Three plural medical systems in East Asia: interpenetrative pluralism in China, exclusionary pluralism in Korea and subjugatory pluralism in Japan

Three plural medical systems in East Asia: interpenetrative pluralism in China, exclusionary... Abstract Amid persistent interest in and concerns about traditional, complementary and alternative medicine (TCAM) in low-, middle- and high-income countries, the global community of healthcare is in need of learning ways to institutionalize TCAM with biomedicine. By investigating how traditional East Asian medicine (TEAM), one of the most popular forms of TCAM in the world, is institutionalized in China, Korea and Japan, this study finds three different ways of instituting a plural medical system in which TCAM and biomedicine intersect with each other. In the interpenetrative pluralism in China and the exclusionary pluralism in Korea, TEAM and biomedicine are institutionalized as independent and equivalent systems of medical practices. However, TEAM and biomedicine are conditioned to cross over into each other unconditionally in practice in the former, whereas the two exclude each other very strictly in the latter. In the subjugatory pluralism in Japan, the crisscrossing of TEAM and biomedicine is allowed, yet in an asymmetrical way whereby the practice of TEAM is dependent upon and subordinated into biomedicine. The practice of various TEAM modalities is overseen by TEAM doctors, biomedicine doctors or integrative TEAM–biomedicine doctors in interpenetrative pluralism, by TEAM doctors only in exclusionary pluralism, and by biomedicine doctors only in subjugatory pluralism. These varying characteristics demonstrate a variety of plural medical systems. They also provide useful cues in accounting for the varying behaviours of medical service providers and users who encounter TCAM as well as biomedicine in their everyday practices. In addition, the growing literature about the outcomes of TCAM and plural medical systems can take advantage of these findings. Medical pluralism, alternative medicine, complementary medicine, traditional medicine, health systems research, sociology, China, Korea, Japan Key Messages Three institutional principles underlie plural medical systems of TCAM and biomedicine in East Asia: interpenetrative pluralism in China, exclusionary pluralism in Korea, and subjugatory pluralism in Japan. These institutional characteristics are potentially related to the varying behaviour of medical service providers and users of both TCAM and biomedicine. Studies of healthcare planning and outcomes need to pay attention to the institutional characteristics of each plural medical system. Introduction Despite the move to transform medical practices to the forms of biomedicine (Parsons 1951; Freidson 1970; Clarke et al. 2003; Phelan 2005; Freese and Shostak 2009), alternative forms of medical practices persist in the world: not only traditional and indigenous medical practices in Asia, Africa, and Latin America (Decoteau 2013; Babis 2014; Josyula et al. 2016), but also complementary and alternative medicine in Europe and North America (Clarke et al. 2015; Givati and Hatton 2015). A significant number of people are found to use these forms of traditional, complementary and alternative medicine (TCAM) in addition to biomedicine for various reasons (Yu et al. 2012; Pedersen 2013; Shim et al. 2014). Amid this popularity, there are concerns about these plural medical systems that are composed of both TCAM and biomedicine. Some systems are found to produce tensions between the two different traditions of medical practices and subsequently adverse healthcare outcomes (Campbell et al. 2008; Downey et al. 2010; Decoteau 2013; Holcomb 2009), while others generate tangible healthcare benefits through collaborations between the different medical traditions (Mehling et al. 2007; Korinenko et al. 2009; Kogure et al. 2010). The ways in which people use TCAM with biomedicine and the expectations that users have toward TCAM are found to be influenced by the institutional conditions in which TCAM is sanctioned (Pillsbury 1982; Johannessen 2010; Liu et al. 2013; Shim 2016; Shim and Kim 2016). The extent to which TCAM users discuss their use of TCAM with their primary healthcare professionals varies among TCAM modalities that are differently incorporated into the medical system (Shim et al. 2014). Even the treatment outcomes of TCAM seem to be affected by these institutional conditions (Shim 2015) or by the degrees to which TCAM users utilize the expertise of healthcare professionals in addition to their own knowledge (Broom 2009; Dew et al. 2014). In sum, the manners in which TCAM is institutionalized in medical systems seem to be consequential for many aspects of healthcare systems. In this regard, it is important for the world healthcare community to be informed of how to incorporate TCAM into the medical systems that are mostly organized around biomedicine (Maclean and Bannerman 1982; Stepan 1985; Leslie 1998; WHO 2002, 2013; Lakshmi et al. 2015). These studies find that there are economic, cultural, or medical rationales for attempting to incorporate TCAM into the mainstream biomedical systems. At the same time, there are political as well as theoretical tensions between TCAM and biomedicine that render these attempts for incorporation not an easy task (Kelner et al. 2004; Lakshmi et al. 2015; Wolpe 1985). Reports even demonstrate the still powerful domination of biomedicine over TCAM to the extent that meaningful collaborations between these different medical traditions are obfuscated (Stevenson et al. 2003; Broom et al. 2009; Ijaz et al. 2016). In this context, the healthcare community is in need of knowledge of which various incorporation efforts can take advantage in designing the institutional arrangements that can reduce the tensions between TCAM and biomedicine and, subsequently, contribute to healthcare. One of the most popular forms of TCAM in the world is the traditional East Asian medicine (TEAM) that is composed of herbal remedies, acupuncture, moxibustion, cupping and manual therapies (massage, tuina, anma and shiatsu) (Cheung 2011; Motoo et al. 2011; Park et al. 2012). Correspondingly, there is a substantial need for knowledge about the possible ways in which TEAM is incorporated into the mainstream biomedicine in many countries. Against this backdrop, several studies have turned to how TEAM is organized in East Asian countries where TEAM originated and has been put into contact with biomedicine for a long time. These studies demonstrate that there indeed seem to be several different ways of implementing plural medical systems that include both TEAM and biomedicine. Most of these studies, however, have not developed a systematic comparative framework and, instead, have focussed on a country (Shin 2008; Motoo et al. 2009, 2011; Xu and Yang 2009; Dobos and Tao 2011; Eisenberg 2011; Chung et al. 2013; Katayama et al. 2013). Studies that employ a comparative perspective often fall short of a systemic and in-depth policy analysis that can lead to producing specific implications for designing a plural medical system and understanding the differential behaviour of medical service providers and users in the system (Lee 1982; Leslie 1998; WHO 2002; Holliday 2003; Bodeker et al. 2005; Park et al. 2012; Yoon and Kim 2013). To fill these deficiencies, this article adopts a comparative analytic perspective and examines how TEAM is institutionalized in three contemporary East Asian societies: China, Korea, and Japan. While focussing on the institutionalization of TEAM in the region, this paper does not address localized and unofficial medical practices (e.g. folk remedies, spiritual healing practices and medical traditions of ethnic minorities). In these countries, TEAM has been the most popular and official form of TCAM. In addition, these three East Asian societies reveal divergent ways of institutionalizing the shared medical tradition of TEAM. This article proposes an original conceptualization of three distinct ways of organizing plural medical systems: the interpenetrative pluralism in China that is defined as a plural medical system in which TEAM and biomedicine incorporate each other bilaterally at multiple locations of professional practice, the exclusionary pluralism in Korea (i.e. a plural system where the crisscrossing between TEAM and biomedicine in professional practices is prohibited), and the subjugatory pluralism in Japan (i.e. a plural system where TEAM is not recognized as an equivalent counterpart of biomedicine and subordinated to the practice of biomedicine). It concludes with the implications of these different systems for the concurrent practice of TEAM and biomedicine. Materials and methods This study focuses on revealing three aspects of medical systems: the legal categorization of TEAM practitioners in relation to biomedicine (Table 1 for summary), the education of TEAM and biomedicine (Table 2 for summary), and the provision of TEAM services vis-a-vis biomedicine in medical service organizations and insurance policies (Table 3 for summary). To this end, it used multiple sources of information. Table 1. Contrast in the legal categorization of TEAM practitioners vis-a-vis biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Recognition of TEAM doctors  distinct recognition as one of four categories of doctors  distinct recognition as one of two categories of doctors  subordinate recognition only as a subtype of biomedicine doctors  TEAM doctors’ practice rights over TEAM  comprehensive and non-exclusive  comprehensive, exclusive and only  comprehensive as biomedicine doctors  Doctors’ practice across TEAM and biomedicine  allowed for both TEAM doctors and biomedicine doctors  not allowed  allowed for biomedicine doctors only  Hybrid doctors  integrative TEAM-biomedicine doctors  not instituted  not instituted  Recognition of TEAM pharmacists  distinct recognition  distinct recognition  no  TEAM pharmacists’ practice rights over TEAM  only herbal remedies prescription and dispensation  only herbal remedies no prescription and dispensation  not applicable  Pharmacists’ practice across TEAM and biomedicine  not allowed, except for OTC  not allowed, except for OTC  allowed for biomed, unconditionally  Hybrid pharmacists  not instituted  not instituted  not instituted  Recognition of acupuncturists/moxibustionists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for licensees before 1962  distinct recognition from doctors  Their practice rights over TEAM  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  Recognition of manual therapists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for the blind  distinct recognition  Their practice rights over TEAM  limited to manual therapies  limited to manual therapies  limited to manual therapies    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Recognition of TEAM doctors  distinct recognition as one of four categories of doctors  distinct recognition as one of two categories of doctors  subordinate recognition only as a subtype of biomedicine doctors  TEAM doctors’ practice rights over TEAM  comprehensive and non-exclusive  comprehensive, exclusive and only  comprehensive as biomedicine doctors  Doctors’ practice across TEAM and biomedicine  allowed for both TEAM doctors and biomedicine doctors  not allowed  allowed for biomedicine doctors only  Hybrid doctors  integrative TEAM-biomedicine doctors  not instituted  not instituted  Recognition of TEAM pharmacists  distinct recognition  distinct recognition  no  TEAM pharmacists’ practice rights over TEAM  only herbal remedies prescription and dispensation  only herbal remedies no prescription and dispensation  not applicable  Pharmacists’ practice across TEAM and biomedicine  not allowed, except for OTC  not allowed, except for OTC  allowed for biomed, unconditionally  Hybrid pharmacists  not instituted  not instituted  not instituted  Recognition of acupuncturists/moxibustionists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for licensees before 1962  distinct recognition from doctors  Their practice rights over TEAM  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  Recognition of manual therapists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for the blind  distinct recognition  Their practice rights over TEAM  limited to manual therapies  limited to manual therapies  limited to manual therapies  Table 2. Contrast in the education of TEAM and biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Differentiation of TEAM schools for doctors  27 TEAM schools and 155 biomedicine schools  12 TEAM schools and 29 biomedicine schools  no TEAM schools and 80 biomedicine schools  Cross-learning of biomedicine and TEAM  mandatory education of biomedicine and TEAM in TEAM schools (50:50% of curricular hours) and in biomedicine schools (85:15%) coexistence of biomedicine programmes and TEAM programmes within school (60% of TEAM schools; 20% of biomedicine schools) programmes for integrative TEAM-biomedicine doctors (27% of all medical schools)  voluntary education of biomedicine and TEAM in TEAM schools (20:80% of curricular hours) and biomedicine schools (99:1%)  mandatory education of TEAM in biomedicine schools (99.8:0.2% of curricular hours)  Differentiation of TEAM pharmacy schools  74 TEAM pharmacy schools and 167 biomedicine pharmacy schools  none (only TEAM programmes in 3 out of 35 biomedicine pharmacy schools)  no TEAM pharmacy schools and 74 biomedicine pharmacy schools  Cross-learning of biomedicine and TEAM in pharmacy  voluntary education of biomedicine and TEAM in biomedicine and TEAM schools (a little) coexistence of biomedicine programmes and TEAM programmes within schools (74% of TEAM schools, 33% of biomedicine pharmacy schools)  voluntary education of biomedicine and TEAM for TEAM students (30:70% of curricular hours) and biomedicine students (99:1%)  voluntary education of TEAM for biomed students (a little)  Differentiation of acupuncture/moxibustion and manual therapy schools  yes; outside TEAM schools (number unknown)  no (except for massage schools for the blind)  yes; outside biomedicine schools (110 schools)  Cross-learning of biomedicine and TEAM  limited education of biomedicine (exact curricular composition unknown)  education of biomedicine and TEAM (30:70% of curricular hours)  education of biomedicine and TEAM (50:50%)    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Differentiation of TEAM schools for doctors  27 TEAM schools and 155 biomedicine schools  12 TEAM schools and 29 biomedicine schools  no TEAM schools and 80 biomedicine schools  Cross-learning of biomedicine and TEAM  mandatory education of biomedicine and TEAM in TEAM schools (50:50% of curricular hours) and in biomedicine schools (85:15%) coexistence of biomedicine programmes and TEAM programmes within school (60% of TEAM schools; 20% of biomedicine schools) programmes for integrative TEAM-biomedicine doctors (27% of all medical schools)  voluntary education of biomedicine and TEAM in TEAM schools (20:80% of curricular hours) and biomedicine schools (99:1%)  mandatory education of TEAM in biomedicine schools (99.8:0.2% of curricular hours)  Differentiation of TEAM pharmacy schools  74 TEAM pharmacy schools and 167 biomedicine pharmacy schools  none (only TEAM programmes in 3 out of 35 biomedicine pharmacy schools)  no TEAM pharmacy schools and 74 biomedicine pharmacy schools  Cross-learning of biomedicine and TEAM in pharmacy  voluntary education of biomedicine and TEAM in biomedicine and TEAM schools (a little) coexistence of biomedicine programmes and TEAM programmes within schools (74% of TEAM schools, 33% of biomedicine pharmacy schools)  voluntary education of biomedicine and TEAM for TEAM students (30:70% of curricular hours) and biomedicine students (99:1%)  voluntary education of TEAM for biomed students (a little)  Differentiation of acupuncture/moxibustion and manual therapy schools  yes; outside TEAM schools (number unknown)  no (except for massage schools for the blind)  yes; outside biomedicine schools (110 schools)  Cross-learning of biomedicine and TEAM  limited education of biomedicine (exact curricular composition unknown)  education of biomedicine and TEAM (30:70% of curricular hours)  education of biomedicine and TEAM (50:50%)  Table 3. Contrast in the provision of TEAM services vis-a-vis biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Number of TEAM doctorsa  152  196  7  Number of TEAM pharmacistsa  44  18  0  Number of acupuncturistsa  data unavailable  0.2  541  Number of moxibustionistsa  data unavailable  0.05  537  Number of manual therapistsa  data unavailable  79  635  Number of TEAM hospitals (per 100 biomedicine hospitals)  14 (90% of biomedicine hospitals have a TEAM department)  13 (not many biomedicine hospitals have a TEAM department)  0 (71% of biomedicine hospitals have a TEAM department)  Number of TEAM clinics (per 100 biomedicine clinics)  30  45  0  TEAM doctors working in biomedicine organizations  40% of licenced TEAM doctors work in biomedicine hospitals and clinics  8% of licenced TEAM doctors work in biomedicine hospitals (no clinics)  all (no TEAM doctors outside biomedicine organizations)  Biomedicine doctors working in TEAM organizations  5% of biomedicine doctors work in TEAM hospitals; 27% of TEAM organization workers are biomedicine doctors; 51% of doctors in TEAM hospitals are biomedicine doctors  0.1% of biomedicine doctors work in TEAM hospitals  none  Herbal remedies in insurance  some herbal extracts (683) and all raw herbs unless listed uninsured  some herbal extracts (68) and no raw herbs  some herbal extracts (148) and raw herbs (200)  Acupuncture/moxibustion in insurance  covered for all conditions  covered for all conditions  covered for six conditions  Manual therapies in insurance  covered for all conditions  no  covered for all conditions  Insurance for biomedicine treatments and TEAM treatments within hospital  yes  no  no    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Number of TEAM doctorsa  152  196  7  Number of TEAM pharmacistsa  44  18  0  Number of acupuncturistsa  data unavailable  0.2  541  Number of moxibustionistsa  data unavailable  0.05  537  Number of manual therapistsa  data unavailable  79  635  Number of TEAM hospitals (per 100 biomedicine hospitals)  14 (90% of biomedicine hospitals have a TEAM department)  13 (not many biomedicine hospitals have a TEAM department)  0 (71% of biomedicine hospitals have a TEAM department)  Number of TEAM clinics (per 100 biomedicine clinics)  30  45  0  TEAM doctors working in biomedicine organizations  40% of licenced TEAM doctors work in biomedicine hospitals and clinics  8% of licenced TEAM doctors work in biomedicine hospitals (no clinics)  all (no TEAM doctors outside biomedicine organizations)  Biomedicine doctors working in TEAM organizations  5% of biomedicine doctors work in TEAM hospitals; 27% of TEAM organization workers are biomedicine doctors; 51% of doctors in TEAM hospitals are biomedicine doctors  0.1% of biomedicine doctors work in TEAM hospitals  none  Herbal remedies in insurance  some herbal extracts (683) and all raw herbs unless listed uninsured  some herbal extracts (68) and no raw herbs  some herbal extracts (148) and raw herbs (200)  Acupuncture/moxibustion in insurance  covered for all conditions  covered for all conditions  covered for six conditions  Manual therapies in insurance  covered for all conditions  no  covered for all conditions  Insurance for biomedicine treatments and TEAM treatments within hospital  yes  no  no  a per 1000 biomedicine doctors. The data collection process began with a review of research papers that investigated the policy environment of TEAM in one or more of the three East Asian countries. During this process, this article was not only informed of some findings about the three plural medical systems but, more importantly, became aware of firsthand data sources that had been used in these prior studies. By utilizing these firsthand data sources, the paper triangulated and revised prior study results with the latest information. In addition, this article utilized additional sources that prior studies had not used yet. As a result, this article is based on a variety of data sources, such as national laws, regulations, government websites, official national statistics, yearbooks and websites of professional associations (specific data sources are identified in the following Results section). Last, these archival sources of data were combined with online and offline consultations with experts on TEAM policy in each of the three countries. Results The following analysis demonstrates three distinct ways of organizing and relating TEAM and biomedicine: the interpenetrative pluralism in China, the exclusionary pluralism in Korea, and the subjugatory pluralism in Japan. Both in the Chinese interpenetrative pluralism and the Korean exclusionary pluralism, TEAM and biomedicine are institutionalized as independent and equivalent systems of medical practices. However, TEAM and biomedicine are institutionalized to cross over into each other unconditionally in their practices in the Chinese pluralism, whereas the two exclude each other very strictly in their practices in the Korean pluralism. In the Japanese subjugatory pluralism, the crisscrossing of TEAM and biomedicine is allowed, yet in a very asymmetrical way. Thus, the practice of TEAM is dependent upon and subordinated into the practice of biomedicine. Legal categorization of TEAM practitioners vis-a-vis biomedicine practitioners Regarding various treatment modalities within TEAM, such as herbal remedies, acupuncture/moxibustion and manual therapies, the three countries demonstrated different ways of instituting practitioners who were entitled to practice all or some of these modalities. In addition, TEAM practitioners were granted different degrees of autonomy in crisscrossing the boundaries of TEAM and biomedicine (Table 1). All three countries legalized the category of TEAM doctors who were allowed to practice a wide range of medical services ranging from diagnosis and medical tests to therapeutic interventions just as medical doctors of biomedicine were. However, the degrees to which these TEAM doctors were recognized as an independent category of practitioners varied from country to country. Chinese national laws and regulations of professional doctors recognized four different types of doctors, namely biomedicine doctors (xi-yi), TEAM doctors (zhong-yi), ethnic doctors (min-jok-yi) and integrative TEAM-biomedicine doctors (zhong-xi-jie-he-yi). Recognized as such, they were all allowed to practice biomedicine, TEAM, or both. TEAM doctors were permitted to practice biomedicine as well as TEAM; biomedical doctors were allowed to practice TEAM as well as biomedicine. Integrative TEAM-biomedicine doctors, which exist only in China and not in the other two countries, were obviously allowed to practice both. The Korean regulatory system instituted two different categories of doctors, namely biomedicine doctors (yangui) and TEAM doctors (hanui). Unlike China, these two groups held exclusive practice rights; biomedicine doctors were allowed to practice only biomedicine and not TEAM whereas TEAM doctors were allowed to practice only TEAM and not biomedicine. Therefore, only doctors who held both the titles of biomedicine doctor and TEAM doctor could cross the boundaries of TEAM and biomedicine. Unlike China or Korea, the Japanese system recognized a single professional category of doctors, or biomedicine doctors, who could practice both biomedicine and TEAM. Whereas there were TEAM doctors in China and Korea who were not biomedicine doctors, the Japanese system did not allow the separate existence of such TEAM doctors. Only biomedicine doctors, once they earned the title, could elect to become certified as TEAM doctors (kampoi). The category of TEAM doctors in Japan was only a subtitle that biomedicine doctors could electively hold. Biomedicine doctors without the title of TEAM doctor had no restriction on their arbitrary practice of TEAM. Doctors legalized to practice TEAM in these countries, whether they be TEAM doctors or biomedicine doctors, could practice all the modalities in TEAM (herbal remedies, acupuncture/moxibusion, and manual therapies). Other practitioners of TEAM, however, held limited rights over specific TEAM modalities. For the delivery of herbal remedies that were made up of several medicinal herbs in a variety of forms, such as decoctions, pills, powders, and granules, the three countries had in common the professional group of pharmacists. However, the specific ways in which pharmacists were allowed to deliver herbal remedies to the public were quite different among the countries. In China, where pharmacists as well as doctors could prescribe and dispense drugs, pharmacists were categorized into two subgroups: TEAM pharmacists (zhong-yao-shi) and biomedicine pharmacists. TEAM pharmacists could deal with herbal remedies only and biomedical pharmacists were permitted to deal with biomedical drugs only. Other than prescription drugs, both biomedical and TEAM pharmacists could dispense over-the-counter (OTC) herbal remedies and biomedical drugs without any restrictions. In this manner, pharmacists were not allowed to crisscross the boundaries of biomedicine and TEAM as easily as doctors. Similarly, the Korean system recognized two separate professional groups of pharmacists: TEAM pharmacists (hanyaksa) and biomedicine pharmacists. Biomedicine pharmacists were permitted to only dispense biomedical drugs for prescriptions from biomedicine doctors, whereas TEAM pharmacists were permitted to dispense herbal remedies for prescriptions from TEAM doctors. Unlike biomedical pharmacists, in addition, TEAM pharmacists were also allowed to prescribe a limited number of herbal remedies (100) that were preselected by the government. Some biomedicine pharmacists who dealt with herbal remedies before 1996 and were certified under the legislations in 1996 continued to be able to deal with them. Like doctors, pharmacists were thus not allowed to practice across biomedical drugs and herbal remedies. OTC herbal remedies and OTC biomedical drugs were the only exceptions. In Japan, there was no separate legal recognition of TEAM pharmacists. Instead, biomedical pharmacists were allowed to deal with herbal remedies as well as biomedical drugs. Since the Japanese system did not outlaw drug prescription by pharmacists, pharmacists did not only dispense herbal remedies for prescriptions written by doctors; they also prescribed herbal remedies themselves. In prescribing these remedies, however, pharmacists were never allowed to produce diagnoses for which doctors were exclusively held responsible. In addition, pharmacists’ prescriptions of herbal remedies were not covered by the national health insurance system, whereas doctors’ prescriptions of herbal remedies were all covered. In this manner, biomedicine pharmacists held the comprehensive and exclusive rights over herbal remedies as well as biomedical drugs. For the practice of acupuncture/moxibustion and manual therapies, the Chinese system recognized acupuncture-moxibustionists (zhen-jiu-shi), manual therapists (bauzan-anma-shi) and acupuncture-moxibustion-manual therapists (zhen-jiu-tuina-shi) as government-certified practitioners (the Ministry of Human Resources and Social Welfare) until 2014. In 2014, the Chinese government announced that there would be no more government certification of these practitioners except for manual therapists. For those practitioners who were certified before 2014, their practices were qualified as preventive measures for health promotion and not as curative treatments for illness. These practitioners could not provide other medical services than those that were specified by their certification. Until 1962, the Korean government recognized three independent practitioner groups: acupuncturists (cheem-sa), moxibustionists (gu-sa) and manual therapists (anma-sa), which were originally introduced into the Korean medical system in 1914. However, the legislations in 1962 outlawed the practice of acupuncture and moxibustion by these practitioners and allowed only TEAM doctors to hold legitimate practice rights. Although it is still possible for acupuncturists and moxibustionists who were certified before 1962 to practice these modalities, the government did not certify new practitioners any more since 1962. Currently, certified acupuncturists were allowed to practice only acupuncture and certified moxibusionists were allowed to practice only moxibustion. Blind manual therapists, who had been exceptions to the legislations in 1962, were exclusively granted the rights to practice manual therapies. When compared with China and Korea, the Japanese system was consistent and more permissive in recognizing acupuncturists (hari-si), moxibustionists (kyu-si) and manual therapists (shiatsu-si and judo-seifuku-si) as legitimate practitioners. Qualified as practitioners in each of these specific modalities, they were not allowed to practice beyond the boundary of each modality. Within the limited scope of their practice, manual therapists could not apply manual treatments on patients with bone dislocations or fractures without a medical doctor’s approval for these treatments. Likewise, acupuncture was typically recommended by medical doctors only for a limited set of musculoskeletal conditions, namely low back pain, frozen shoulder, neuralgia, rheumatoid arthritis, cervico-brachial syndrome and neck pain (Ishizaki et al. 2010; Motoo et al. 2009; Payyappallimana and Serbulea 2013). These TEAM practitioners were permitted to run their own clinics, unlike occupational therapists and physical therapists who were not allowed to practice without being employed and supervised by biomedical doctors. Education of TEAM vis-a-vis biomedicine The extent to which each of these TEAM practitioners were educated about TEAM and biomedicine varied among the countries. In addition, biomedicine doctors were exposed to different degrees of TEAM education (Table 2). In China, TEAM medical schools were instituted distinctly from biomedicine schools (Park et al. 2016). These schools provided 3–8 years of education for students to become TEAM doctors. Some of these schools also had separate programmes for producing biomedicine doctors and programmes for students to become integrative TEAM-biomedicine doctors. Likewise, biomedicine schools did not only have programmes for students to become biomedicine doctors; some also had programmes for students to become TEAM doctors and programmes for integrative TEAM-biomedicine doctors. According to the World Directory of Medical Schools (http://www.wdoms.org/), there were 155 medical schools in China, 27 of which (17%) were TEAM schools. According to a Chinese website compiling information about Chinese universities and colleges (http://college.gaokao.com/), there were 172 schools that taught TEAM or/and biomedicine; 151 of them (88%) taught biomedicine and 51 (30%) taught TEAM; 30 schools had distinct programmes for TEAM doctors and biomedicine doctors at once (60% of all TEAM schools and 20% of all biomedicine schools); 46 schools had programmes for integrative TEAM-biomedicine doctors. In addition, TEAM programmes were required to allot significant curricular time for the education of biomedicine (Xu and Yang 2009, p. 135). They were found to spend 40–50% of the curricular time teaching biomedicine, including anatomy (a required course) and surgery (an elective) (Yoon and Kim 2013). Reciprocally, biomedicine programmes devoted 10–15% of their curricular time to teaching TEAM (Xu and Yang 2009). In sum, while schools were distinctly instituted to educate TEAM and biomedicine doctors, they were substantially engaged in teaching students both TEAM and biomedicine. The education of TEAM pharmacy for herbal remedies was differentiated from that of biomedicine pharmacy, as well. There were 186 programmes teaching traditional Chinese pharmacy, biomedicine pharmacy or both (http://college.gaokao.com/) in pharmacy schools or medical schools. 112 programmes taught biomedicine pharmacy alone; 19 taught TEAM pharmacy alone; 55 taught both. 33% of the 167 programmes that taught biomedicine pharmacy coexisted with a TEAM pharmacy programme within the school, whereas 74% of the 74 programmes that taught TEAM pharmacy coexisted with a biomedicine pharmacy programme. In these organizational environments, pharmacy students were given chances to learn both biomedicine and TEAM pharmacy by crossing two distinct programmes within schools. The education of acupuncture/moxibustion and manual therapies was incorporated within the organizational structure of medical schools of TEAM or biomedicine, except for an unknown number of private-sector organizations that provided a brief education of weeks or months to high school graduates for them to get a vocational certificate (Lim et al. 2015, p. 2). TEAM schools in China typically had a department of herbal medicine, a department of acupuncture and tuina, and sometimes a department of integrative TEAM-biomedicine. Acupuncture/moxibustion and manual therapies were educated within the department of acupuncture and tuina as a part of medical training for students to become TEAM doctors. 71% of 51 TEAM schools and 16% of 151 biomedicine schools taught acupuncture/moxibustion and manual therapies (http://college.gaokao.com/). In this organizational context, students of acupuncture/moxibustion and manual therapies were exposed to biomedicine as well as the other TEAM modalities. In Korea, TEAM medical schools were instituted distinctly from biomedicine schools like in China. There were 12 TEAM schools that provided 6 years of education (KIOM 2015), whereas there were 29 biomedicine schools. Unlike in China, however, TEAM schools were not permitted to institute any biomedicine programmes and biomedicine schools were not permitted to institute any TEAM programmes. Instead, each could voluntarily provide some courses of the other side. It turned out that biomedicine schools taught TEAM only as a part of the mandatory education of complementary and alternative medicine, which resulted in <1% of their total curricular hours; TEAM schools voluntarily devoted 18–28% of their curriculum to biomedicine education (Han et al. 2013). Anatomy was included as a required course in most TEAM schools, whereas surgery was not offered even as an elective (KIOM 2015). In Korea, pharmacists of either TEAM or biomedicine were educated for 6 years. There were 35 biomedicine pharmacy schools, 3 of which belonged to universities that had a TEAM medical school within its organization. The government allowed only these three schools to institute a department of TEAM pharmacy. There was no school only for the education of TEAM pharmacists. In addition, biomedicine pharmacy programmes in the 35 pharmacy schools had no required courses on TEAM pharmacy and instead offered one to two elective courses. On the contrary, 30–35% of the curriculum in most TEAM pharmacy departments taught biomedicine pharmacy (KIOM 2015). When compared with China, therefore, the likelihood of pharmacy students of TEAM or biomedicine to learn across both TEAM and biomedicine was limited. Korean laws did not recognize any educational institutes for acupuncture/moxibustion except for TEAM medical schools. One exception was that the education of manual therapies was legalized for blind people in 24 high schools and vocational schools (http://www.anmaup.or.kr/). The 2- to 3-year curriculum covered massage, acupressure and acupuncture, while about 30% of the training was devoted to biomedicine courses involving anatomy. Unlike China and Korea, there were no TEAM medical schools in Japan for educating TEAM doctors. Therefore, Japanese doctors who wanted to practice TEAM as one of their subspecialties needed to complete a three year-long practice at TEAM institutions certified by the Japanese Society of Oriental Medicine, the Japanese professional association of TEAM doctors. This TEAM education addressed herbal remedies, acupuncture/moxibustion and manual therapies, although it was mostly focussed on herbal remedies kampo (Muramatsu et al. 2012). All 80 medical schools taught herbal remedies for about 12 h, or 0.2% of their curriculum (Payyappallimana and Serbulea 2013) which was half the amount of training for other subspecialties in biomedicine (Yoon and Kim 2013), following the mandate of the Ministry of Education, Science, and Technology in 2001 (Namiki and Nagamine 2012). This curricular recommendation of mandatory education, however, did not involve acupuncture/moxibustion or manual therapies. Kampo was also taught to pharmacists who were educated for 4 years in the postgraduate programmes of the departments of pharmacy in 74 universities, whereas there was no department or programme specifically for kampo or TEAM pharmacy (Payyappallimana and Serbulea 2013). The number and the specific content of courses on kampo varied from school to school (Kobayashi 2016), since the 2008 Standard Examination Questions for the Pharmacist Licensure involved kampo formulae for the first time (Namiki and Nagamine 2012, p. 47). The Japanese educational system for acupuncture/moxibustion and manual therapies took shape following the enactment of the 1947 Law for Businesses of Massage, Acupuncture, Moxa-Cautery, and Judo-Orthopedics. As of 2015, there were 110 schools that provided college-level vocational programmes specifically for these modalities. High-school graduates were allowed to apply to these programmes that usually ran for 3 years (http://youseijo.mhlw.go.jp/). Out of the 110 schools, 108 schools taught acupuncture/moxibustion, whereas 31 schools taught manual therapies such as anma, shiatsu and massage; 29 schools taught both acupuncture/moxibustion and manual therapies. In addition, a majority of acupuncture/moxibustion schools (65 out of 108) taught judo therapy; reciprocally, 66% of 99 judo therapy schools taught acupuncture/moxibustion. There were six 4-year colleges for acupuncture/moxibustion with some having post-graduate programmes as well (Shim 2015). These figures show that there was a significant amount of TEAM education outside herbal medicine kampo. None of these schools, however, taught herbal medicine kampo to the students. Instead, 50% of the curriculum was composed of biomedicine courses. Provision of TEAM services vis-a-vis biomedicine In China, TEAM and biomedicine services were provided simultaneously by multiple professionals and organizations (Table 3). The number of medical professionals of TEAM or biomedicine (doctors, nurses and pharmacists) was 7 200 528 in 2013 (NBSC 2015). 7% (505 917) of them were TEAM professionals (395 674 doctors and 110 243 pharmacists) (SATCM 2016). Of all the medical professionals, 11% worked in organizations specialized in TEAM. Interestingly, 27% of these workers were biomedicine professionals. The percentage of biomedicine doctors among all doctors in TEAM hospitals was even greater (51%) (SATCM 2016). Among all TEAM professionals, reciprocally, 60% worked in biomedicine organizations that provided TEAM services (SATCM 2016). Among all biomedicine doctors, about 5% worked at TEAM hospitals where they provided biomedicine services. In terms of organizations, there were 24 709 hospitals, 86% of which were biomedicine hospitals; the remaining included TEAM hospitals (12%), integrative TEAM-biomedicine hospitals (1%), and ethnic hospitals (1%) (SATCM 2016). 90% of these biomedicine hospitals had TEAM departments and 8% of the outpatient visits were made to those TEAM departments (Xu and Yang 2009, p. 136). Reciprocally, most TEAM hospitals and all integrative TEAM-biomedicine hospitals provided biomedicine services; 55–60% of the medical treatments in integrative TEAM-biomedicine hospitals were biomedicine services (Xu and Yang 2009:136; Zhang et al. 2015) and 37% of outpatient medication revenue and 78% of inpatient medication revenue in TEAM hospitals were from biomedicine (Xu and Yang 2009, p. 137). Out of the 183 982 clinics and community health centres where basic public health needs were met without inpatient services, 47% were biomedicine clinics with the rest being TEAM clinics and specialty clinics. Most of these biomedicine clinics had TEAM departments as well (SATCM 2016). Therefore, >40% of the centres had TEAM doctors and >60% provided TEAM services (Cai et al. 2015, p. NP2492, NP2494). About a third of the total utilization in clinics was TEAM services (Xu and Yang 2009, p. 137). All of these clinics provided biomedicine services as well. The crisscrossing of TEAM and biomedicine was shaped by the national insurance system, as well. Once the current insurance system was put in place (Barber and Yao 2011), the Chinese government progressively integrated TEAM into the system. 102 out of the 307 items on the List of Essential Drugs were herbal remedies of TEAM (Barber and Yao 2011, p. 353; Chung et al. 2013, p. 5). The Chinese system guaranteed higher reimbursement rates for these essential drugs. In addition, the List of National Health Insurance Drugs that registered insured drugs included 683 herbal remedies for which users co-paid at most 10% of the total cost (Chung et al. 2013, p. 5). Furthermore, the national insurance covered all raw herbs unless specified as uninsured (Lim and Kim 2016). Therefore, medical service users were incentivized to utilize herbal remedies readily (Chung et al. 2013). Medical treatments of acupuncture/moxibustion and manual therapies for all medical conditions were also covered. Last, since medical service providers and users might practice both TEAM and biomedicine, the insurance system covered the medical costs for both TEAM and biomedicine treatments that were applied to a patient for the same medical conditions within a service organization. In Korea, the presence of TEAM doctors was very noticeable. There were 22 074 TEAM doctors and 112 476 biomedicine doctors in 2014 (196 TEAM per 1000 biomedicine doctors) (KIOM 2015). 11% of these TEAM doctors were specialists in such fields as internal medicine, rehabilitation, and obstetrics/gynecology, with 89% being general practitioners (cf. Japan). 247 were dual licensees, holding the licence for doctor of biomedicine as well. In contrast, there were only a few other TEAM practitioners: 23 acupuncturists, 6 moxibustionists and 13 bone-setters who had been licenced according to old laws that were repealed in 1962. There were only 2000 TEAM pharmacists. There were 2038 hospitals in 2014, 89% of which were biomedicine hospitals and 11% were TEAM hospitals (www.komha.or.kr). Unless they employed doctors of the other medical tradition, these hospitals could provide only biomedicine or only TEAM services, depending on their registered specialty area. Only 0.1% of biomedicine doctors were employed by TEAM hospitals, whereas 8% of TEAM doctors were employed by biomedicine hospitals including elderly care. In this exclusionary context, another way that TEAM hospitals used to secure biomedicine services (and for biomedicine hospitals to secure TEAM services) was to send their patients to other hospitals via patient referral (Park 2016). With regard to clinics, there were a total of 42 028 facilities: 28 883 biomedicine clinics (68%) and 13 135 TEAM clinics (32%). These clinics provided either biomedicine or TEAM services. Korean national health insurance covered acupuncture/moxibustion practiced for all treatment purposes. On the contrary, manual therapies were not covered by the national insurance (www.anmaup.or.kr). The insurance coverage for herbal remedies was very selective and limited so that only some herbal extracts and no raw herbs were covered. Out of the 451 multi-herbal extracts that drug companies manufactured according to established herbal remedies of TEAM, only 56 extracts (12%) were insured. 68 uni-herbal extracts were additionally insured. However, a majority of TEAM doctors and service users relied in reality on the traditional style of herbal decoctions of raw herbs that were not insured (Son 2012). Last, unlike China, the Korean insurance system did not cover the costs of both TEAM and biomedicine services for a single medical condition when they were provided by the same medical service organization on the same day; whichever service that was registered first in the insurance claiming system was covered, while the service that was registered later was not. In Japan, the number of licenced medical doctors was 295 049, 0.7% of which held the title of TEAM doctor as well (http://www.jasom.or.jp). This numerical presence of TEAM doctors paled in comparison to that in China and Korea. In addition, 71% of these doctors who had the additional title of TEAM doctor worked in clinics, whereas only 38% of all doctors worked in clinics. Among the medical doctors affiliated with hospitals, only 0.2% held the title of TEAM doctor. These figures demonstrate that TEAM doctors were more common in clinics than hospitals. 70–90% of medical doctors were found to prescribe herbal remedies kampo (Moschik et al. 2012); 1.3% of all prescription drugs covered by the national insurance system were herbal remedies (Katayama et al. 2013). On the contrary, a very small proportion of medical doctors (4%) practiced acupuncture/moxibustion; not many medical doctors (4%) referred their patients to acupuncturists/moxibustionists, either (Muramatsu et al. 2012). In this way, the practice of TEAM by medical doctors was significantly biased toward herbal remedies. However, there were many other TEAM practitioners: 159 607 acupuncturists, 158 341 moxibustionists, and 187 295 anma/massage/shiatsu therapists (http://youseijo.mhlw.go.jp/). On an organizational level, 57 of 80 medical schools (71%) had a department of herbal remedies within the university hospital structure (Payyappallimana and Serbulea 2013). On the contrary, the other TEAM modalities were not incorporated in these hospitals. Instead, acupuncturists/moxibustionists and manual therapists were authorized to practice in their own facilities; 80% of them were employed in independent specialty clinics, where acupuncturists and moxibustionists mostly practiced together. In 2014, there were 25 445 clinics for acupuncture/moxibustion, 19 271 clinics for anma/massage/shiatsu, and 37 682 clinics that provided all of these services (MHLW 2015). The Japanese national health insurance system covered herbal remedies comprehensively, as in China. The Japanese medical community’s efforts to evaluate the evidence base of herbal remedies had accompanied this development (Tsutani 1993; Okabe and Tsutani 2010). 148 kampo extracts that mixed different herbs were currently insured (Katayama et al. 2013). In addition, 241 raw herbs that doctors could mix and prescribe for patients were covered by insurance. Doctors usually prescribed the pre-established 148 kampo extracts that were manufactured by drug companies rather than their own remedies that mix raw herbs. Whether a specific herbal remedy was supported by insurance did not depend on the kind of medical conditions that the remedy was used for, once it was prescribed by a medical doctor. On the contrary, insurance support for acupuncture/moxibustion was conditional upon the medical conditions that the modality was used for. Only six musculo-skeletal conditions were covered by insurance (Ishizaki et al. 2010; Payyappallimana and Serbulea 2013). The treatment for these conditions was, however, not covered by insurance without a medical doctor’s approval in advance. In addition, like in Korea, the Japanese insurance system did not cover the costs of both TEAM and biomedicine services for a single medical condition when they were provided by the same medical service organization on the same day. When this simultaneous practice happened, biomedicine services were usually covered and TEAM services were not. Discussion The characteristics of various medical systems are represented in the literature, focussed on the relationships among three key actors: medical service providers, service users and insurers (Wagstaff 2007; Freeman and Frisina 2010; Toth 2016). The fundamental interest in the financing and the population/benefit coverage of healthcare systems reflects the significance of the different ways in which these actors are held responsible for healthcare systems. This concern about responsibility extends to attention about who constitute legitimate medical service providers and how they are produced; how these different providers interact with one another and with service users; how insurers shape these interactions. Drawing on this perspective, this article turns to the often-forgotten and yet long-lasting element of medical systems (i.e. TCAM) and examines how it is organized and related to biomedicine. In this context, the medical systems in the East Asian countries that incorporate TEAM have gained interest. In response, this paper proposes an original conceptualization of the three plural medical systems. In the interpenetrative pluralism in China, all the modalities of TEAM are recognized explicitly via legal categorizations, medical education, and service provisions. In addition, these modalities are connected and held together under the oversight and the comprehensive practice rights of TEAM doctors (and biomedicine doctors) who can also practice biomedicine on the basis of their professional discretion. There is yet another group of practitioners of acupuncture/moxibustion and manual therapies who are independent from TEAM doctors. To this extent, the interpenetrative pluralism features multiple social locations for TEAM practitioners that lead to non-exclusivity and mutual incorporation between TEAM and biomedicine. Therefore, there are opportunities for the hybridization of TEAM and biomedicine in practitioners and medical service organizations. The exclusionary pluralism in Korea recognizes all the TEAM modalities as much as the interpenetrative pluralism. These modalities are, however, connected and practiced together only by TEAM doctors. To TEAM doctors, these TEAM modalities are the only interventions that they are allowed to practice legally. In addition, there are no other practitioners who can practice acupuncture/moxibustion and manual therapies, independent from TEAM doctors. In this way, the oversight of TEAM doctors over TEAM modalities is the greatest. The exclusionary pluralism also features the mutual exclusion of TEAM and biomedicine and, subsequently, little interaction between the two sides. In the subjugatory pluralism in Japan, some TEAM modalities are recognized explicitly as medicine (e.g. herbal remedies), whereas others are called quasi-medicine (e.g. acupuncture/moxibustion) in national laws and regulations. In addition, these modalities are disconnected from one another under the oversight of various practitioners. Whereas there are no TEAM doctors as in China and Korea, the Japanese system has a significant number of acupuncturists/moxbustionists and manual therapists who have limited practice rights over only some modalities and not all. Regarding the TEAM–biomedicine relationship, this system features asymmetrical incorporation where TEAM is incorporated within biomedicine so that there are chances for the biomedical transformation of TEAM (Lock 1980) in which TEAM becomes assimilated to biomedicine in its practices. This conceptualization of three distinct plural medical systems speaks to existing studies of East Asian medical systems and adds an updated theory to the literature. It expands an early comparative study of three Chinese societies (China, Hong Kong, Taiwan) by further elaborating the ‘functionally diverse systems’ of the common ‘hierarchical pluralism’ in the region (Lee 1982). This article also updates the perspective in the WHO report (WHO 2002) that categorizes both China and Korea as ‘integrative’ systems, by showing that the two countries in fact feature quite different ways of integration. This article agrees with the view that due analytical foci about plural medical systems should be placed on the ‘cross-sectoral links’ between TEAM and biomedicine and on the ‘general state practice’ (Holliday 2003). Rather than taking a schematic conceptualization (Holliday 2003, p. 384), however, this article proposes an alternative conceptualization resulting from a systematic analysis of more specific policies on the ground. Thus, this new conceptualization sheds lights not only on whether there is the ‘fusion’ or ‘separation’ (Holliday 2003, p. 384) between TEAM and biomedicine but also on the fact that the fusion (or separation) is implemented in significantly different manners among China, Korea and Japan. This article further contributes to providing potential answers to the varying practices of medical service providers and users who are situated at the intersection of TEAM and biomedicine. For example, the holistic and explicit institutionalization of all TEAM modalities in China and Korea seems to be an important factor in accounting for the fact that Chinese and Koreans tend to use both TEAM and biomedicine more than Japanese (Shim 2016). The existence of a professional group (i.e. TEAM doctors in Korea) that holds the comprehensive and exclusive practice rights over TEAM seems to provide an explanation to the pattern that Koreans are most likely to use several TEAM modalities together (dubbed the ‘holistic’ use of TEAM) in the region (Shim and Kim 2016). If these different patterns in the co-utilization of TEAM and biomedicine and in the holistic use of TEAM have anything to do with healthcare outcomes in plural medical systems (Xue et al. 2003; Wan 2007; Huang et al. 2008; Salameh et al. 2008), studies of healthcare outcomes need to pay substantial attention to the institutional context of plural medical systems. In addition, this comparative study suggests the need to examine how these different institutional contexts affect the patterns in which TEAM is (re)constructed as a medical tradition that is discernable from biomedicine. In the exclusionary pluralism vis-a-vis the interpenetrative or the subjugatory pluralism, for example, TEAM is likely to be reconstructed as a different medical tradition than biomedicine. It is worth investigating how TEAM users respond differently in these countries to various developments in biomedicine including genetic advances (Arribas-Ayllon 2016; Teo et al. 2016). Regarding the controversies among East Asian countries over how to represent TEAM to the world healthcare community beyond the region (Lim 2010), it should be stressed that not only nationalist politics (Hsu 2013) but practical institutional differences reported in this article can play a significant role. This article also suggests that the degrees to which professional practitioners and everyday service users are held responsible for deciding how to mix and match TEAM and biomedicine vary significantly from one type of plural medical system to another. In the Chinese interpenetrative pluralism, medical service users can rely on professional practitioners and medical service organizations of TEAM or biomedicine when users are not sure by themselves of how to use both TEAM and biomedicine for their benefits. In the Japanese subjugatory pluralism, medical service users can turn to medical doctors of biomedicine for professional advice. The Korean exclusionary pluralism, however, makes it more difficult for medical service users to get professional advice when they crisscross the boundary between TEAM and biomedicine, since it does not allow any medical professionals to practice both traditions of medicine. Future research needs to examine the consequences of these variations for healthcare outcomes as well as user behaviour. Last, this study invites a comparative-historical investigation of what has created these cross-national differences and how different experiences of modernization in the region intervene in the process. Historically, TEAM originated in China and diffused to Korea and to Japan (Motoo et al. 2011). This historical movement itself seems to have had impacts on how TEAM was shaped, punctuating different theoretical elements of TEAM in different countries. 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Evidence-Based Complementary and Alternative Medicine  2015: 12. © The Author(s) 2018. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Policy and Planning Oxford University Press

Three plural medical systems in East Asia: interpenetrative pluralism in China, exclusionary pluralism in Korea and subjugatory pluralism in Japan

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0268-1080
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1460-2237
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10.1093/heapol/czy001
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Abstract

Abstract Amid persistent interest in and concerns about traditional, complementary and alternative medicine (TCAM) in low-, middle- and high-income countries, the global community of healthcare is in need of learning ways to institutionalize TCAM with biomedicine. By investigating how traditional East Asian medicine (TEAM), one of the most popular forms of TCAM in the world, is institutionalized in China, Korea and Japan, this study finds three different ways of instituting a plural medical system in which TCAM and biomedicine intersect with each other. In the interpenetrative pluralism in China and the exclusionary pluralism in Korea, TEAM and biomedicine are institutionalized as independent and equivalent systems of medical practices. However, TEAM and biomedicine are conditioned to cross over into each other unconditionally in practice in the former, whereas the two exclude each other very strictly in the latter. In the subjugatory pluralism in Japan, the crisscrossing of TEAM and biomedicine is allowed, yet in an asymmetrical way whereby the practice of TEAM is dependent upon and subordinated into biomedicine. The practice of various TEAM modalities is overseen by TEAM doctors, biomedicine doctors or integrative TEAM–biomedicine doctors in interpenetrative pluralism, by TEAM doctors only in exclusionary pluralism, and by biomedicine doctors only in subjugatory pluralism. These varying characteristics demonstrate a variety of plural medical systems. They also provide useful cues in accounting for the varying behaviours of medical service providers and users who encounter TCAM as well as biomedicine in their everyday practices. In addition, the growing literature about the outcomes of TCAM and plural medical systems can take advantage of these findings. Medical pluralism, alternative medicine, complementary medicine, traditional medicine, health systems research, sociology, China, Korea, Japan Key Messages Three institutional principles underlie plural medical systems of TCAM and biomedicine in East Asia: interpenetrative pluralism in China, exclusionary pluralism in Korea, and subjugatory pluralism in Japan. These institutional characteristics are potentially related to the varying behaviour of medical service providers and users of both TCAM and biomedicine. Studies of healthcare planning and outcomes need to pay attention to the institutional characteristics of each plural medical system. Introduction Despite the move to transform medical practices to the forms of biomedicine (Parsons 1951; Freidson 1970; Clarke et al. 2003; Phelan 2005; Freese and Shostak 2009), alternative forms of medical practices persist in the world: not only traditional and indigenous medical practices in Asia, Africa, and Latin America (Decoteau 2013; Babis 2014; Josyula et al. 2016), but also complementary and alternative medicine in Europe and North America (Clarke et al. 2015; Givati and Hatton 2015). A significant number of people are found to use these forms of traditional, complementary and alternative medicine (TCAM) in addition to biomedicine for various reasons (Yu et al. 2012; Pedersen 2013; Shim et al. 2014). Amid this popularity, there are concerns about these plural medical systems that are composed of both TCAM and biomedicine. Some systems are found to produce tensions between the two different traditions of medical practices and subsequently adverse healthcare outcomes (Campbell et al. 2008; Downey et al. 2010; Decoteau 2013; Holcomb 2009), while others generate tangible healthcare benefits through collaborations between the different medical traditions (Mehling et al. 2007; Korinenko et al. 2009; Kogure et al. 2010). The ways in which people use TCAM with biomedicine and the expectations that users have toward TCAM are found to be influenced by the institutional conditions in which TCAM is sanctioned (Pillsbury 1982; Johannessen 2010; Liu et al. 2013; Shim 2016; Shim and Kim 2016). The extent to which TCAM users discuss their use of TCAM with their primary healthcare professionals varies among TCAM modalities that are differently incorporated into the medical system (Shim et al. 2014). Even the treatment outcomes of TCAM seem to be affected by these institutional conditions (Shim 2015) or by the degrees to which TCAM users utilize the expertise of healthcare professionals in addition to their own knowledge (Broom 2009; Dew et al. 2014). In sum, the manners in which TCAM is institutionalized in medical systems seem to be consequential for many aspects of healthcare systems. In this regard, it is important for the world healthcare community to be informed of how to incorporate TCAM into the medical systems that are mostly organized around biomedicine (Maclean and Bannerman 1982; Stepan 1985; Leslie 1998; WHO 2002, 2013; Lakshmi et al. 2015). These studies find that there are economic, cultural, or medical rationales for attempting to incorporate TCAM into the mainstream biomedical systems. At the same time, there are political as well as theoretical tensions between TCAM and biomedicine that render these attempts for incorporation not an easy task (Kelner et al. 2004; Lakshmi et al. 2015; Wolpe 1985). Reports even demonstrate the still powerful domination of biomedicine over TCAM to the extent that meaningful collaborations between these different medical traditions are obfuscated (Stevenson et al. 2003; Broom et al. 2009; Ijaz et al. 2016). In this context, the healthcare community is in need of knowledge of which various incorporation efforts can take advantage in designing the institutional arrangements that can reduce the tensions between TCAM and biomedicine and, subsequently, contribute to healthcare. One of the most popular forms of TCAM in the world is the traditional East Asian medicine (TEAM) that is composed of herbal remedies, acupuncture, moxibustion, cupping and manual therapies (massage, tuina, anma and shiatsu) (Cheung 2011; Motoo et al. 2011; Park et al. 2012). Correspondingly, there is a substantial need for knowledge about the possible ways in which TEAM is incorporated into the mainstream biomedicine in many countries. Against this backdrop, several studies have turned to how TEAM is organized in East Asian countries where TEAM originated and has been put into contact with biomedicine for a long time. These studies demonstrate that there indeed seem to be several different ways of implementing plural medical systems that include both TEAM and biomedicine. Most of these studies, however, have not developed a systematic comparative framework and, instead, have focussed on a country (Shin 2008; Motoo et al. 2009, 2011; Xu and Yang 2009; Dobos and Tao 2011; Eisenberg 2011; Chung et al. 2013; Katayama et al. 2013). Studies that employ a comparative perspective often fall short of a systemic and in-depth policy analysis that can lead to producing specific implications for designing a plural medical system and understanding the differential behaviour of medical service providers and users in the system (Lee 1982; Leslie 1998; WHO 2002; Holliday 2003; Bodeker et al. 2005; Park et al. 2012; Yoon and Kim 2013). To fill these deficiencies, this article adopts a comparative analytic perspective and examines how TEAM is institutionalized in three contemporary East Asian societies: China, Korea, and Japan. While focussing on the institutionalization of TEAM in the region, this paper does not address localized and unofficial medical practices (e.g. folk remedies, spiritual healing practices and medical traditions of ethnic minorities). In these countries, TEAM has been the most popular and official form of TCAM. In addition, these three East Asian societies reveal divergent ways of institutionalizing the shared medical tradition of TEAM. This article proposes an original conceptualization of three distinct ways of organizing plural medical systems: the interpenetrative pluralism in China that is defined as a plural medical system in which TEAM and biomedicine incorporate each other bilaterally at multiple locations of professional practice, the exclusionary pluralism in Korea (i.e. a plural system where the crisscrossing between TEAM and biomedicine in professional practices is prohibited), and the subjugatory pluralism in Japan (i.e. a plural system where TEAM is not recognized as an equivalent counterpart of biomedicine and subordinated to the practice of biomedicine). It concludes with the implications of these different systems for the concurrent practice of TEAM and biomedicine. Materials and methods This study focuses on revealing three aspects of medical systems: the legal categorization of TEAM practitioners in relation to biomedicine (Table 1 for summary), the education of TEAM and biomedicine (Table 2 for summary), and the provision of TEAM services vis-a-vis biomedicine in medical service organizations and insurance policies (Table 3 for summary). To this end, it used multiple sources of information. Table 1. Contrast in the legal categorization of TEAM practitioners vis-a-vis biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Recognition of TEAM doctors  distinct recognition as one of four categories of doctors  distinct recognition as one of two categories of doctors  subordinate recognition only as a subtype of biomedicine doctors  TEAM doctors’ practice rights over TEAM  comprehensive and non-exclusive  comprehensive, exclusive and only  comprehensive as biomedicine doctors  Doctors’ practice across TEAM and biomedicine  allowed for both TEAM doctors and biomedicine doctors  not allowed  allowed for biomedicine doctors only  Hybrid doctors  integrative TEAM-biomedicine doctors  not instituted  not instituted  Recognition of TEAM pharmacists  distinct recognition  distinct recognition  no  TEAM pharmacists’ practice rights over TEAM  only herbal remedies prescription and dispensation  only herbal remedies no prescription and dispensation  not applicable  Pharmacists’ practice across TEAM and biomedicine  not allowed, except for OTC  not allowed, except for OTC  allowed for biomed, unconditionally  Hybrid pharmacists  not instituted  not instituted  not instituted  Recognition of acupuncturists/moxibustionists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for licensees before 1962  distinct recognition from doctors  Their practice rights over TEAM  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  Recognition of manual therapists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for the blind  distinct recognition  Their practice rights over TEAM  limited to manual therapies  limited to manual therapies  limited to manual therapies    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Recognition of TEAM doctors  distinct recognition as one of four categories of doctors  distinct recognition as one of two categories of doctors  subordinate recognition only as a subtype of biomedicine doctors  TEAM doctors’ practice rights over TEAM  comprehensive and non-exclusive  comprehensive, exclusive and only  comprehensive as biomedicine doctors  Doctors’ practice across TEAM and biomedicine  allowed for both TEAM doctors and biomedicine doctors  not allowed  allowed for biomedicine doctors only  Hybrid doctors  integrative TEAM-biomedicine doctors  not instituted  not instituted  Recognition of TEAM pharmacists  distinct recognition  distinct recognition  no  TEAM pharmacists’ practice rights over TEAM  only herbal remedies prescription and dispensation  only herbal remedies no prescription and dispensation  not applicable  Pharmacists’ practice across TEAM and biomedicine  not allowed, except for OTC  not allowed, except for OTC  allowed for biomed, unconditionally  Hybrid pharmacists  not instituted  not instituted  not instituted  Recognition of acupuncturists/moxibustionists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for licensees before 1962  distinct recognition from doctors  Their practice rights over TEAM  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  limited to acupuncture or moxibustion  Recognition of manual therapists  distinct recognition from TEAM doctors  not distinct from TEAM doctors, except for the blind  distinct recognition  Their practice rights over TEAM  limited to manual therapies  limited to manual therapies  limited to manual therapies  Table 2. Contrast in the education of TEAM and biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Differentiation of TEAM schools for doctors  27 TEAM schools and 155 biomedicine schools  12 TEAM schools and 29 biomedicine schools  no TEAM schools and 80 biomedicine schools  Cross-learning of biomedicine and TEAM  mandatory education of biomedicine and TEAM in TEAM schools (50:50% of curricular hours) and in biomedicine schools (85:15%) coexistence of biomedicine programmes and TEAM programmes within school (60% of TEAM schools; 20% of biomedicine schools) programmes for integrative TEAM-biomedicine doctors (27% of all medical schools)  voluntary education of biomedicine and TEAM in TEAM schools (20:80% of curricular hours) and biomedicine schools (99:1%)  mandatory education of TEAM in biomedicine schools (99.8:0.2% of curricular hours)  Differentiation of TEAM pharmacy schools  74 TEAM pharmacy schools and 167 biomedicine pharmacy schools  none (only TEAM programmes in 3 out of 35 biomedicine pharmacy schools)  no TEAM pharmacy schools and 74 biomedicine pharmacy schools  Cross-learning of biomedicine and TEAM in pharmacy  voluntary education of biomedicine and TEAM in biomedicine and TEAM schools (a little) coexistence of biomedicine programmes and TEAM programmes within schools (74% of TEAM schools, 33% of biomedicine pharmacy schools)  voluntary education of biomedicine and TEAM for TEAM students (30:70% of curricular hours) and biomedicine students (99:1%)  voluntary education of TEAM for biomed students (a little)  Differentiation of acupuncture/moxibustion and manual therapy schools  yes; outside TEAM schools (number unknown)  no (except for massage schools for the blind)  yes; outside biomedicine schools (110 schools)  Cross-learning of biomedicine and TEAM  limited education of biomedicine (exact curricular composition unknown)  education of biomedicine and TEAM (30:70% of curricular hours)  education of biomedicine and TEAM (50:50%)    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Differentiation of TEAM schools for doctors  27 TEAM schools and 155 biomedicine schools  12 TEAM schools and 29 biomedicine schools  no TEAM schools and 80 biomedicine schools  Cross-learning of biomedicine and TEAM  mandatory education of biomedicine and TEAM in TEAM schools (50:50% of curricular hours) and in biomedicine schools (85:15%) coexistence of biomedicine programmes and TEAM programmes within school (60% of TEAM schools; 20% of biomedicine schools) programmes for integrative TEAM-biomedicine doctors (27% of all medical schools)  voluntary education of biomedicine and TEAM in TEAM schools (20:80% of curricular hours) and biomedicine schools (99:1%)  mandatory education of TEAM in biomedicine schools (99.8:0.2% of curricular hours)  Differentiation of TEAM pharmacy schools  74 TEAM pharmacy schools and 167 biomedicine pharmacy schools  none (only TEAM programmes in 3 out of 35 biomedicine pharmacy schools)  no TEAM pharmacy schools and 74 biomedicine pharmacy schools  Cross-learning of biomedicine and TEAM in pharmacy  voluntary education of biomedicine and TEAM in biomedicine and TEAM schools (a little) coexistence of biomedicine programmes and TEAM programmes within schools (74% of TEAM schools, 33% of biomedicine pharmacy schools)  voluntary education of biomedicine and TEAM for TEAM students (30:70% of curricular hours) and biomedicine students (99:1%)  voluntary education of TEAM for biomed students (a little)  Differentiation of acupuncture/moxibustion and manual therapy schools  yes; outside TEAM schools (number unknown)  no (except for massage schools for the blind)  yes; outside biomedicine schools (110 schools)  Cross-learning of biomedicine and TEAM  limited education of biomedicine (exact curricular composition unknown)  education of biomedicine and TEAM (30:70% of curricular hours)  education of biomedicine and TEAM (50:50%)  Table 3. Contrast in the provision of TEAM services vis-a-vis biomedicine   China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Number of TEAM doctorsa  152  196  7  Number of TEAM pharmacistsa  44  18  0  Number of acupuncturistsa  data unavailable  0.2  541  Number of moxibustionistsa  data unavailable  0.05  537  Number of manual therapistsa  data unavailable  79  635  Number of TEAM hospitals (per 100 biomedicine hospitals)  14 (90% of biomedicine hospitals have a TEAM department)  13 (not many biomedicine hospitals have a TEAM department)  0 (71% of biomedicine hospitals have a TEAM department)  Number of TEAM clinics (per 100 biomedicine clinics)  30  45  0  TEAM doctors working in biomedicine organizations  40% of licenced TEAM doctors work in biomedicine hospitals and clinics  8% of licenced TEAM doctors work in biomedicine hospitals (no clinics)  all (no TEAM doctors outside biomedicine organizations)  Biomedicine doctors working in TEAM organizations  5% of biomedicine doctors work in TEAM hospitals; 27% of TEAM organization workers are biomedicine doctors; 51% of doctors in TEAM hospitals are biomedicine doctors  0.1% of biomedicine doctors work in TEAM hospitals  none  Herbal remedies in insurance  some herbal extracts (683) and all raw herbs unless listed uninsured  some herbal extracts (68) and no raw herbs  some herbal extracts (148) and raw herbs (200)  Acupuncture/moxibustion in insurance  covered for all conditions  covered for all conditions  covered for six conditions  Manual therapies in insurance  covered for all conditions  no  covered for all conditions  Insurance for biomedicine treatments and TEAM treatments within hospital  yes  no  no    China: interpenetrative pluralism  Korea: exclusionary pluralism  Japan: subjugatory pluralism  Number of TEAM doctorsa  152  196  7  Number of TEAM pharmacistsa  44  18  0  Number of acupuncturistsa  data unavailable  0.2  541  Number of moxibustionistsa  data unavailable  0.05  537  Number of manual therapistsa  data unavailable  79  635  Number of TEAM hospitals (per 100 biomedicine hospitals)  14 (90% of biomedicine hospitals have a TEAM department)  13 (not many biomedicine hospitals have a TEAM department)  0 (71% of biomedicine hospitals have a TEAM department)  Number of TEAM clinics (per 100 biomedicine clinics)  30  45  0  TEAM doctors working in biomedicine organizations  40% of licenced TEAM doctors work in biomedicine hospitals and clinics  8% of licenced TEAM doctors work in biomedicine hospitals (no clinics)  all (no TEAM doctors outside biomedicine organizations)  Biomedicine doctors working in TEAM organizations  5% of biomedicine doctors work in TEAM hospitals; 27% of TEAM organization workers are biomedicine doctors; 51% of doctors in TEAM hospitals are biomedicine doctors  0.1% of biomedicine doctors work in TEAM hospitals  none  Herbal remedies in insurance  some herbal extracts (683) and all raw herbs unless listed uninsured  some herbal extracts (68) and no raw herbs  some herbal extracts (148) and raw herbs (200)  Acupuncture/moxibustion in insurance  covered for all conditions  covered for all conditions  covered for six conditions  Manual therapies in insurance  covered for all conditions  no  covered for all conditions  Insurance for biomedicine treatments and TEAM treatments within hospital  yes  no  no  a per 1000 biomedicine doctors. The data collection process began with a review of research papers that investigated the policy environment of TEAM in one or more of the three East Asian countries. During this process, this article was not only informed of some findings about the three plural medical systems but, more importantly, became aware of firsthand data sources that had been used in these prior studies. By utilizing these firsthand data sources, the paper triangulated and revised prior study results with the latest information. In addition, this article utilized additional sources that prior studies had not used yet. As a result, this article is based on a variety of data sources, such as national laws, regulations, government websites, official national statistics, yearbooks and websites of professional associations (specific data sources are identified in the following Results section). Last, these archival sources of data were combined with online and offline consultations with experts on TEAM policy in each of the three countries. Results The following analysis demonstrates three distinct ways of organizing and relating TEAM and biomedicine: the interpenetrative pluralism in China, the exclusionary pluralism in Korea, and the subjugatory pluralism in Japan. Both in the Chinese interpenetrative pluralism and the Korean exclusionary pluralism, TEAM and biomedicine are institutionalized as independent and equivalent systems of medical practices. However, TEAM and biomedicine are institutionalized to cross over into each other unconditionally in their practices in the Chinese pluralism, whereas the two exclude each other very strictly in their practices in the Korean pluralism. In the Japanese subjugatory pluralism, the crisscrossing of TEAM and biomedicine is allowed, yet in a very asymmetrical way. Thus, the practice of TEAM is dependent upon and subordinated into the practice of biomedicine. Legal categorization of TEAM practitioners vis-a-vis biomedicine practitioners Regarding various treatment modalities within TEAM, such as herbal remedies, acupuncture/moxibustion and manual therapies, the three countries demonstrated different ways of instituting practitioners who were entitled to practice all or some of these modalities. In addition, TEAM practitioners were granted different degrees of autonomy in crisscrossing the boundaries of TEAM and biomedicine (Table 1). All three countries legalized the category of TEAM doctors who were allowed to practice a wide range of medical services ranging from diagnosis and medical tests to therapeutic interventions just as medical doctors of biomedicine were. However, the degrees to which these TEAM doctors were recognized as an independent category of practitioners varied from country to country. Chinese national laws and regulations of professional doctors recognized four different types of doctors, namely biomedicine doctors (xi-yi), TEAM doctors (zhong-yi), ethnic doctors (min-jok-yi) and integrative TEAM-biomedicine doctors (zhong-xi-jie-he-yi). Recognized as such, they were all allowed to practice biomedicine, TEAM, or both. TEAM doctors were permitted to practice biomedicine as well as TEAM; biomedical doctors were allowed to practice TEAM as well as biomedicine. Integrative TEAM-biomedicine doctors, which exist only in China and not in the other two countries, were obviously allowed to practice both. The Korean regulatory system instituted two different categories of doctors, namely biomedicine doctors (yangui) and TEAM doctors (hanui). Unlike China, these two groups held exclusive practice rights; biomedicine doctors were allowed to practice only biomedicine and not TEAM whereas TEAM doctors were allowed to practice only TEAM and not biomedicine. Therefore, only doctors who held both the titles of biomedicine doctor and TEAM doctor could cross the boundaries of TEAM and biomedicine. Unlike China or Korea, the Japanese system recognized a single professional category of doctors, or biomedicine doctors, who could practice both biomedicine and TEAM. Whereas there were TEAM doctors in China and Korea who were not biomedicine doctors, the Japanese system did not allow the separate existence of such TEAM doctors. Only biomedicine doctors, once they earned the title, could elect to become certified as TEAM doctors (kampoi). The category of TEAM doctors in Japan was only a subtitle that biomedicine doctors could electively hold. Biomedicine doctors without the title of TEAM doctor had no restriction on their arbitrary practice of TEAM. Doctors legalized to practice TEAM in these countries, whether they be TEAM doctors or biomedicine doctors, could practice all the modalities in TEAM (herbal remedies, acupuncture/moxibusion, and manual therapies). Other practitioners of TEAM, however, held limited rights over specific TEAM modalities. For the delivery of herbal remedies that were made up of several medicinal herbs in a variety of forms, such as decoctions, pills, powders, and granules, the three countries had in common the professional group of pharmacists. However, the specific ways in which pharmacists were allowed to deliver herbal remedies to the public were quite different among the countries. In China, where pharmacists as well as doctors could prescribe and dispense drugs, pharmacists were categorized into two subgroups: TEAM pharmacists (zhong-yao-shi) and biomedicine pharmacists. TEAM pharmacists could deal with herbal remedies only and biomedical pharmacists were permitted to deal with biomedical drugs only. Other than prescription drugs, both biomedical and TEAM pharmacists could dispense over-the-counter (OTC) herbal remedies and biomedical drugs without any restrictions. In this manner, pharmacists were not allowed to crisscross the boundaries of biomedicine and TEAM as easily as doctors. Similarly, the Korean system recognized two separate professional groups of pharmacists: TEAM pharmacists (hanyaksa) and biomedicine pharmacists. Biomedicine pharmacists were permitted to only dispense biomedical drugs for prescriptions from biomedicine doctors, whereas TEAM pharmacists were permitted to dispense herbal remedies for prescriptions from TEAM doctors. Unlike biomedical pharmacists, in addition, TEAM pharmacists were also allowed to prescribe a limited number of herbal remedies (100) that were preselected by the government. Some biomedicine pharmacists who dealt with herbal remedies before 1996 and were certified under the legislations in 1996 continued to be able to deal with them. Like doctors, pharmacists were thus not allowed to practice across biomedical drugs and herbal remedies. OTC herbal remedies and OTC biomedical drugs were the only exceptions. In Japan, there was no separate legal recognition of TEAM pharmacists. Instead, biomedical pharmacists were allowed to deal with herbal remedies as well as biomedical drugs. Since the Japanese system did not outlaw drug prescription by pharmacists, pharmacists did not only dispense herbal remedies for prescriptions written by doctors; they also prescribed herbal remedies themselves. In prescribing these remedies, however, pharmacists were never allowed to produce diagnoses for which doctors were exclusively held responsible. In addition, pharmacists’ prescriptions of herbal remedies were not covered by the national health insurance system, whereas doctors’ prescriptions of herbal remedies were all covered. In this manner, biomedicine pharmacists held the comprehensive and exclusive rights over herbal remedies as well as biomedical drugs. For the practice of acupuncture/moxibustion and manual therapies, the Chinese system recognized acupuncture-moxibustionists (zhen-jiu-shi), manual therapists (bauzan-anma-shi) and acupuncture-moxibustion-manual therapists (zhen-jiu-tuina-shi) as government-certified practitioners (the Ministry of Human Resources and Social Welfare) until 2014. In 2014, the Chinese government announced that there would be no more government certification of these practitioners except for manual therapists. For those practitioners who were certified before 2014, their practices were qualified as preventive measures for health promotion and not as curative treatments for illness. These practitioners could not provide other medical services than those that were specified by their certification. Until 1962, the Korean government recognized three independent practitioner groups: acupuncturists (cheem-sa), moxibustionists (gu-sa) and manual therapists (anma-sa), which were originally introduced into the Korean medical system in 1914. However, the legislations in 1962 outlawed the practice of acupuncture and moxibustion by these practitioners and allowed only TEAM doctors to hold legitimate practice rights. Although it is still possible for acupuncturists and moxibustionists who were certified before 1962 to practice these modalities, the government did not certify new practitioners any more since 1962. Currently, certified acupuncturists were allowed to practice only acupuncture and certified moxibusionists were allowed to practice only moxibustion. Blind manual therapists, who had been exceptions to the legislations in 1962, were exclusively granted the rights to practice manual therapies. When compared with China and Korea, the Japanese system was consistent and more permissive in recognizing acupuncturists (hari-si), moxibustionists (kyu-si) and manual therapists (shiatsu-si and judo-seifuku-si) as legitimate practitioners. Qualified as practitioners in each of these specific modalities, they were not allowed to practice beyond the boundary of each modality. Within the limited scope of their practice, manual therapists could not apply manual treatments on patients with bone dislocations or fractures without a medical doctor’s approval for these treatments. Likewise, acupuncture was typically recommended by medical doctors only for a limited set of musculoskeletal conditions, namely low back pain, frozen shoulder, neuralgia, rheumatoid arthritis, cervico-brachial syndrome and neck pain (Ishizaki et al. 2010; Motoo et al. 2009; Payyappallimana and Serbulea 2013). These TEAM practitioners were permitted to run their own clinics, unlike occupational therapists and physical therapists who were not allowed to practice without being employed and supervised by biomedical doctors. Education of TEAM vis-a-vis biomedicine The extent to which each of these TEAM practitioners were educated about TEAM and biomedicine varied among the countries. In addition, biomedicine doctors were exposed to different degrees of TEAM education (Table 2). In China, TEAM medical schools were instituted distinctly from biomedicine schools (Park et al. 2016). These schools provided 3–8 years of education for students to become TEAM doctors. Some of these schools also had separate programmes for producing biomedicine doctors and programmes for students to become integrative TEAM-biomedicine doctors. Likewise, biomedicine schools did not only have programmes for students to become biomedicine doctors; some also had programmes for students to become TEAM doctors and programmes for integrative TEAM-biomedicine doctors. According to the World Directory of Medical Schools (http://www.wdoms.org/), there were 155 medical schools in China, 27 of which (17%) were TEAM schools. According to a Chinese website compiling information about Chinese universities and colleges (http://college.gaokao.com/), there were 172 schools that taught TEAM or/and biomedicine; 151 of them (88%) taught biomedicine and 51 (30%) taught TEAM; 30 schools had distinct programmes for TEAM doctors and biomedicine doctors at once (60% of all TEAM schools and 20% of all biomedicine schools); 46 schools had programmes for integrative TEAM-biomedicine doctors. In addition, TEAM programmes were required to allot significant curricular time for the education of biomedicine (Xu and Yang 2009, p. 135). They were found to spend 40–50% of the curricular time teaching biomedicine, including anatomy (a required course) and surgery (an elective) (Yoon and Kim 2013). Reciprocally, biomedicine programmes devoted 10–15% of their curricular time to teaching TEAM (Xu and Yang 2009). In sum, while schools were distinctly instituted to educate TEAM and biomedicine doctors, they were substantially engaged in teaching students both TEAM and biomedicine. The education of TEAM pharmacy for herbal remedies was differentiated from that of biomedicine pharmacy, as well. There were 186 programmes teaching traditional Chinese pharmacy, biomedicine pharmacy or both (http://college.gaokao.com/) in pharmacy schools or medical schools. 112 programmes taught biomedicine pharmacy alone; 19 taught TEAM pharmacy alone; 55 taught both. 33% of the 167 programmes that taught biomedicine pharmacy coexisted with a TEAM pharmacy programme within the school, whereas 74% of the 74 programmes that taught TEAM pharmacy coexisted with a biomedicine pharmacy programme. In these organizational environments, pharmacy students were given chances to learn both biomedicine and TEAM pharmacy by crossing two distinct programmes within schools. The education of acupuncture/moxibustion and manual therapies was incorporated within the organizational structure of medical schools of TEAM or biomedicine, except for an unknown number of private-sector organizations that provided a brief education of weeks or months to high school graduates for them to get a vocational certificate (Lim et al. 2015, p. 2). TEAM schools in China typically had a department of herbal medicine, a department of acupuncture and tuina, and sometimes a department of integrative TEAM-biomedicine. Acupuncture/moxibustion and manual therapies were educated within the department of acupuncture and tuina as a part of medical training for students to become TEAM doctors. 71% of 51 TEAM schools and 16% of 151 biomedicine schools taught acupuncture/moxibustion and manual therapies (http://college.gaokao.com/). In this organizational context, students of acupuncture/moxibustion and manual therapies were exposed to biomedicine as well as the other TEAM modalities. In Korea, TEAM medical schools were instituted distinctly from biomedicine schools like in China. There were 12 TEAM schools that provided 6 years of education (KIOM 2015), whereas there were 29 biomedicine schools. Unlike in China, however, TEAM schools were not permitted to institute any biomedicine programmes and biomedicine schools were not permitted to institute any TEAM programmes. Instead, each could voluntarily provide some courses of the other side. It turned out that biomedicine schools taught TEAM only as a part of the mandatory education of complementary and alternative medicine, which resulted in <1% of their total curricular hours; TEAM schools voluntarily devoted 18–28% of their curriculum to biomedicine education (Han et al. 2013). Anatomy was included as a required course in most TEAM schools, whereas surgery was not offered even as an elective (KIOM 2015). In Korea, pharmacists of either TEAM or biomedicine were educated for 6 years. There were 35 biomedicine pharmacy schools, 3 of which belonged to universities that had a TEAM medical school within its organization. The government allowed only these three schools to institute a department of TEAM pharmacy. There was no school only for the education of TEAM pharmacists. In addition, biomedicine pharmacy programmes in the 35 pharmacy schools had no required courses on TEAM pharmacy and instead offered one to two elective courses. On the contrary, 30–35% of the curriculum in most TEAM pharmacy departments taught biomedicine pharmacy (KIOM 2015). When compared with China, therefore, the likelihood of pharmacy students of TEAM or biomedicine to learn across both TEAM and biomedicine was limited. Korean laws did not recognize any educational institutes for acupuncture/moxibustion except for TEAM medical schools. One exception was that the education of manual therapies was legalized for blind people in 24 high schools and vocational schools (http://www.anmaup.or.kr/). The 2- to 3-year curriculum covered massage, acupressure and acupuncture, while about 30% of the training was devoted to biomedicine courses involving anatomy. Unlike China and Korea, there were no TEAM medical schools in Japan for educating TEAM doctors. Therefore, Japanese doctors who wanted to practice TEAM as one of their subspecialties needed to complete a three year-long practice at TEAM institutions certified by the Japanese Society of Oriental Medicine, the Japanese professional association of TEAM doctors. This TEAM education addressed herbal remedies, acupuncture/moxibustion and manual therapies, although it was mostly focussed on herbal remedies kampo (Muramatsu et al. 2012). All 80 medical schools taught herbal remedies for about 12 h, or 0.2% of their curriculum (Payyappallimana and Serbulea 2013) which was half the amount of training for other subspecialties in biomedicine (Yoon and Kim 2013), following the mandate of the Ministry of Education, Science, and Technology in 2001 (Namiki and Nagamine 2012). This curricular recommendation of mandatory education, however, did not involve acupuncture/moxibustion or manual therapies. Kampo was also taught to pharmacists who were educated for 4 years in the postgraduate programmes of the departments of pharmacy in 74 universities, whereas there was no department or programme specifically for kampo or TEAM pharmacy (Payyappallimana and Serbulea 2013). The number and the specific content of courses on kampo varied from school to school (Kobayashi 2016), since the 2008 Standard Examination Questions for the Pharmacist Licensure involved kampo formulae for the first time (Namiki and Nagamine 2012, p. 47). The Japanese educational system for acupuncture/moxibustion and manual therapies took shape following the enactment of the 1947 Law for Businesses of Massage, Acupuncture, Moxa-Cautery, and Judo-Orthopedics. As of 2015, there were 110 schools that provided college-level vocational programmes specifically for these modalities. High-school graduates were allowed to apply to these programmes that usually ran for 3 years (http://youseijo.mhlw.go.jp/). Out of the 110 schools, 108 schools taught acupuncture/moxibustion, whereas 31 schools taught manual therapies such as anma, shiatsu and massage; 29 schools taught both acupuncture/moxibustion and manual therapies. In addition, a majority of acupuncture/moxibustion schools (65 out of 108) taught judo therapy; reciprocally, 66% of 99 judo therapy schools taught acupuncture/moxibustion. There were six 4-year colleges for acupuncture/moxibustion with some having post-graduate programmes as well (Shim 2015). These figures show that there was a significant amount of TEAM education outside herbal medicine kampo. None of these schools, however, taught herbal medicine kampo to the students. Instead, 50% of the curriculum was composed of biomedicine courses. Provision of TEAM services vis-a-vis biomedicine In China, TEAM and biomedicine services were provided simultaneously by multiple professionals and organizations (Table 3). The number of medical professionals of TEAM or biomedicine (doctors, nurses and pharmacists) was 7 200 528 in 2013 (NBSC 2015). 7% (505 917) of them were TEAM professionals (395 674 doctors and 110 243 pharmacists) (SATCM 2016). Of all the medical professionals, 11% worked in organizations specialized in TEAM. Interestingly, 27% of these workers were biomedicine professionals. The percentage of biomedicine doctors among all doctors in TEAM hospitals was even greater (51%) (SATCM 2016). Among all TEAM professionals, reciprocally, 60% worked in biomedicine organizations that provided TEAM services (SATCM 2016). Among all biomedicine doctors, about 5% worked at TEAM hospitals where they provided biomedicine services. In terms of organizations, there were 24 709 hospitals, 86% of which were biomedicine hospitals; the remaining included TEAM hospitals (12%), integrative TEAM-biomedicine hospitals (1%), and ethnic hospitals (1%) (SATCM 2016). 90% of these biomedicine hospitals had TEAM departments and 8% of the outpatient visits were made to those TEAM departments (Xu and Yang 2009, p. 136). Reciprocally, most TEAM hospitals and all integrative TEAM-biomedicine hospitals provided biomedicine services; 55–60% of the medical treatments in integrative TEAM-biomedicine hospitals were biomedicine services (Xu and Yang 2009:136; Zhang et al. 2015) and 37% of outpatient medication revenue and 78% of inpatient medication revenue in TEAM hospitals were from biomedicine (Xu and Yang 2009, p. 137). Out of the 183 982 clinics and community health centres where basic public health needs were met without inpatient services, 47% were biomedicine clinics with the rest being TEAM clinics and specialty clinics. Most of these biomedicine clinics had TEAM departments as well (SATCM 2016). Therefore, >40% of the centres had TEAM doctors and >60% provided TEAM services (Cai et al. 2015, p. NP2492, NP2494). About a third of the total utilization in clinics was TEAM services (Xu and Yang 2009, p. 137). All of these clinics provided biomedicine services as well. The crisscrossing of TEAM and biomedicine was shaped by the national insurance system, as well. Once the current insurance system was put in place (Barber and Yao 2011), the Chinese government progressively integrated TEAM into the system. 102 out of the 307 items on the List of Essential Drugs were herbal remedies of TEAM (Barber and Yao 2011, p. 353; Chung et al. 2013, p. 5). The Chinese system guaranteed higher reimbursement rates for these essential drugs. In addition, the List of National Health Insurance Drugs that registered insured drugs included 683 herbal remedies for which users co-paid at most 10% of the total cost (Chung et al. 2013, p. 5). Furthermore, the national insurance covered all raw herbs unless specified as uninsured (Lim and Kim 2016). Therefore, medical service users were incentivized to utilize herbal remedies readily (Chung et al. 2013). Medical treatments of acupuncture/moxibustion and manual therapies for all medical conditions were also covered. Last, since medical service providers and users might practice both TEAM and biomedicine, the insurance system covered the medical costs for both TEAM and biomedicine treatments that were applied to a patient for the same medical conditions within a service organization. In Korea, the presence of TEAM doctors was very noticeable. There were 22 074 TEAM doctors and 112 476 biomedicine doctors in 2014 (196 TEAM per 1000 biomedicine doctors) (KIOM 2015). 11% of these TEAM doctors were specialists in such fields as internal medicine, rehabilitation, and obstetrics/gynecology, with 89% being general practitioners (cf. Japan). 247 were dual licensees, holding the licence for doctor of biomedicine as well. In contrast, there were only a few other TEAM practitioners: 23 acupuncturists, 6 moxibustionists and 13 bone-setters who had been licenced according to old laws that were repealed in 1962. There were only 2000 TEAM pharmacists. There were 2038 hospitals in 2014, 89% of which were biomedicine hospitals and 11% were TEAM hospitals (www.komha.or.kr). Unless they employed doctors of the other medical tradition, these hospitals could provide only biomedicine or only TEAM services, depending on their registered specialty area. Only 0.1% of biomedicine doctors were employed by TEAM hospitals, whereas 8% of TEAM doctors were employed by biomedicine hospitals including elderly care. In this exclusionary context, another way that TEAM hospitals used to secure biomedicine services (and for biomedicine hospitals to secure TEAM services) was to send their patients to other hospitals via patient referral (Park 2016). With regard to clinics, there were a total of 42 028 facilities: 28 883 biomedicine clinics (68%) and 13 135 TEAM clinics (32%). These clinics provided either biomedicine or TEAM services. Korean national health insurance covered acupuncture/moxibustion practiced for all treatment purposes. On the contrary, manual therapies were not covered by the national insurance (www.anmaup.or.kr). The insurance coverage for herbal remedies was very selective and limited so that only some herbal extracts and no raw herbs were covered. Out of the 451 multi-herbal extracts that drug companies manufactured according to established herbal remedies of TEAM, only 56 extracts (12%) were insured. 68 uni-herbal extracts were additionally insured. However, a majority of TEAM doctors and service users relied in reality on the traditional style of herbal decoctions of raw herbs that were not insured (Son 2012). Last, unlike China, the Korean insurance system did not cover the costs of both TEAM and biomedicine services for a single medical condition when they were provided by the same medical service organization on the same day; whichever service that was registered first in the insurance claiming system was covered, while the service that was registered later was not. In Japan, the number of licenced medical doctors was 295 049, 0.7% of which held the title of TEAM doctor as well (http://www.jasom.or.jp). This numerical presence of TEAM doctors paled in comparison to that in China and Korea. In addition, 71% of these doctors who had the additional title of TEAM doctor worked in clinics, whereas only 38% of all doctors worked in clinics. Among the medical doctors affiliated with hospitals, only 0.2% held the title of TEAM doctor. These figures demonstrate that TEAM doctors were more common in clinics than hospitals. 70–90% of medical doctors were found to prescribe herbal remedies kampo (Moschik et al. 2012); 1.3% of all prescription drugs covered by the national insurance system were herbal remedies (Katayama et al. 2013). On the contrary, a very small proportion of medical doctors (4%) practiced acupuncture/moxibustion; not many medical doctors (4%) referred their patients to acupuncturists/moxibustionists, either (Muramatsu et al. 2012). In this way, the practice of TEAM by medical doctors was significantly biased toward herbal remedies. However, there were many other TEAM practitioners: 159 607 acupuncturists, 158 341 moxibustionists, and 187 295 anma/massage/shiatsu therapists (http://youseijo.mhlw.go.jp/). On an organizational level, 57 of 80 medical schools (71%) had a department of herbal remedies within the university hospital structure (Payyappallimana and Serbulea 2013). On the contrary, the other TEAM modalities were not incorporated in these hospitals. Instead, acupuncturists/moxibustionists and manual therapists were authorized to practice in their own facilities; 80% of them were employed in independent specialty clinics, where acupuncturists and moxibustionists mostly practiced together. In 2014, there were 25 445 clinics for acupuncture/moxibustion, 19 271 clinics for anma/massage/shiatsu, and 37 682 clinics that provided all of these services (MHLW 2015). The Japanese national health insurance system covered herbal remedies comprehensively, as in China. The Japanese medical community’s efforts to evaluate the evidence base of herbal remedies had accompanied this development (Tsutani 1993; Okabe and Tsutani 2010). 148 kampo extracts that mixed different herbs were currently insured (Katayama et al. 2013). In addition, 241 raw herbs that doctors could mix and prescribe for patients were covered by insurance. Doctors usually prescribed the pre-established 148 kampo extracts that were manufactured by drug companies rather than their own remedies that mix raw herbs. Whether a specific herbal remedy was supported by insurance did not depend on the kind of medical conditions that the remedy was used for, once it was prescribed by a medical doctor. On the contrary, insurance support for acupuncture/moxibustion was conditional upon the medical conditions that the modality was used for. Only six musculo-skeletal conditions were covered by insurance (Ishizaki et al. 2010; Payyappallimana and Serbulea 2013). The treatment for these conditions was, however, not covered by insurance without a medical doctor’s approval in advance. In addition, like in Korea, the Japanese insurance system did not cover the costs of both TEAM and biomedicine services for a single medical condition when they were provided by the same medical service organization on the same day. When this simultaneous practice happened, biomedicine services were usually covered and TEAM services were not. Discussion The characteristics of various medical systems are represented in the literature, focussed on the relationships among three key actors: medical service providers, service users and insurers (Wagstaff 2007; Freeman and Frisina 2010; Toth 2016). The fundamental interest in the financing and the population/benefit coverage of healthcare systems reflects the significance of the different ways in which these actors are held responsible for healthcare systems. This concern about responsibility extends to attention about who constitute legitimate medical service providers and how they are produced; how these different providers interact with one another and with service users; how insurers shape these interactions. Drawing on this perspective, this article turns to the often-forgotten and yet long-lasting element of medical systems (i.e. TCAM) and examines how it is organized and related to biomedicine. In this context, the medical systems in the East Asian countries that incorporate TEAM have gained interest. In response, this paper proposes an original conceptualization of the three plural medical systems. In the interpenetrative pluralism in China, all the modalities of TEAM are recognized explicitly via legal categorizations, medical education, and service provisions. In addition, these modalities are connected and held together under the oversight and the comprehensive practice rights of TEAM doctors (and biomedicine doctors) who can also practice biomedicine on the basis of their professional discretion. There is yet another group of practitioners of acupuncture/moxibustion and manual therapies who are independent from TEAM doctors. To this extent, the interpenetrative pluralism features multiple social locations for TEAM practitioners that lead to non-exclusivity and mutual incorporation between TEAM and biomedicine. Therefore, there are opportunities for the hybridization of TEAM and biomedicine in practitioners and medical service organizations. The exclusionary pluralism in Korea recognizes all the TEAM modalities as much as the interpenetrative pluralism. These modalities are, however, connected and practiced together only by TEAM doctors. To TEAM doctors, these TEAM modalities are the only interventions that they are allowed to practice legally. In addition, there are no other practitioners who can practice acupuncture/moxibustion and manual therapies, independent from TEAM doctors. In this way, the oversight of TEAM doctors over TEAM modalities is the greatest. The exclusionary pluralism also features the mutual exclusion of TEAM and biomedicine and, subsequently, little interaction between the two sides. In the subjugatory pluralism in Japan, some TEAM modalities are recognized explicitly as medicine (e.g. herbal remedies), whereas others are called quasi-medicine (e.g. acupuncture/moxibustion) in national laws and regulations. In addition, these modalities are disconnected from one another under the oversight of various practitioners. Whereas there are no TEAM doctors as in China and Korea, the Japanese system has a significant number of acupuncturists/moxbustionists and manual therapists who have limited practice rights over only some modalities and not all. Regarding the TEAM–biomedicine relationship, this system features asymmetrical incorporation where TEAM is incorporated within biomedicine so that there are chances for the biomedical transformation of TEAM (Lock 1980) in which TEAM becomes assimilated to biomedicine in its practices. This conceptualization of three distinct plural medical systems speaks to existing studies of East Asian medical systems and adds an updated theory to the literature. It expands an early comparative study of three Chinese societies (China, Hong Kong, Taiwan) by further elaborating the ‘functionally diverse systems’ of the common ‘hierarchical pluralism’ in the region (Lee 1982). This article also updates the perspective in the WHO report (WHO 2002) that categorizes both China and Korea as ‘integrative’ systems, by showing that the two countries in fact feature quite different ways of integration. This article agrees with the view that due analytical foci about plural medical systems should be placed on the ‘cross-sectoral links’ between TEAM and biomedicine and on the ‘general state practice’ (Holliday 2003). Rather than taking a schematic conceptualization (Holliday 2003, p. 384), however, this article proposes an alternative conceptualization resulting from a systematic analysis of more specific policies on the ground. Thus, this new conceptualization sheds lights not only on whether there is the ‘fusion’ or ‘separation’ (Holliday 2003, p. 384) between TEAM and biomedicine but also on the fact that the fusion (or separation) is implemented in significantly different manners among China, Korea and Japan. This article further contributes to providing potential answers to the varying practices of medical service providers and users who are situated at the intersection of TEAM and biomedicine. For example, the holistic and explicit institutionalization of all TEAM modalities in China and Korea seems to be an important factor in accounting for the fact that Chinese and Koreans tend to use both TEAM and biomedicine more than Japanese (Shim 2016). The existence of a professional group (i.e. TEAM doctors in Korea) that holds the comprehensive and exclusive practice rights over TEAM seems to provide an explanation to the pattern that Koreans are most likely to use several TEAM modalities together (dubbed the ‘holistic’ use of TEAM) in the region (Shim and Kim 2016). If these different patterns in the co-utilization of TEAM and biomedicine and in the holistic use of TEAM have anything to do with healthcare outcomes in plural medical systems (Xue et al. 2003; Wan 2007; Huang et al. 2008; Salameh et al. 2008), studies of healthcare outcomes need to pay substantial attention to the institutional context of plural medical systems. In addition, this comparative study suggests the need to examine how these different institutional contexts affect the patterns in which TEAM is (re)constructed as a medical tradition that is discernable from biomedicine. In the exclusionary pluralism vis-a-vis the interpenetrative or the subjugatory pluralism, for example, TEAM is likely to be reconstructed as a different medical tradition than biomedicine. It is worth investigating how TEAM users respond differently in these countries to various developments in biomedicine including genetic advances (Arribas-Ayllon 2016; Teo et al. 2016). Regarding the controversies among East Asian countries over how to represent TEAM to the world healthcare community beyond the region (Lim 2010), it should be stressed that not only nationalist politics (Hsu 2013) but practical institutional differences reported in this article can play a significant role. This article also suggests that the degrees to which professional practitioners and everyday service users are held responsible for deciding how to mix and match TEAM and biomedicine vary significantly from one type of plural medical system to another. In the Chinese interpenetrative pluralism, medical service users can rely on professional practitioners and medical service organizations of TEAM or biomedicine when users are not sure by themselves of how to use both TEAM and biomedicine for their benefits. In the Japanese subjugatory pluralism, medical service users can turn to medical doctors of biomedicine for professional advice. The Korean exclusionary pluralism, however, makes it more difficult for medical service users to get professional advice when they crisscross the boundary between TEAM and biomedicine, since it does not allow any medical professionals to practice both traditions of medicine. Future research needs to examine the consequences of these variations for healthcare outcomes as well as user behaviour. Last, this study invites a comparative-historical investigation of what has created these cross-national differences and how different experiences of modernization in the region intervene in the process. Historically, TEAM originated in China and diffused to Korea and to Japan (Motoo et al. 2011). This historical movement itself seems to have had impacts on how TEAM was shaped, punctuating different theoretical elements of TEAM in different countries. 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Health Policy and PlanningOxford University Press

Published: Apr 1, 2018

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