Issues Magazine

Regulation of Naturopaths

By Jon Wardle

Many naturopaths support further regulation, but other industry elements disagree. Jon Wardle discusses this dichotomy and the benefits of regulation.

Further regulation of complementary medicines is advocated for many reasons by various groups, but popular opinion suggests that practitioners may not support regulation of their industry. The reasons for this are complex and may be representative of not only the extraordinary breadth of the industry but also its fragmentation and division. Combined studies from La Trobe University, the University of Queensland and the University of Western Sydney show the reality, however, is that over 90% of grass-roots naturopathic practitioners do actually want further regulation despite the vast majority of the large organisations representing the complementary industry (and the practitioners that work in it) actively campaigning against it.

To find out the reasons for these contradictions it is important to understand the current frameworks that naturopaths currently work under. The current regulatory model used for naturopaths is one of self-regulation. This means that the naturopaths – or rather the professional associations that represent them – are responsible for policing their own industry.

The major professional associations for naturopaths in Australia are the Australian Naturopathic Practitioners Association (ANPA), the Australian Natural Therapists Association (ANTA), the Australian Traditional Medicine Society (ATMS) and the National Herbalists Association of Australia (NHAA). However, not all these groups cater for naturopaths alone, so the interests of other complementary therapists must be taken into account when they make decisions or statements. Also, other groups with interests apart from those of naturopaths may also be represented in these associations, such as education providers or the manufacturing industry.

The entry standards for practitioners, complaints mechanisms and professional standards vary quite considerably between these associations. Some require a degree for registration as a naturopath, while others may only require diploma-level qualifications. These differences have led to a difference of opinion among these groups about regulation. The ATMS is adamantly against registration; ANTA supports what it calls a “meta-regulation” model (where associations regulate on behalf of the government); and ANPA and NHAA support and campaign for statutory (or government) regulation of naturopaths.

Statutory regulation is the form of regulation most supported by practitioners, with over 97% of practitioners who support regulation favouring this model. We already know from previous studies that naturopaths do support regulation, so our studies at the University of Queensland investigated the reasons for this support.

The major reasons naturopaths themselves want regulation are to:

  • improve practitioner quality and remove rogue practitioners;
  • improve access of qualified practitioners to the public;
  • improve complementary medicine treatments; and
  • improve access by naturopaths to research and policy development.

Practitioner Qualifications and Training

To become a qualified naturopath, practitioners are required to complete a 4-year health science degree with levels of health science comparable to more conventional health professions. The University of Western Sydney offers a 3-year course, but a further 1-year graduate certificate is required before graduates can practice.

However, the title of naturopath is not protected so anyone can (and many people do) call themselves naturopaths without adequate training, and in some cases without any training. Naturopaths believe this belittles their profession. Often the most visible negative cases against naturopaths are often due to people who are either unqualified or practising unethically and who would have been barred from practice under a regulatory framework. Examples include the Sydney naturopath narrowly acquitted of manslaughter after a patient died during a radical treatment regime, and the Newcastle naturopath who told an infant’s parents to cancel a necessary life-saving operation for their baby’s congenital heart condition.

Regulation would also ensure minimum standards of practice. Although some institutions (e.g. the Australian College of Natural Medicine, Nature Care College, Southern Cross University, Southern School of Natural Therapies and the University of Western Sydney) currently offer accredited degree-level naturopathic qualifications, other institutions offer much lower standards of naturopathic courses at certificate or diploma level. Charles Sturt University and the University of New England also run “upgrade courses” whereby graduates of some of these diploma courses can complete a number of health science subjects and upgrade to a Bachelor of Complementary Medicine, although without the extra clinical training offered in a 4-year degree. To add to this confusing mess some institutions, such as the now-defunct Perth Academy of Natural Therapies, have even offered degree courses without seeking accreditation from relevant authorities such as the Office of Higher Education.

This situation may affect the level of support for regulation by the professional associations. The ATMS – the largest professional association with over 11,000 members, most of whom are not naturopaths – does not have an elected board and is instead run by a board comprising representatives of a number of education institutions, some of which do not offer sufficient training to survive regulation, and this may in part explain the ATMS’s resistance to further regulation.

However, naturopaths believe that regulation can ensure minimum standards of training, and this will allow the public to more easily identify competent, qualified practitioners and give conventional health professionals the ability to confidently refer to an appropriately trained professional for complementary medicine treatment.

Referral to Qualified Practitioners

Naturopaths believe that they are most qualified to make clinical decisions relating to complementary medicine. Indeed, those that have gone through an accredited degree program easily have more knowledge about complementary medicine than any other health professional. However, due to the lack of regulation and the extremely variable quality of practitioners, naturopaths aren’t often consulted for their complementary medicine expertise. Instead, many people will consult conventional medical doctors or pharmacists for questions about these medicines. For several reasons they may not be the most appropriate people for complementary medicine advice.

In a study of Melbourne hospitals, Lesley Braun of RMIT University found that 81% of medical doctors did not feel confident enough in their knowledge of complementary medicines to be able to identify whether complementary medicines would interact with other medicines or adversely affect their patients. Other studies have found that 85% of pharmacists don’t feel confident in answering patient questions about complementary medicines.

The doctors in the Melbourne study scored an average of 18% on tests of the most commonly used complementary medicines. This has nothing to do with doctors’ abilities to prescribe complementary medicines, but rather reflects the poor training they have received in this area.

More training in complementary medicine may not be the answer because this would require other elements of their training to be omitted. Various studies also suggest that some patients may be unwilling to talk about complementary medicine with their doctor, and many doctors may be unwilling to practise complementary therapies themselves but would be happy to refer to an appropriately qualified practitioner.

Naturopaths believe that by ensuring minimum standards of training, other health professionals could be confident that referral to a naturopath would be handled professionally, competently and appropriately and therefore encourage integration of professional complementary medicine treatment into health care.

It is important to note here that naturopaths in our study were not opposed to other health professionals practising complementary medicine; they just felt that these professionals should also abide by minimum training standards specific to complementary medicine before doing so.

Correct and Appropriate Treatments

Naturopaths are worried that ineffective treatments, often self-administered or recommended by unqualified persons (such as “vitamin consultants” in pharmacies), may unfairly tarnish complementary medicine. People may have a bad experience that could have been predicted and prevented if they had consulted a qualified professional. Many naturopaths believe that many issues with lack of efficacy of complementary medicines are due either to lack of regulation of products or injudicious use of products.

Many complementary medicines are natural supplements and, like other natural supplements, can exhibit very different qualities depending on their growing location, time of harvesting, part used or manufacturing processes. Two good analogies are wine and coffee. Wine is just fermented grape juice and coffee just a roasted seed, but people savour the subtle quality differences that small variations in production can make.

Herbal medicines also exhibit enormous differences. For example, the effective compound in Tribulus, a herb used in menopause and men’s health, is found only in plants grown in Bulgaria and the Balkans.

The form of the treatment is also important. Glucosamine is only effective when taken as glucosamine sulfate at a dose of at least 1500 mg per day, yet most Australian supplements contain the ineffective forms (www.choice.com.au). Other issues include substitution (for example of one closely related herbal species for another) or contamination of complementary medicine products. Naturopaths believe that regulation will ensure that quality, effective products are easily accessible.

The other efficacy issue that naturopaths identified was the use of the wrong remedy in the wrong circumstance. Doctors wouldn’t use heart medications to treat infection, yet many people with a poor understanding of complementary medicine do similar things every day. Echinacea, for example, is used by many people to treat colds or flu despite research that it is ineffective for this use. Traditional use by naturopaths supports this research because Echinacea has a lead-in period of 7–10 days before having an effect. Naturopaths use it more for prevention or recovery in chronic patients, or for other immune conditions (such as asthma or autoimmune disorders). Naturopaths claim that complementary medicines are often used incorrectly, which is why they are ineffective.

Naturopaths also claim that not all complementary medicines are safe, and therefore a qualified practitioner with intimate knowledge of the therapy should be sought in complementary medicine treatment. These safety concerns certainly have merit. Despite massive under-reporting, the Adverse Drug Reactions Advisory Committee of the Therapeutic Goods Administration suggests that 62 deaths in Australia have been linked to complementary medicines in the 10 years from 1998 to 2007, and an average of 395 adverse reactions are reported every year. However, risks are minimised when professionals with suitable levels of knowledge administer these medicines.

Kava, for example, is banned in some jurisdictions, including Western Australia, because it has been linked to some cases of liver damage. But when Kava supplements are manufactured properly and administered in appropriate circumstances they are a very effective (even validated by a positive Cochrane Review by Max Pittler and Edzard Ernst in 2003) alternative for the more harmful anxiety medications currently used. Naturopaths believe that regulation will restrict inappropriate medicines to those most suited to use them and allow those most suited to use currently restricted medicines.

Research and Policy

According to our study, one of the major concerns naturopaths did have with regulatory processes in their industry was that there would be no consultation with their profession. Their major concern was that the process would be controlled by people from professions that had little knowledge of complementary medicine or its practice. Naturopaths also believed that regulation, particularly minimum standards of training, would make them more attractive to research and policy positions, ensuring that complementary medicines were practised both safely and effectively. For statutory regulation of naturopaths to work properly, naturopaths believed that they must be consulted appropriately throughout the development and application of this process.

Self-regulation is used in other industries such as accounting, and isn’t an inappropriate form of regulation in all cases. However, when practices are deemed to put the population at certain levels at risk they are required to be regulated. These risks don’t always have to be directly related to health. This is why some medications that seem relatively harmless require a prescription from a qualified medical doctor.

Antibiotics are freely available over the counter in some countries but Australia has chosen to restrict them to prevent the evolution of resistant bacteria. Naturopaths believe that parallels exist in complementary medicine: when used incorrectly, complementary medicines can also cause adverse effects, and thus should be regulated to the same levels as other health professions and options of similar risks.

A lot of factors come into play in the arguments for regulating naturopaths. The two government reports commissioned to investigate regulation (by the Complementary Medicines Expert Committee reporting to the Minister for Health and Ageing in 2003 and the Victorian Department of Human Services in 2005) have both strongly recommended statutory regulation of naturopaths.

However, opposition from within the industry may be due to the various interests of the most powerful and visible components. The manufacturing industry has a very clear financial interest in ensuring that regulation does not take place, the professional associations may fear loss of political influence under a regulatory framework, and some professional associations may be representing the interests of their board (who have much to lose from regulation) rather than their members (who have much to gain). Unfortunately those elements opposed to regulation are also those with the most influence, resources and media presence and may represent a false view of practitioner opinion.

Naturopaths see themselves as valid health professionals with the potential to play an important part in healthcare delivery. However, the voices that represent them may not be loud enough to be heard over those that oppose them.