Articles

Some Arguments
Against the Standardization of Herbalists

By Stephen Harrod Buhner

Copyright © 2003 Stephen Harrod Buhner

The drive by segments of the herb industry to begin certification for herbalists is a parallel movement to the standardization of plant medicines - a way of standardizing herbalist practitioners. It is accompanied by the same arguments put forward in support of standardizing herbs - to protect the consumer and raise quality. There is evidence that such an approach to herbal practice will not produce the outcomes that proponents assert.
Milton Friedman comments succinctly in Capitalism and Freedom (Friedman, 1962) that the overthrow of the European guild system was indispensable to the rise of freedom in the Western world. It allowed everyone to pursue whichever trade they desired; the huge surge in the development of new knowledge, the growth of an entrepreneurial society, was completely dependent on this freedom to explore, cross boundaries, and interblend disparate information and skills. He argues convincingly that licensure and certification are simply a return to the guild system of medieval Europe. Guilds, he remarks, exist for three reasons: money, power, and control. They restrict entry into certain areas of trade, they allow more money to flow to those working in the restricted areas of trade, they concentrate power in the hands of a few.
Friedman is not alone in questioning whether or not the publicly stated goals of these groups - protecting the consumer and raising quality (of either product or practitioner) - are actually met. Increasingly, studies show that there is no relation between licensure or certification, consumer protection, and higher standards.
The lack of relationship is possibly due to the reasons why licensure or certification is pursued. It is very rare that consumers themselves initiate licensure or certification processes. The drive for licensure and certification is nearly always begun by the to-be-licensed groups. The underlying reason has been found to be universal, irrespective of trade - the desire carve out protected territory in which they can practice either uninhibited or without competition - in other words, protecting turf and increasing income. (Shimberg, 1980, 1984, 1991) And restrictive legislation does seem to provide this: studies show that professional incomes generally double after state regulation is instituted. (Clarkson, 1980)
An essential point about herbal certification is that there is no drive by consumers - no clarion call - for legislation protecting them from badly trained practitioners. The call comes, as it historically seems to do, from the practitioners themselves, in this instance, a particular type of herbal practitioner - the rational phytotherapists or "science-based" clinicians. But does certification or licensure of these kinds of groups actually result in better care, consumer protection and higher standards of practice. A century of such laws finds that it does not.
Numerous articles and studies have appeared over the past three decades commenting on the health care crisis in the United States. Rising costs, poor or no care for certain groups, delays in even minimal services for the ill have all illustrated the need for health care reforms. A number of studies have examined whether or not regulation of health care workers has any relationship to these problems. One Iowa study found that while medical licensure was originally established for the purported purpose of raising the quality of care for the ill, the actual result was a decreased availability of services, especially for the poor. (Contemporary Studies Project, 1972)
Neither do these types of regulations seem to protect consumers from harm. An FTC study on regulation of the television repair industry found that the incidence of consumer harm was unrelated to regulation, levels of harm remained the same irrespective of comprehensive licensing laws designed to protect consumers. Prices, however, were significantly higher. Similar studies have shown that levels of real estate fraud and consumer harm are unrelated to the licensure of real estate agents. (Rose, 1979) And a Bureau of Economics study of seven licensed professions noted that "While a few studies indicate that higher quality levels may result from such licensing restrictions, a majority of the work to date finds quality to be unaffected by licensing or business practice restrictions associated with licensing. In some cases quality actually decreases." The study found that restrictions on professional practice - in all cases - were ultimately detrimental to consumers. (Cox and Foser, 1990)
Closer to herbalism perhaps, laws regulating psychologists have not been found to protect consumers from harm. The reform legislation eventually instituted in Colorado occurred not because there were no laws in place to protect consumers but because existing licensure laws did not do what legislators were told they would when passed. In revisiting the issue Colorado's Department of Regulatory Agencies noted that licensure did not effectively prevent harm and further found that there was, in fact, no relation between training and competence. "Traditional licensing theory," they commented, "assumes that competent practice is derived from the educational base, the skills development and the supervised experience that licensees must demonstrate prior to licensure. There is not, however, a lot of empirical data that supports this assumption as accurate." (Colorado Department of Regulatory Agencies, 1991, 11) The state of Colorado took a unique approach to solving the problem: they decided to allow anyone who wishes to do so to practice as a psychotherapist. To protect the public they instituted, instead of licensure or certification, a comprehensive process of informed consent backed up by a regulatory board to hear complaints of harm.
There are increasing reasons to apply the Colorado findings to the licensing of physicians and other health care practitioners. Studies continue to show that the licensure of medicine has resulted in the very same outcomes found in other fields - poorer care, higher prices, less innovation, and strident protectionism. (Feldman, 2000; Friedman, 1962; Morrison, 2000; Shimberg, 1991); Contemporary Studies Project, 1972; Cox and Foser, 1990; Svorny, 2000)
The extensive education and training required of physicians does not actually seem to reduce patient harm. A landmark study commissioned by the Institute of Medicine's Committee on Quality of Health Care in America found physician error to be rampant. The study estimated that between 44,000 and 98,000 people die each year from medical errors. The authors of the report concluded that their figures are almost certainly conservative. (Kohn, 1999) An additional study, reported in the Journal of the American Medical Association, showed that some 300 people are killed every day by properly prescribed pharmaceuticals. Nearly 7000 people per day are hospitalized or permanently disabled by those same drugs. (JAMA, 1998) While it might be argued that physicians have little control over the impact of pharmaceuticals on their clients, that it is an FDA issue, it is in fact the physicians that actually prescribe the drugs and death and disability from pharmaceuticals is rightly viewed as an iatrogenic, or docter-caused, disease.
Questions are also being raised about the type of training that physicians receive. They are highly steeped in a "science-based Western" approach toward disease - mandated by their licensure boards - but there is increasing evidence that this approach possesses untenable assumptions that are actually creating disease rather than curing it. For example, historical, Western, scientific, medical assumptions about bacteria and DNA are now known to be seriously misguided.
DNA has long been assumed (and taught) to be somewhat like a fixed software program that determines organism shape and behavior. However, DNA is actually a highly flexible organ of the cell. A number of cellular structures, in fact, exist for no other reason than to mediate DNA rearrangement. (Powel, 2000) Bacteria are assumed to be unintelligent and virulent bringers of disease - hence the medical war on disease bacteria. The combination of these two beliefs, as many epidemiologists and researchers have shown, has been nothing short of disastrous. Bacteria are actually highly intelligent (though researchers tend to describe this as genomic intelligence) and engage in promiscuous DNA rearrangement in the presence of antibiotics. They actively create solutions to antibiotics - even antibiotics they have never encountered - which they then teach to other bacteria. (Levy, 1992) The unrestrained use of antibiotics has created what the press are calling supergerms - virulent bacteria that are responsive to no known antibiotics. Researcher Mark Lappe', in his book When Antibiotics Fail, sets the deaths from these antibiotic-resistant bacteria at 100,000 per year. (Lappe', 1986) The Centers for Disease Control are slightly more optimistic, they estimate that 2 million people acquire infections while hospitalized while only 90,000 of them die. (American Iatrogenic Association, 2002)
While the medical approach to bacterial disease was based on the best science of the time, no competing systems, which might have moderated this one approach, were allowed entrance to the field of medicine. The problem is not medical science but its dominance and the lack of culturally accepted alternate perspectives.
In-depth knowledge of a "science-based Western" approach to the human body and illness does not, in practice, seem to necessarily produce safer outcomes or competent practice. In part this is because many of the areas that physicians must now study have not come out of what they have found they need, but from licensure boards that set standards for physicians and the schools they attend. This is common in any field where licensure or certification occurs.
Once a regulatory law is passed, a board is appointed to oversee the implementation of the law. These boards are generally composed of members of the trade group being regulated - for they are generally more aware of and motivated about the needs of the profession than the general public. There may or may not be one or two consumer members of the board. Over time the boards set more and more complex educational and testing requirements for those seeking licensure or certification. (Morrison, 2000) Friedman has some succinct comments about the licensure of barbers as an example of this.
All potential barbers must attend a school for barbering, then participate in an internship. They must show proficiency in "the scientific fundamentals of barbering, hygiene, bacteriology, histology of the hair, skin, nails, muscles and nerves, structure of the head, face and neck, elementary chemistry relating to sterilization and antiseptics, disease of the skin, hair, glands and nails, haircutting, shaving, arranging, dressing, coloring, bleaching, and tinting of the hair." (Friedman, 1962, 142) There is little evidence that the majority of these areas of study actually produce a better barber or are even related to barbering. They do support an increasingly complex education industry that provides both the initial education and continuing education credits (CEUs) afterward. (No studies confirm the belief that CEUs enhance practitioner competence - e.g. see Morrison [page 5] where he notes: "National organizations in pharmacy have also pressed for continuing education credits in each state using material approved by the American Council on Pharmaceutical Education, despite criticism that these requirements bear little relationship to what pharmacists need to enhance their actual competence in practice.") These increasingly complex regulations do increase prices to the consumer and prevent people who want to approach barbering from a different orientation from entering the field and creating alternatives.
Economists such as Milton Friedman make an important point - prices are always lower and consumer protection higher in the presence of the least intrusive government regulation. This is because the field remains open to innovative outsiders, to cross-mixing between disciplines, and to competitive pricing. Just what produces the best training and knowledge base (and hence outcomes) is left open to those who feel compelled to work in the field to discover.
Those arguing for the certification of herbalists might insist that certification is not intended to be state sanctioned but is merely voluntary. This approach, outlined in Kathy Abascal's and Eric Yarnell's article "Certifying Skill in Medicinal Plant Use" in HerbalGram 52 is, in actuality, no better than state licensure, and indeed, is only a prelude to it. It will, voluntary or not, possess the same problems that state certification has been found to have for it is, in general, being pursued for the same reasons.
Herbal certification in, as Abascal and Yarnel describe it, a "science-based, Western system of botanical medicine" is being promoted as a means to protect the consumer and raise the standards of the profession - things which certification (and even licensure) has generally been found incapable of doing. It is also being pursued, as Aviva Romm - the American Herbalist Guild (AHG) president - puts it (in a response to a Letter to the Editor in HerbalGram 54), so that "those wishing to practice herbalism in increasingly public venues such as hospitals and clinics" can do so. It has to do with gaining a legally recognized status so that herbalists can continue to practice, with getting into and becoming a part of the American health care system of hospitals, referrals, and insurance. If it were only about protecting the people who need herbs for their medicine and making sure they have access to the best quality of health care, there are other options available to choose from, options that have actually been found to decrease prices, protect the public, and enhance health care.
While a careful reading of the writings by those arguing for certification reveals an escalating argument for consumer protection, there is, in fact, little harm from herbs, even in the hands of inexperienced practitioners. Herbalism is a very safe modality. In contrast to the harm from pharmaceuticals, a study by Let's Live estimates that one person dies per year from properly prescribed herbal medicines. (Brevoort, 1998) (The irresponsible popular use of ephedra for weight loss and energy is a different issue.) Again, this can be addressed by much less intrusive means than certification.
In their article, Abascal and Yarnell argue that government regulators and media opposition to herbs and herbalism will be quieted by a voluntary certification program. They cite no studies or historical circumstances that support these assertions, however the actual nature of state government indicates that this assertion is quite likely incorrect. (Indeed, Richard Morrison, former Executive Director of the Virginia board of Health Professions and an expert on this issue comments that "the existence of private certification has not stemmed the growth of licensure or government certification programs for allied health occupations.") (Morrison, 2000, 3)
For herbalists to practice in hospital settings, with doctors, accorded the same respect and practice rights, to easily receive referrals, to get into the health care system as an equal player necessitates state recognition. As herbalism gains more visibility (much like midwifery or traditional Chinese medicine), each state will sooner or late feel compelled to deal with it as a practice category. Some states will keep it strongly illegal - much as many do now with naturopathic practice. Some will allow limited practice, some will allow only those licensed in some other category to practice it: acupuncturists, midwives, and so on. Some will legalize it through some form of registration, certification, or licensure. Trade regulation is a primary area of state control and oversight and the states control it jealously. Lobbyists in this field exist to convince state legislatures to allow uncontrolled practice by specific groups or conversely to pass licensure/certification laws enabling certain groups to practice or receive insurance. The assumption that the states will give up this power simply because a trade group has instituted voluntary certification is seemingly naive and historically inaccurate. Proponents of voluntary certification want herbalists to be able to legally practice within the existing medical system. Nothing can allow that to happen except state recognized status, for it is only the state that can grant the right of practice - especially since most existing medical practice statues restrict exactly this type of work. Voluntary certification is therefore only a prelude to state regulation for herbalists. Once states begin to accept the certification of herbalists, only the certification proponents' approach of a "science-based, Western systenm of botanical medicine" is likely to be put forward as a model for herbal training. The Botanical Medical Association (BMA) and the American Herbalists Guild, by authoring the certification process, put themselves in position to approach legislatures with this particular platform - indeed Yarnell's and Abascal's article insists that working with government regulators is a primary reason for their certification drive. Eric Yarnell has commented separately (in an email to Mark Blumenthal of the American Botanical Council) that by having a certification process already in place, if states do begin to implement licensure, an existing standard will be available for use. Because the certification system emphasizes Western scientific approaches, the state legislatures who adopt it will tend to restrict practice to herbalists trained in that system; nothing in the proposed certification testing supports the practice, for instance, of wise woman or community folk practitioners who use alternate paradigms. Those who use other approaches will - based on how states have historically responded to this kind of industry certification - most likely be marginalized or denied the right to practice. To help prevent this it only makes sense that, if all approaches to herbalism are to be protected, to begin with a certification that is not limited in scope.
There are very real problems inherent in proposals to restrict certification to only a "science-based, Western system of botanical medicine." There are numerous approaches to herbal practice in the U.S. - an obvious question is why this particular restriction? Why not choose a wise woman or even community herbalist approach for certification? Obviously, the reason is that a "science-based, Western system of botanical medicine" is somehow considered to possess more value, to more accurately desribe and prepare practitioners for the treatment of disease, or, perhaps, to be more acceptable to those who control access to the existing health care system.
But a "science-based, Western" model is itself problematic as a primary model - is it really the most accurate approach or is it only one approach. There is a bias among groups seeking licensure in favor of awarding a special ontological status or fundamental reality to the elementary particles discovered by physicists and an attempt to emulate that orientation in other scientific and healing disciplines. There is an inherent belief that the understanding of the physicality and interrelationship of matter in its tiniest realms somehow connects people more successfully to reality than other approaches. A "science-based, Western system" is generally assumed to get people closer to the way things "really" are and therefore to possess more value than other approaches. Underneath this belief is another, deeper assumption that the use of such a system will result in sufficient understanding to allow effective control over nature and disease. In consequence, it is given a kind of first ranking in the hierarchy of approaches to disease description and treatment. (Rorty, 2000; Gadamer, 1983; Buhner, 2002, 11-82) Other approaches, such as wise woman or folk herbalism, appear, from this perspective, more "fuzzy," less accurate, not as valuable or real. But does such physicalist reductionism really get us closer to reality. Consistent research over the past five decades increasingly indicates that it does not.
For example, emerging interdisciplinary research - initially begun by "popular" researchers rather than institutional scientists - is indicating that the heart is not merely a muscular pump but a part of the brain with the same number of sensory neurons as that possessed by certain subcortical portions of the brain. There are tightly interwoven biofeedback loops that exist between the brain and heart - what is seemingly exchanged is information about the heart's perceptions of the world. The heart uses a highly detailed emotional language to perceive and describe the world - the contemporay Western capacity for this language is apparently stunted because of the emphasis on more analytical reasoning during decades of schooling - but the heart is more accurately thought of as a brain, not a muscular pump. A number of healers now insist that there is a reason heart disease is the number one killer in the U.S. - because the nature of the heart has been misunderstood from the Western emphasis on rationality and something gets broken in the process. (Childre, 1999; Buhner, 2003) For herbal schools to teach and test for heart as muscular pump merely institutionalizes this cultural illness in a new profession. This knowledge of the heart as a brain is not new, most ancient and non-technological cultures recognize the heart as the seat of consciousness as do many herbalists that work from non-scientific, non-Western paradigms.
Certification criteria will also emphasize Latin nomenclature as part of a "science-based Western" system of learning plants. There is increasing concern among a number of groups about the use of this kind of language to describe the world. Functional taxonomists, for example, insist that for ecology to succeed "classical taxonomy will have to give way to functional classifications." (Heal and Grime, 1991, 3) Classical botanical taxonomy in fact teaches students many things that are not accurate to reality - such as the name for osha - Ligusticum porterii. Ligusticum refers to Liguria, Italy. Porterii means "of Porter" referring to Thomas Conrad Porter (1822-1901), a Philadelphia botanist. So, this plant that has been embedded within the ecosystems of North America for at least 100 millennia is now know as Porter's Liguria, Italy. Such naming, many assert, causes a dissociation from the living reality of the plants in the ecosystem and the delicate web of interactions that branch out from them and of which they are a part. Training herbalists in such thinking, as they take on the language can cause them to dissociate themselves and to begin viewing plants as isolated entities, unconnected to the ecosystem in which they grow. A better approach, the functional taxonomists believe, is to name plants for what they do. This embeds within their names their functional actions and connections and bonds the speaker to fundamental ecological realities. This type of languaging promotes connection within the students who learn it rather than dissociation. (Bateson, 1979; Heal and Grime, 1991)
These two examples reveal a by-no-means settled debate over the proper approach to describe fundamental physical realities in herbal education. The danger in one school of herbalism designating "science-based Western botanical medicine" as that most proper for certification is that, through their parallel drive to certify educational training programs for herbalists, this one perspective will begin to eclipse other paradigms. There is also a very real danger of financial conflicts of interest. Historically, those who own the educational institutions or have financial stakes in them are also those who design the educational criteria for licensure or certification. Studies show that the exams designed for licensure or certification testing are often influenced by special interest groups within professional organizations, by education committees with financial interests in the types of tests designed, or by industry seeking to promote a specific approach to practice. (Morrison, 2000)
Herbalists at this juncture possess a unique opportunity to not only help heal those who come to them, but to also work for a cure for the medical system put in place a century ago by allopathic physicians. That system clearly possesses design flaws as can be seen by a century of unexpected outcomes (such as the rapid rise of antibiotic resistant bacteria). There are alternate views of the nature of human and plant reality than those possessed by the proponents of certification. The proposed certification of herbalists only takes into account one perspective, one that many people feel may be too limited. By certifying this one perspective, groups such as the BMA and AHG set it apart from other approaches as somehow more desirable and pertinent to practice in contemporary society. Certification itself imbues that orientation with more value - it cannot help but do so.
A number of practice advocates and states are beginning to use an alternative approach to licensure and certification - that is to allow all people who want to to work as healers. Colorado and Washington state have both instituted this for psychotherapists - Minnesota has done so for anyone who wants to treat physical disease. The only requirement is that the individual practitioner register with the state, pay a fee, and disclose all of his or her training in written form to everyone coming to them. There is usually a board that is created to hear complaints from people who feel that they have been harmed. The areas of potential harm are clearly delineated in the legislation. They include such things as inappropriate sexual contact, leveraging the client into goods and services that they do not need, not supporting them in ceasing services when they wish to do so, and not referring them out when the disease condition is beyond the ability of the practitioner to treat. These kinds of laws allow maximum exploration and development of healing modalities without one group deciding just what should or should not be part of competent training. They allow competition in the marketplace between competing types of healing. They protect the consumer. They do not set one approach apart from others by certifying its practitioners.
Licensure and certification movements, in their quest for legitimacy and market share, are, however unconsciously, emulating the model of practice regulation developed by the American Medical Association and the American Bar Association in the late nineteenth century. (Begun and Lippincott, 1993; Morrison, 2000) The current inability to explore systems of regulation not rooted in nineteenth century guild perspectives, as Friedman comments, "reveals the tyranny of the status quo and the poverty of our imagination in fields which we are laymen, and even those in which we have some competence." (Friedman, 1962, 158) There are many approaches to healing, perhaps it is time to intentionally choose a kind of certification that embraces all of them. In that way, those who seek the unique healing that herbal medicines can bring will face the prospect, not of an impoverished, single approach, but a system of practice that contains within it the diversity of life that plants themselves possess.

Sources:
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