.72 These successes supported The Rockefeller Foundation in its effort to spread an approach to ‘tackling public health problems through large technically-based disease eradication, [and] integrating it into the newly emerging public health systems around the world’.73 To achieve these goals they funded ‘hospitals, universities and churches to support education, research and medicine’.74 Ultimately, they cre-ated ‘an epistemic community around global health issues’.75

The success of the domestic hookworm programme led to the formation of the RF’s International Health Commission in 1913, later to be renamed the International Health Board (IHB).76 In addition to the funding of schools of medicine and public health internationally, The Rockefeller Foundation had

69 Martens and Seitz 2015, p. 24.70 Brown 1976, p. 898.71 Ibid.72 Martens and Seitz 2015, p. 24.73 Ibid.74 Ibid.75 Ibid.76 The hookworm campaign provided a ‘means of entry into the colonial tropics’ potentially

‘permitting ingress to a colony, or new state’, Anderson 2002, p. 702.


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‘regional field offices in Paris, New Delhi, Cali and Mexico, and stationed hun-dreds of officers around the world’.77 Beyond the promise of increased produc-tivity of labour, international health projects provided a safe, irrefutable, and inherently beneficent means by which to disseminate an American political-economic ideology across the globe. Nye labels this subtle form of international diplomacy ‘soft power’, in which one country is able to ‘get other countries to want what it wants through attraction rather than coercion’.78 Nye’s thesis appears to be supported by the RF’s own report of 1917 in which they state: ‘Dispensaries and physicians have of late been peacefully penetrating areas of the Philippine Islands and demonstrating the fact that, for purposes of pla-cating primitive and suspicious peoples, medicine has some advantages over machine guns’.79

Purportedly, The Rockefeller Foundation intended to achieve US economic and political domination in four steps. First, through American control of resources and markets.80 Second, via increased international development.81 Third, by effectively disseminating an understanding that disease prohibited economic development.82 And lastly, through the implementation of biomedi-cal public health programmes ‘that would improve the population’s health and working capacity’.83 When the Foundation’s work was met with ‘suspicion and hostility’, they ‘found it expedient to play down its American origins by high-lighting itself as a representative and promoter of a culturally odourless brand of modern medical science’ that was innately beneficent.84 Thus, embedded in the paradigm of biomedicine is the creation of a perpetual need—and thereby market—for technological solutions and innovation.

The RF was not only influential in embedding ‘its science-enabled innova-tion approach into national health systems around the world’, but it similarly ‘influenced international health organizations’.85 In order to fully disseminate their épisteme internationally, The Rockefeller Foundation required a multilat-eral platform, which they found in the League of Nations Health Organization.

77 Martens and Seitz 2015, p. 24.78 Nye 1990, p. 166.79 Rockefeller Foundation 1917, p. 42.80 Brown 1976, p. 897.81 Ibid.82 Ibid.83 Ibid.84 Liew 2006, p. 9.85 Martens and Seitz 2015, p. 25.




Building an Elite Network of Biomedical Expertise: The League of Nations Health Organization

As a result of their ‘large resources and confidence in their goals, the trustees and officers of a few of the largest American foundations became convinced they could change the practice of science and medicine on a worldwide scale’.86 In their attempts to determine international standards and goals for public health and medicine, cooperation with international agencies was essential.87 The International Health Board of The Rockefeller Foundation identified that in order to achieve its mission, an ‘international transfer of expertise’ was essential to improve national health care systems.88 This objective was achieved through the precursor of the World Health Organization, the League of Nations Health Organization (LNHO).

The RF funded 40 per cent of the budget of the LNHO.89 ‘It also supported the LNHO in staff recruitment’, and many of the LNHO’s staff and the advisory board were former Rockefeller Foundation fellows.90 The Foundation’s empha-sis at LNHO was on ‘the development of a pool of international experts in public health’.91 ‘The RF’s funds were specifically targeted to broaden the involvement of medical officers and medical researchers in the work of LNHO, particularly through study visits and its network of specialist committees’.92 The RF used the LNHO as the means to improve health through the institutional resources of a scientific and medical expert elite. By 1927, the Foundation supported 435 individuals on League of Nations exchanges and 75 individual scholarships.93 This matured into a more elitist scheme for meetings of directors of the new schools of hygiene to which the Foundation had so substantially contributed.94 Thereby, the LNHO provided a framework for international health through which a Rockefeller Foundation ideology was embedded, that could be fur-ther sustained and disseminated through the Foundation’s continued train-ing of public health experts who were to hold important positions in health sectors both in their home countries and internationally. But the RF’s inter-national influence did not end with the LHNO. Rockefeller Foundation staff

86 Schneider 2002, p. 2.87 Ibid.88 Weindling 1997, p. 269.89 Loughlin and Berridge 2002.90 Martens and Seitz 2015, p. 25.91 Weindling 1997, p. 273.92 Ibid., p. 275.93 Ibid.94 Ibid.


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held leadership positions in the World Health Organization from its creation in 1948.95 And ‘many of WHO’s programmes initially followed the Rockefeller Foundation’s technical approach to health’.96

Thereby, the RF’s international training of an elite cadre of experts provided a demonstrable means to achieve both biomedical hegemony and US capital market domination. By 1917, the IHB ‘was at work in 37 areas, which included 25 foreign states and countries’.97 By the early 1920s, the IHB was present-ing itself as ‘the watchtower of public health for the world at large’.98 During this period, China was believed to offer ‘a vast potential market for American goods, American culture, and American democracy’.99 China also became a route through which the discourse of health care integration, and thereby the safety of traditional medicines in the global arena, was formally adopted into the global discourse of the World Health Organization.

The Silk Road to Safety: Health Care Integration

From the Reception of Biomedicine in China to the Reception of the Chinese Model of Integration in the WHO

The reception of Western modernity in China was neither a uniform process, nor was it agreed upon by all segments of the Chinese population, nor even by the same segments of the population over time. At the onset, China appeared disinterested in Western modernisation until a series of crises occurred begin-ning in 1840 with the Opium War, followed by the 13 year-long Taiping rebellion in 1851, the loss of Vietnam to France in 1885, the Anglo-French invasion of 1857, and finally ending with the loss of Korea to Japan in 1895.100

China’s initial reception of biomedicine in the nineteenth century was selec-tive and often dismissive. Elites originally rejected Christianity and questioned Euro-American biomedicine. The lowly status of biomedicine was reinforced by the Western missionary practitioners who treated the local indigent popula-tion for free.101 Many Chinese were resentful of medical missionaries, because of the emphasis placed by the missionaries on the link between ‘health and

95 Martens and Seitz 2015.96 Ibid., p. 25.97 Rockefeller Foundation 1917, p. 36.98 Solomon 2000, p. 409.99 Ma 1995, p. 57.100 Barnes 2005.101 Ma 2002.




Christianity’.102 In fact, some were so outraged by surgical practices, perceived as a defiance of Confucianism in its mutilation of the body, that anti-Christian riots ensued.103

Although a distinct shift in the Imperial Court’s resistance toward what they regarded as ‘Western medicine’ can be identified from the time of the Self-Strengthening Movement (Yang Wu Yun Dong 洋務運動), lasting from 1860 to 1895, it was not until after the Revolution of 1911 that the Chinese govern-ment accepted biomedicine.104 Thereafter, a new Chinese biomedical elite was established who worked in cities and catered to the wealthy. And who, through their association with ‘the politicians and bureaucrats of the emergent Chinese state, were able to acquire some of the status and authority of the state’.105

China was to become ‘the most important foreign recipient’ of Rockefeller philanthropy.106 The Foundation established the China Medical Board (CMB) in 1914 to oversee its work in China.107 The function of the CMB was ‘assistance in the development of a comprehensive and adequate system of medicine in China’.108 The CMB specifically supported Chinese medical schools and hospitals.109 Chinese students were also sponsored by the CMB for medical studies in the US. For example, during 1917, US $45,487 in Foundation funds enabled ‘57 individuals to come to the United States for training. The group included: 3 Chinese pharmacists, 3 Chinese nurses, 7 Chinese students, 13 Chinese physicians, and 31 medical missionaries from China’.110

The Foundation also sponsored the professionalisation of American medi-cine in China by developing a leading medical centre for research and teaching in Beijing.111 As its first medical project in Asia—and most expensive medi-cal project to date—the Foundation reopened the mission-run Union Medical College of Peking as Peking Union Medical College (PUMC) in 1921.112 Over the next 30 years The Rockefeller Foundation provided grants and endowments to PUMC totalling US $45 million, ‘the largest contribution it ever made to a

102 Yip 1982, p. 1200.103 Andrews 1996, p. 11. For further discussion, see Andrews 2015.104 Andrews 1996.105 Ibid., p. 15.106 Rockefeller Foundation 1917, p. 84.107 Ibid.108 Ibid., p. 223.109 Ibid.110 Ibid., p. 47.111 Elman 2003, p. 21.112 Ma 1995, p. 1.


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single international project’.113 The Foundation modelled PUMC on their most successful educational venture, The Johns Hopkins Medical School.114 The ‘total commitment to the scientific method, high academic standard, and elite social status of its students and faculty’ has been singled out as distinguishing features of PUMC.115 The PUMC charged twice the tuition of other medical col-leges and actively sought to recruit the Chinese elite.116 But most importantly, the majority of the 315 physicians granted degrees from PUMC became ‘lead-ing administrators of China’s modern medical education. PUMC Graduates became leaders of China’s medical institutions and officials in governmental health organizations’.117

The Foundation’s projects in China tended to ignore and even disregard Chinese medicine. Frederick Gates argued that the Chinese were ‘not a host of souls to be converted’ to religion, as identified in the unsuccessful approach of missionaries in China, but rather ‘a people who were suffering under the yoke of primitive medicine’ and thereby in need of conversion to biomedicine.118 The RF’s failure to acknowledge the importance of Chinese medicine for the majority of the population is argued to have led to the limited acceptability of many of the Foundation’s programmes in China. ‘Instead of seeking to integrate traditional medicine with Western, scientific methods of medicine, they [RF] tended to reinforce the gulf that already existed between the two systems’.119 And yet, despite their dismissal of Chinese medicines some Foundation proj-ects may have indirectly influenced the later practice of health care integration in China.

An Early Rockefeller Foundation Project for Health Care Integration in China

The integration of traditional birth attendants was enforced in China in the early twentieth century.120 Local and national governments ‘began to regulate midwives as early as 1913. As part of this process, midwives who had received some formal medical training were required to be licensed, while, those working

113 Ma 2002, p. 159.114 Ma 1995, p. 1.115 Ibid., p. 146.116 Brown Bullock 1980.117 Ma 2002, p. 168.118 Baick 2004, p. 86.119 Yip 1982.120 Johnson 2008.




without the prescribed training began to be forced out of the field’.121 The Rockefeller Foundation funded the First National Midwifery School of the National Midwifery Board of China in 1930, which instituted training for midwives.122 Some of the students receiving certificates and licences were traditional birth attendants who thereby were integrated into the biomedical health care system.123

The Director of the School who oversaw this integration process, Marion Yang (aka Yang Chongrui), was trained as a physician at PUMC. In a 1932 letter to the RF, Yang writes, ‘It is estimated that there are about 400,000 untrained midwives. The main responsibility for the excessive deaths among the moth-ers and babies may be laid on this untrained group’.124 Like Flexner and Gates before her, Yang equated non-biomedical practices with danger, and in need of safe biomedical oversight. Similar to Flexner’s solution for homoeopathy to become ‘scientised’ and integrated and, in effect, weakened, Yang sought to train ‘old-type’ midwives to be (safe) biomedical midwives. As of 1933, 246 old-type midwives had been reported as registered and licensed. Yang noted, ‘The number of old-type midwives is gradually decreasing and the number of modern midwives is increasing’.125

‘The Reformation’: The Modern Integration of Schools of Chinese Medicine

But the suppression of non-biomedical practices and practitioners was not restricted to traditional birth attendants. In 1929, the bill entitled Abolishing the Old Medicine in Order to Clear the Obstacle for Health and Medicine was accepted by the Department of Health.126 Among many social and political influences of the period, the turn against Chinese medical practices can, at least in part, be located in the pervasive intellectual debates among physicians and scientists, particularly among those educated overseas, in the political influence of the leading nationalist party Guomindang, and in the increased number of foreign schools, whose country support the Guomingdang sought and dared not offend.127

121 Ibid., p. 283.122 Yang 1932.123 Ibid., p. 1.124 Ibid., p. 2.125 Yang 1933, p. 20.126 Ma 1995.127 Ibid., p. 218.


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In addition, from the late nineteenth century to the end of the Republican era, a small contingent of scholar-practitioners of Chinese medical practices known as the ‘School of Merging’ [Chinese medical tradition and biomedi-cine] (Huitong pai 匯通派) sought to preserve Chinese medicines through modernisation and ‘synthesis’ (huitong 匯通) with biomedicine.128 This group was part of a larger national movement, ‘which opposed the wholesale adop-tion of Western culture’.129 Yet, they thought it detrimental to ignore biomedi-cine, and instead sought to justify Chinese medicine via biomedicine.130 ‘Their efforts ranged across a wide spectrum from assimilation of certain Western ideas of Chinese medicine to the use of biomedical knowledge to instigate total reform of Chinese Medicine’.131 They attempted to standardise the teaching and practice of Chinese medicines through government licensing of schools and practitioners.132

The reforms of the School of Merging foreshadowed Mao’s call for the uni-fication of Chinese medicines with biomedicine. During the formation of the CCP, Mao Zedong wrote his key text, On New Democracy (Xin minzhu zhuyi lun 新民主主義論, in which he emphasised: ‘We want to change a China which has been ignorant and backward under the rule of the old culture into a China that will be enlightened and progressive’.133 Surprisingly similar to Flexner, Mao spoke of science as truth, whilst eschewing all ‘feudal and superstitious ideas’.134 As with his Republican Era predecessors, Mao initially singled out Chinese medicine as a ‘hindering factor’ towards the new democratic culture, which required ‘remoulding’ in order to become part of the revolutionary movement.135

However, in constructing modern communist health care, Mao faced the paradox that Chinese biomedical physicians would only agree to work in mod-ern urban hospitals and clinics, rather than in poor rural areas. Mao’s solution to the resulting inequity in rural health was to unite biomedical physicians ‘with

128 Scheid 2001, p. 370.129 Andrews 1996, p. 15.130 Ma 1995.131 Scheid 2001, pp. 370–1.132 Ibid.133 Taylor 2001, p. 344.134 Ibid., p. 345.135 Ibid. Similar to Mao’s path, Castro originally rejected all non-biomedical practices as

backward and counter-productive to the modernisation of the communist state, until economic necessity, stemming from the US embargo on Cuba, resulted in the Cuban state’s embrace of non-biomedicine through the integration of Medicina Tradicional y Natural; see Kadetz and Perdomo 2011.




the old style doctors who can be used to help educate and remould them’.136 In attempting to maximise human health resources, and encourage biomedical physicians to study Chinese medicines, Mao reverted to nationalism, relaying in 1958 that ‘China’s medicine and pharmacology is a great treasure house and should be diligently explored and improved upon’ (Zhongguo yiyaoxue shi yige weida de baoku (中国医药学是一个伟大的宝库).137 However, Mao was not ultimately interested in promoting Chinese medicines, per se, but in training biomedical physicians in Chinese medicine.138 His goal was to have ‘high level medical professionals’ ‘integrating China and the West’139 as identified by the political slogan that ‘Chinese and Western medicine/physicians [should] join forces’ (Zhongxiyi tuanjie 中西醫團結).140 Though he ultimately sought a new hybrid of biomedicine and Chinese medicines, Mao’s first step was to render Chinese medicines more acceptable to biomedicine through the integration of Chinese medicines into what has been labelled in English, ‘traditional Chinese medicine’ or TCM.

From the late 1950s onwards, Mao specifically called for integration of biomedicine and Chinese medicine under the slogan ‘Chinese and Western medicine [should] be integrated’ (Zhongxiyi jiehe 中西醫結合).141 Thus, inte-gration was being distinctly conceived as a process of modernisation via the standardisation and Western ‘scientisation’ of different schools of Chinese medicine142 and via the attempted ‘biomedicalisation’ of Chinese physicians.143 Although the Chinese Communist Party (CCP) took control of PUMC in 1951, the influence of The Rockefeller Foundation’s work may have been dissemi-nated through many of the PUMC graduates who oversaw important aspects of public health,144 including the integration of Chinese medicines with

136 Taylor 2001, p. 346.137 See Taylor 2005, p. 120.138 Ibid.139 Ibid.140 See Taylor 2001, p. 361. Note that, as the third Chinese character (醫) can refer to both

physician and medicine, this slogan may be interpreted as calling for solidarity between health practices and practitioners.

141 See Taylor 2001, p. 361. See also Hsu 2008.142 Taylor 2005.143 Ibid.144 Despite CCP directives, the Ministry of Health, comprised predominantly of graduates

from Peking Union Medical College, continued to oppose integration of Chinese and biomedicine throughout the 1950s, cf. Lampton 1974. Mao attacked the Ministry for only being concerned with the urban elite, as well as for their sole focus on curative rather than


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biomedicine.145 Similar to Flexner’s advice for biomedical oversight of the inte-gration of homoeopathy into biomedicine, Mao employed biomedical physi-cians, many of whom were PUMC graduates, to comb through the practices of Chinese medicines and remove any superstitious or spiritual elements. Those elements that were deemed to be more ‘biomedical-like’, and thereby more capable of being understood by the West, were retained.146

However, Mao’s ultimate goal of unification, with the formation of a new hybrid of biomedicine and Chinese medicine, was never fully realised. Instead only the first step of unification, namely the integration of Chinese medical practices (in the form of TCM curricula, biomedicalised research, and inte-grated practitioners) into biomedical health care institutions was achieved. This shortcoming was partly due to the resistance to unification by both Chinese medicine and biomedicine physicians. During the early campaigns for integration, biomedical physicians were forced to engage in TCM studies. Those physicians who resisted risked being purportedly labelled bourgeois, criticised, and/or exiled to live and work in distant areas.147 Subsequently, the same pres-sures that had been directed toward biomedical physicians were then directed with even greater ferocity towards those Chinese medicine practitioners who sought to maintain autonomy and ideological separation from biomedicine. Chinese classic medical texts were burned, Chinese medicine schools were closed, and Chinese medicine physicians became the object of ridicule or physical attack and their practices and pharmacies were destroyed.148 Hence, even though integration in China was a process that was enforced, required coercion, and even led to violence to gain the cooperation of biomedical and Chinese medical doctors, this model of integration was the one adopted by the World Health Organization after the end of the Maoist era in 1976.

The Discourse of Traditional Medicine Safety Finds a Safe Global Home at the WHO

Health care integration not only established the need for ensuring the safety of non-biomedical practices and practitioners, but also the means by which

preventive medicine; over-dependence on the Soviet health care model; and refusal to unify TCM and biomedicine. Sidel 1973; Lampton 1974.

145 Taylor 2005. 146 Ibid.147 Ibid. 148 Scheid 2002.




to do this. In the WHO’s 1977 Meeting on the Promotion and Development of Traditional Medicine, it was decided that:

effective integration, like that of the Chinese experience, entails a synthe-sis of the merits of both the traditional and so called Western through the application of modern scientific knowledge and techniques.149

This statement reifies the need for local health care practices to be under-stood, validated, and practised via bioscientific paradigms. Although the WHO ‘believes in the potential of traditional medicine’ they need to ‘subject it to rigorous scientific evaluation’.150 The WHO identifies the development of norms, standards, and guidelines as the means by which to achieve the safety of non-biomedical practices.151 However, it is acknowledged that ‘both a lack of research’ and ‘a lack of adequate or accepted research methodology for evaluating traditional medicine’ are challenging the establishment of safety of non-biomedicines.152 Hence, embedded within this discourse is the paradox that, although the safety of local practices purportedly needs to be validated by biomedicine, non-biomedicines may not ultimately be able to be evaluated or validated according to biomedical standards. According to participant obser-vation in the Traditional Medicine Unit of the WHO and through the analysis of current WHO literature, ‘effective integration’ continues to be promoted as a solution to the paradox of biomedical validation. But in terms of effective inte-gration, it is not immediately evident why the ‘Chinese experience of integra-tion’ became the WHO model for ‘effective integration’, when there were other examples from which to choose, such as the successful and far less violent, bottom-up, practitioner-initiated integration of Ayurveda in India.153

Although leaving the World Health Organization in 1949, due to the US-led recognition of the Republic of China (Taiwan) as the ‘diplomatic China’, The People’s Republic of China rejoined the WHO in 1973.154 Five years later, at the urging of Russian WHO delegates, and possibly influenced by the Chinese nationals in positions of power in the WHO at the time, China’s purported success in reducing rural health care disparities through the integration of

149 WHO 1977, p. 16.150 Vuori 1982, p. 131.151 WHO 2002c.152 WHO 2002b, p. 21.153 See Leslie 1992 for further discussion.154 Siddiqi 1995.


24 Kadetz


traditional Chinese medicine into the health care system155 and the use of integrated rural community health workers (or barefoot doctors) to redress the lack of human health resources in rural areas, were adopted as the model by which to achieve universal health care in the WHO’s 1978 Declaration of Alma Ata.156 However, the purported successes of this model may be based more on political mythology than actual outcomes, for as Fang identifies, the inte-grated barefoot doctors programme resulted in the promotion of biomedicine into rural China along with the simultaneous decline in popularity of Chinese medicines.157

But the then Secretary General of the WHO, Halfden Mahler, advised that in order to achieve Health for All by the Year 2000 ‘all useful methods will have to be employed and all possible resources mobilized [including] various kinds of indigenous practices; and among those resources are various types of tradi-tional practitioners who are suitably trained socially and technically to work as a health team’.158 Thereby, the erratic and sometimes violent political process that resulted in the integration of (the actually already integrated) TCM into the Chinese health care system has remained the WHO’s primary model for health care integration and serves as the means to oversee the safe use of non-biomedical practices.

After Alma Ata, the discourse on traditional medicine became the domain of the Traditional Medicine Unit at the WHO headquarters in Geneva and in its sister regional office units. However, under Director-General Hiroshi Nakajima (1988–98), the Traditional Medicine Unit was placed under the control of the Essential Medicines Division of the WHO. During Nakajima’s tenure, myriad circumstances, including the restraints of a static budget, led to an ideo-logical shift at the WHO toward economism and a fixation on economic effi-ciency, whilst ‘developing closer links with the World Bank, the World Trade Organization, and the private sector’.159 Invariably, these changes impacted all divisions of the WHO, including the Traditional Medicine Unit.

In a chronological analysis of WHO publications, the WHO’s traditional medicine discourse can be identified to have shifted from a focus of access

155 But it is important to note that what the WHO represents as the model for health care integration, is not the integration of various schools of Chinese medicine and biomedi-cine into the state health care system, but rather the integration of, what is, in actuality, the already integrated TCM.

156 WHO 1978a.157 See Fang 2015 for further discussion.158 Mahler 1983, p. 7.159 Lee 2009, p. 128.




and primary health care to distinctly more pharmacological and commodi-fied priorities after the reorganisation of traditional medicine under Essential Medicines. These commodified priorities are evident in such WHO publica-tions as Good Agricultural and Collection Practices,160 Herbal Regulations,161 Good Manufacturing Practices,162 and Quality for Herbal Medicines regard-ing contaminants and residues.163 All of these guidelines are overwhelmingly concerned with the safety, particularly the intrinsic safety, of manufactured local and regional non-biomedicines, often based on ‘traditional’ herbal ingredients.164 Even the term ‘safety’ appeared with far greater frequency in WHO literature after these organisational changes. Thus, although the para-digm of biomedical safety was already embedded in the traditional medicine discourse of the WHO, it may have become even more central to this dis-course because of both political-economic changes within the World Health Organization and the rapidly growing commodification of non-biomedicines.

Conclusion

This paper has argued that the biomedical paradigm of safety, globally dis-seminated through the WHO’s discourse for traditional medicines, can, at least in part, be traced back to an American construction of biomedical domination and expertise. This process was guided by the politics, policies, and actions of the American Medical Association in establishing scientific biomedical train-ing and placing the biomedical physician into a dominant position within American health care. The Flexner Report documented the need for a scien-tific biomedical order of health care training, while the work of The Rockefeller Foundation established the hegemony of biomedicine and the authorita-tive knowledge of the biomedical expert throughout the world. Thereby, The Rockefeller Foundation played a significant role in the construction and global dissemination of the biomedical discourse of safety and the control of safety through the biomedical expert. The Foundation achieved this through their work in international vertical public health projects, the funding of medical and public health schools, assistance in the formation of public health systems in numerous countries, significant support of the first international health

160 WHO 2003.161 WHO 2005.162 WHO 2007a.163 WHO 2007b.164 See Kadetz 2014 for further discussion.


26 Kadetz


agency, The League of Nations Health Organization, and the training and employment of public health administrators, particularly in China. Thereafter, biomedical expertise has been able to dictate what safety is and what crite-ria non-biomedicines must achieve in order to be deemed safe. Biomedicine’s dominion over non-biomedicine is particularly evidenced in the integration of Chinese medicine with biomedicine, as led by biomedical physicians, and the subsequent adoption of this model by the WHO, as a means to ensure the safe use of non-biomedical practices.

This paper has also argued that biomedical safety serves as the justification for entire hierarchical regimes of health care. These hierarchies of expertise have become so normative and embedded in contemporary conscience that it is assumed to be a universal foundational pattern of nature and thereby irrefutable.

However, preserving the integrity of one’s social and cultural order may be understood as a foundational force that has fuelled this colonisation of bio-medical safety. Anthropologist Mary Douglas identifies how any loss of the boundary between the order of Self and Other can be understood to poten-tially pollute the order of both. This may explain the great resistance to inte-gration that Mao faced from physicians of both biomedicine and Chinese medicine. ‘These are pollution powers which inhere in the structure of ideas itself and which punish a symbolic joining of that which should be separate. It follows from this that pollution is a type of danger where the lines of structure are clearly defined’.165 Safety is thereby ritualised in the mechanisms by which dominant social orders, such as biomedicine, are protected from internal and external threats. Thus, biomedicine’s Other (the non-biomedical practitioner) and the order of the Other (non-biomedical practices and the cultures from which they developed), can be perceived as a threat to dominant social order and security.166 And, therefore, they must be controlled.

Although biomedical safety has been constructed as a universal representa-tion, safety is locally situated and practised. Safety, then, may best be under-stood as a cultural value, specific to local and regional medical cultures. Yet attending to the understandings of the local is not possible when the local is depicted as the same as the global. This confusion of global as local is embed-ded throughout the WHO’s traditional medicine discourse. We can even iden-tify this confusion in the WHO’s designation of ‘traditional medicine’. A label that is applied to all local and regional non-biomedical practices, regardless

165 Douglas 1966, p. 140.166 Currently, this can be evidenced in the modern securitisation discourse of the state that

represents global health issues as issues of state security.




of how ‘traditional’ they actually are and regardless that this label masks how the processes of integration of traditional medicine is often the integration of standardised and ‘biomedicalised’ regional practices, such as TCM, at the expense of local cultural practices that are effectively being marginalised.

Finally, the discourse of biomedical safety cannot be isolated from its political-economic roots. Commodification is dependent on the creation of demand through the creation of need. The commodification of safety creates the need for external (biomedical) expertise and technology, as individuals and groups are deemed incapable of determining and providing their own safety. In this manner, local culture and local expertise are rendered fully dependent upon global policies and frameworks.

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Safety Net: The Construction of Biomedical Safety in the Global Health Discourse.

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