In Canada, complementary/alternative and traditional medicines are known as natural health products and are subject to food and drug regulations. Natural health products include herbal medicines; traditional Chinese, ayurvedic, and native North American medicines; homeopathic preparations; and vitamin and mineral supplements.
There are a number of associations of complementary/alternative medical practitioners. In 1983, the Chinese Medicine and Acupuncture Association of Canada (CMAAC) was established as a national organization. CMAAC works to unite practitioners and to lobby the Government for the regulation of traditional Chinese medicine and acupuncture. In 1987, the World Federation of Acupuncture and Moxibustion Societies was formed with the support of the World Health Organization. In 1996, allopathic physicians interested in traditional and complementary/alternative medicine in Canada created the Canadian Complementary Medical Association.
Several reports from the late 1990’s found that between 15% and 70% of the Canadian population had used complementary/alternative medicine in the proceeding six to 12 months. A 1999 study, for example, reported 70% of Canadians had used one or more natural health products in the preceding six months, but only 24% consulted one or more complementary/alternative health practitioners.
The use of complementary/alternative medicine is increasing in Canada. The following chart represents findings of the 1999 Berger Monitor survey on the six-month use of complementary/alternative health practitioners in 1993 and 1999. According to a study by the Fraser Institute, of the Canadians who have used complementary/alternative medicine, 36% have consulted a chiropractor, 23% have used relaxation techniques, 23% massage. 21% prayer, 17% herbal therapies, 12% special diet, 12% folk remedies, 12% acupuncture, 10% yoga, 8% self-help groups, 8% lifestyle diets, and 8% homeopathy.
Respondents who had consulted a practitioner of complementary/alternative medicine
A significant proportion of Canadians report spending 30 Canadian dollars or more per month on complementary/alternative health services or natural health products. From 1996 to 1997, a total of 3.8 billion Canadian dollars was spent on complementary/alternative health care in Canada. The amount spent on vitamins and food supplements is rising by 20% a year.
In general, the use of complementary/alternative health care in Canada is higher at younger ages, among women, among people with higher formal education and higher incomes, and in the West. Canadian users of complementary/alternative medicine have more good health habits and better overall health. However, these differences are partly minimized when adjusted for age, education, and household income. Users of complementary/alternative medicine make fewer visits than non-users to both allopathic general practitioners and specialists.
The most common reasons for which patients consult complementary/alternative practitioners are problems of the musculoskeletal system and connective tissue. These complaints account for 56% of consultations. Other problems include respiratory diseases, injuries, poisonings, ill-defined conditions, and special investigations.
Complementary/alternative practitioners provide most complementary/alternative treatments. However, allopathic physicians are increasingly involved in the provision of complementary/alternative medicine. There are approximately 4500 chiropractors practicing in Canada.
Canadian physicians choosing to provide alternative treatments must comply with guidelines set by the relevant province’s College of Physicians and Surgeons. The Federal Food and Drug Act does not recognize traditional Chinese doctors, naturopaths, homeopaths, or herbalists. However, the recent Federal Report (supra) noted that access to quality health care is tied to the education, training, and licensing of practitioners and products. As such, it seems likely that Canada will soon give formal recognition to more complementary/alternative practitioners.
Most of the health care legislation, such as the Canada Health Act, focuses on allopathic medical practitioners. However, the regulation of professionals is a provincial matter, and many provinces have become tolerant of non-allopathic health care providers. Ontario’s Regulated Health Professions Act, S.O. 1991, c.18 is an example of the more inclusive legislation adopted by a number of provinces.
On 26 March 1999, the Federal Government accepted all 53 recommendations made by the Standing Committee on Health in their report, Natural Health Products: A New Vision. While the Health Minister’s formal acceptance of these recommendations will not immediately change the status of natural health products in Canada, the policy direction has been set. A transition team was created and it is now working to implement these recommendations. One of the recommendations led to the creation of the Office of Natural Health Products, which regulates the safety, quality, and proper labelling of these products. It is also responsible for supporting epidemiological and social science research and for the dissemination of information to Canadian consumers to enable them to make informed self-care decisions.
Beginning in the spring of 2000, the Office of Natural Health Products invited comments and suggestions from a wide range of interested Canadians – including manufacturers, distributors, and retailers of natural health products – on the formation of a regulatory framework for natural health products, covering their production, import, sale, and use in Canada. In March 2001, the Proposed Regulatory Framework for Natural Health Products was drafted. The Framework contains provisions for natural products sold in Canada, including licensing of products and sites, good manufacturing practices, labeling and packaging, and reporting of adverse reactions. The intent is to address consumers’ concerns for safety and product quality without being unduly restrictive of the natural health product industry.
The Expert Advisory Committee on Complementary Medicines was recently formed to provide scientific advice to the Therapeutic Products Program of Health Canada on issues regarding the safety, quality, and efficacy of natural health products.
Traditional Native North American Medicine
In the Yukon Territory, the Health Act of 1990 endorses traditional native North American medical practices. Section 5 includes provisions to secure “aboriginal control over traditional aboriginal nutritional and healing practices and to protect these healing practices as a viable alternative for seekers of health and healing services”. The Minister of Health also “promote(s) mutual understanding, knowledge, and respect between providers of health and social services offered within the health and social service system and the providers of aboriginal nutrition and healing”.
In Ontario, traditional birth attendants providing midwifery services to aboriginal persons or members of an aboriginal community are exempt from the general rule that restricts “managing labor or conducting the delivery of a baby” to allopathic physicians, nurses, and midwives. Traditional birth attendants can adopt the title “Aboriginal Midwife” as a professional designation and portray themselves as qualified to practise in Ontario.
In at least nine Canadian provinces, special statutes restrict the practice of manipulative therapy to persons who fulfill specific requirements and have been registered and/or licensed. All provinces have laws regulating the practice of chiropractic. In Ontario, manipulative therapy is regulated under the Regulated Health Professions Act of 1991 and the Chiropractic Act of 1991. The Health Professions Act states that it is an offence for a person to “move the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low-amplitude thrust” unless the person is authorized by one of the listed health profession acts, such as the Chiropractic Act. The Chiropractic Act limits the practice of chiropractic to members of the College of Chiropractors. The legislation permits the use of the title “Doctor” by members of the College of Chiropractors of Ontario.
No offence is committed under the Health Professions Act when an otherwise impermissible joint movement is performed in the course of “treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment” or where the treatment is performed by an aboriginal medical practitioner providing traditional medicine services to aboriginal persons or members of an aboriginal community.
Chiropractors have professional status in Alberta. In 1994, Alberta introduced requirements for the continuing education of licensed chiropractors (103). Practitioners must acquire 75 hours of continuing education every three years as a condition for renewal of their annual licence. Full credit is given for participation in programmes accredited with listed professional bodies. Credit may also be given for other educational activities with an emphasis in chiropractic, such as research or university studies.
In Saskatchewan, the Chiropractic Act of 1994 repeals the 1978 Act on the same subject and prohibits anyone other than a member of the Chiropractors’ Association from using the titles “Chiropractor”, “Doctor of Chiropractic”, or “any word, title or designation, abbreviated or otherwise, to imply that the person is engaged in or qualified to engage in the practice of chiropractic.” Section 22 of the Act lays out the restrictions on and exemptions to the practice of chiropractic in Saskatchewan:
1. No person other than a practising member shall engage, for fee or reward, in the practice of chiropractic.
2. Subsection 1 does not apply to a person providing first aid or temporary assistance in cases of emergency.
3. Nothing in this Act extends to or interferes with the privileges conferred on any person who practices a profession, trade or calling that the person is licensed or authorized to practise pursuant to any other Act.
Traditional Chinese Medicine and Acupuncture
Health Canada, through the Therapeutic Products Programme, is actively pursuing the National Initiative on Traditional Chinese Medicine (97). British Columbia, Alberta, and Quebec include acupuncture among their regulated health professions. Saskatchewan and the Yukon Territory have guidelines on the practice of acupuncture.
A 1993 report by the British Columbia Health Professions Council recommended the designation of acupuncture as a health profession with three limitations: acupuncture should not be used in the treatment of serious illnesses, such as cancer; acupuncture should not be used as anesthesia during surgery, unless supervised by a physician or dentist; and the patient must be told to consult an allopathic physician, dentist, or naturopath if acupuncture fails to improve the patient’s condition within two months.
The Ministry of Health in British Columbia has agreed that traditional Chinese medicine and acupuncture should be regulated. In April 1998, the British Columbia Health Professions Council recommended designating “the profession of traditional Chinese medicine as a health profession under the Health Professions Act.” The Council also recommended that a college be established to govern both practitioners of acupuncture and practitioners of traditional Chinese medicine. This college will ensure that practitioners complete adequate training based on Government standards.
The Health Disciplines Act of 1980 sets out a framework for the recognition and regulation of health disciplines in Alberta. Acupuncture is governed by the accompanying Acupuncture Regulation. In order to be registered as a member of the acupuncture health profession, an applicant, who need not be an allopathic physician, must complete both an approved programme of study and an examination. Competence in English must also be demonstrated. However, this requirement may be waived where the applicant practices under the supervision of an English-speaking acupuncturist.
Before acupuncture treatment is administered in Alberta, the patient must have consulted with an allopathic physician or dentist and informed the acupuncturist of this. Acupuncturists are prohibited from implying to patients that acupuncture cures diseases or advising patients to discontinue treatment recommended by an allopathic physician or dentist. If an improvement in the patient’s condition does not occur within six months, the patient must be referred to an allopathic physician or dentist.
In Alberta, permissible technical modes of practice are restricted to needle acupuncture, electro-acupuncture, moxibustion, cupping, and acupressure. Only non-invasive measuring equipment may be used in patient examinations. The Acupuncture Regulation also lists a number of procedures that cannot be delegated to non-acupuncturists, including taking patients’ medical histories, using diagnostic instruments or therapeutic devices on patients, and inserting or removing acupuncture needles.
The Quebec Medical Act of 1973 required the Bureau of the Ordre des Médecins to enact rules for the training, practice, and annual registration of allopathic physicians practicing acupuncture. Rules were also introduced concerning the practice of acupuncture by non-physicians. Non-physician practitioners must hold a recognized college diploma and pass an acupuncture exam set by the Quebec medical regulatory body. Detailed patient records must be kept covering matters such as diagnoses made, treatments rendered, and details of patient consultations with other medical professionals, including allopathic physicians.
Under Section 44 of the Medical Act of Quebec, no person can claim to be an acupuncturist unless he or she is a registered non-physician or allopathic physician who has undergone the required training in acupuncture. Moreover, non-physician practitioners are precluded from using the title “Doctor” or any title that may infer that status unless they have a doctorate in acupuncture, in which case they may use the title “Doctor of Acupuncture”.
A number of medical professional regulatory bodies in Canada have published guidelines relating to acupuncture. In Saskatchewan, such guidelines were drawn up by the College of Physicians and Surgeons. These permit the practice of acupuncture by allopathic physicians who hold a recognized diploma. The guidelines do not mention the practice of acupuncture by non-physicians.
Guidelines issued by the Yukon Medical Council, however, state that acupuncture is a medical procedure that should only be performed by allopathic physicians or dentists with an appropriate level of training. The guidelines do not permit physicians to delegate acupuncture procedures to others, such as physiotherapists, “except in an approved institutional setting such as a public hospital”. The reasoning behind this is that the Yukon guidelines acknowledge that acupuncture has a “valid role” in patient management but warn that, based on current knowledge, “it does not have a curative effect on the fundamental disease process”. The guidelines strongly endorse two training programmes recognized by the College of Physicians and Surgeons in British Columbia, but stop short of requiring completion of a programme of study.
Naturopathy is regulated in Alberta, Manitoba, and Saskatchewan. In each of these three provinces, naturopaths must meet specified educational requirements and be registered in order to practise naturopathy or use the title of “Naturopath”. Educational requirements include the completion of a four-year college programme. Manitoba and Saskatchewan also require an examination in anatomy, physiology, chemistry, general diagnosis, and the principles of naturopathy. In all provinces, naturopaths are prohibited from performing certain health care activities, such as the prescription and administration of allopathic drugs, obstetrical practice, and surgery.
In Alberta, two corresponding provisions in the Chiropractic Profession Act of 1984 forbid dual registration as a naturopath and chiropractor. One states that registered chiropractors cannot practise naturopathy and the other that practising naturopaths cannot be registered as chiropractors.
Education and Training
Complementary/alternative training programs are provided by private institutes, universities, and community colleges, but there is no universal system of accrediting and validating programs. Though there is no standardized complementary/alternative component in allopathic curricula, most medical schools offer some form of training in complementary/alternative medicine to their students of allopathic medicine, but this usually takes the form of a two-hour to four-hour lecture. The 1998 Standing Committee Report states that there is increasing interest in having more training programmes and more standardized training curricula in complementary/alternative medicine for both complementary/alternative and allopathic providers.
In 1985, the Institute of Chinese Medicine and Acupuncture was established to promote the training standards of the Chinese Medicine and Acupuncture Association of Canada. Students interested in entering the four-year programme offered by the Institute are required to have first completed three years of coursework in the sciences at a recognized university. There are two chiropractic colleges in Canada recognized by the World Federation of Chiropractic.
Coverage of complementary/alternative therapies by provincial health insurance plans and workers’ compensation boards is selective and minimal. Some provincial health insurance plans cover chiropractic (Alberta, British Columbia, Manitoba, Ontario, Saskatchewan, and New Brunswick only for seniors who purchase extended coverage), and one covers naturopathy (British Columbia). Osteopathy is covered in Alberta.
Workers’ compensation boards cover chiropractic in all provinces and territories. Workers’ compensation boards in British Columbia, Newfoundland, Ontario, Prince Edward Island, Quebec, and the Yukon Territory cover acupuncture on a case-by-case basis or on prescription by an allopathic physician. The Alberta Health Care Insurance Plan discontinued its coverage of acupuncture on 1 March 1994. Patients are now solely responsible for the cost of acupuncture treatment.
About 96% of the private health insurance coverage in Canada is group policies purchased primarily by employers. This insurance is a non-taxable benefit so long as, among other things, reimbursement is only provided for qualified medical practitioners, which include chiropractors, osteopaths, naturopaths, therapists, acupuncturists, and dietitians.