From Nature Cure to Naturopathic Medicine: the institutionalizing of naturopathic medical education in Ontario. 1. Purpose of this study The larger purpose of this historical case study is to contribute to a growing literature about the institutionalizing of the professional education activities and strategies of the complementary and alternative medical fields in North America. The study will document the institutionalizing of naturopathic medical education in Ontario from its early informal apprenticeship model to the emergence of the Canadian College of Naturopathic Medicine exhibiting many characteristics of the higher education sector to which it currently aspires. The study will describe the development and positioning of the institution to meet the standards and enjoy the benefits of mainstream higher education, especially degree-granting authority from a location within civil society characterized by its non-profit, private status. In the end I wish to have elucidated the intersection of those key factors which have led to the ultimate acceptance of the school's graduates by the regulatory licensing bodies in five Canadian provinces and fourteen American states, and which have also led to a rapidly expanding awareness among educators, politicians, mainstream medical health professionals and the general public of its role in training naturopathic doctors for the primary health care field.
There are four broad areas which intersect in this case study:
the documenting of key events and junctures in the history of the school (historical precedent)
an analysis of the school's evolving educational structures and status from 1978 through 2001 culminating in accreditation and access to degree-granting authority within the province
an analysis of the impact on naturopathic medical education of the development of naturopathic medicine as a profession in Ontario, and finally,
an exploration of the location of the school within the social economy of the third sector, and within the higher education framework of professional education in Ontario.
The study examines documents and data about how the Canadian College of Naturopathic Medicine has evolved through a period of considerable disadvantage and scarce resources into a higher education institution, all the while independent of direct government financial support, and all the while making a substantial contribution to the preparation of primary health care professionals for Ontario and Canada.
a. Central and sub-questions for the study Grand tour question: How and why did naturopathic medical education evolve institutionally in Ontario? Relevant sub-questions:
i. What factors influenced the development of naturopathic medical education in Ontario rather than in another Canadian jurisdiction?
ii. What policies, regulations and legislation determined the structure of the several manifestations of an educational enterprise supporting naturopathic medical education in Ontario?
iii. Which individuals and what public and private institutions influenced the development of naturopathic medical education in Ontario, and how?
b. Limitations Medical and educational historians have published widely on the "professionalized heterodox medical systems" (Baer, 1992) in North America, particularly in the United States. However, as pointed out by Gort and Coburn (1986), there are only "fragments of information on the development of naturopathy in Canada". This study will be limited in part by the availability of documentation about the early days of naturopathy in Canada (1900 - 1950) and by the lack of written documents about the first years of the Ontario College of Naturopathic Medicine and access to what remains of documents from the later established Canadian College of Naturopathic medicine. As well, constraints in assembling data may arise out of the availability of living naturopathic practitioners with personal recollections, documentation and other historical information from that period. I am encouraged, though, that associations such as the Canadian Naturopathic Association have recently begun to assemble documents and anecdotal information about the profession's early history. What this study will notice depends, then, in large measure, on what still survives within a profession that has not been centrally organized for the most part. For these reasons, I expect to improvise along the way, as the inductive mode of the research process in the qualitative design captures the direction of the study and reveals new sources and unanticipated information.
In addition, my particular location within the naturopathic field, as President of CCNM, may impact on the willingness of certain members of the profession to share information since during my tenure, rapid and unrelenting change has on occasion been controversial and transformative in terms of systems, entitlements and policies. Weber's counsel that the researcher carry a healthy skepticism about findings which prove to be consistent with preconceived values and positions is very much on the mind of this investigator as I strive for a clear objectivity despite my direct and indirect relationship to the informants, and the utility and delicateness of some of the data given my position. Happily, the current executives and the former President of the Ontario Naturopathic Association and of the Canadian Naturopathic Association have given approval for access to files and materials valuable to this study.
Finally, as discussed below in sections c, d and e, there are limitations in accessing certain of my data sources and then in judging the reliability, credibility, and value of that data. Most immediately limiting is that many of the documents which I hope to investigate were not generated for research purposes. As Merrian points out, such data may not be in a "form that is useful or understandable to the investigator" (p. 124). Certainly I anticipate a large number of "personal" documents which can be "subject to purposeful or nonpurposeful deception" (p. 125). In any case, conducting interviews and analyzing documents are important data collection techniques for this study. Merriam (1998), citing Riley (1963), explains when events "can no longer be observed and informants may not recall or be available for recall" (p. 125), documents can be critical. The " recursive, interactive process" (Merriam, p. 134) implied in data collection which makes use of these two techniques can be an interesting and even exciting process, but subject nevertheless to certain possibilities for conflicting data, a problem which the qualitative researcher needs to minimize.
c. A note on analyzing conflicting anecdotal data Crucial to the success of the work proposed here is the verifiability of documents and personal accounts related to the founding of the Ontario College of Naturopathic Medicine (OCNM), the predecessor to CCNM. At an early stage in preparing a research strategy, I have encountered continuing animosities among players in that process. Perhaps, then, a launching point for an analysis of data gathered via interviews, study of minutes, memos and other relevant archives from the naturopathic associations of the time, will be to consider the concrete behaviour of those principal players using what Robert Stake calls a "palette of methods" (1995). Clearly an important component of the data I shall gather will derive from stories key informants tell about the founding and gradual development of CCNM. John Van Maanen (Tales of the Field, 1988) attests to the richness of this approach for the qualitative researcher. Within this research dynamic, then, it is important for me not to draw conclusions too speedily as I analyze anecdotal data, some significant portions of which may well be in conflict. Situational analysis hinges on structural and functional analysis (cf. Berkhofer, 1969) and is hampered at the outset by there potentially being far too many conflicting views of the function or structure of the institution called OCNM/CCNM to be of enduring value here. The key, I believe, is to look very closely at the complexity of functions in this instance. Many people to be interviewed who were around during the formative years of CCNM and beyond will have quite different recollections and opinions about the key questions I will be posing. To aid in organizing and later interpreting these data, I will employ a topical outline whose questions will surround the information needed as I attempt to describe the particular case here, the institutionalizing of CCNM. As this progresses I expect, during the cross-checking of information and accounts, that I will encounter tensions. For example, there may be those who will understand the accelerated, advanced and intensive programs of the earliest years of the institution to have been opportunistic, weakly delivered and poorly evaluated. Others will declare that those early institutional decisions about curriculum were necessary and effective. Still others may dismiss the early design of the institution as hardly acceptable as a higher education institution, and whose graduates still carry a marginalized credential as a result.
d. Data collection approaches and controls Qualitative study is quite subjective and there is never enough time to deal with the abundant data available, not to mention unanticipated data percolating out of emerging issues or the unexpected in the field. Stake's depiction of the case researcher as an advocate, evaluator, biographer and interpreter all in the same breath sometimes makes the prospect of field work a little daunting in prospect, especially in terms of data collection approaches and controls. There is even the underlying framework of constructivism to keep in mind as the study's design evolves; that is, making sure I recognize that the knowledge I am "gathering" may well be being "constructed" by me rather than "discovered" by me. All the more reason, then, to locate and present good raw material which invites generalizing. In that same breath, though, to iterate the varieties of research modes cited above, I know that I am a relativist too, in that the interpretations I bring to those raw data will vary depending on the credibility, validity and utility of the data collected.
Thus, this investigator, aware of the ethical obligation of the case study researcher, wants to purge misinterpretations of complex, uneven data as much as possible. Seeking guidance from such qualitative research experts as Stake, Merriam and Denzin (The Research Act, 1984), I will utilize data source triangulation techniques wherever possible (e.g. data source triangulation, investigator triangulation, and theory triangulation). As part of that objective of validating what I find, I will employ a series of interrelated activities, aimed at gathering useful information addressing the key research questions. Enough valid data may be available within the study to permit direct interpretation or some form of categorical aggregation. In any case, the forms of data which will be gathered include structured interviews, public and private documents, and audio-visual materials including e-mails and web sites. A personal diary will be at my side throughout the entire process, aiding me in categorizing, recalling, editing information as I proceed, particularly with compiling and studying interview data, but also certainly with document analysis.
Treating interview data
The interview is a useful technique for this project (Merriam, 1988; Guba and Lincoln, 1981), but as Stake (1995) points out, requires a good advance plan. As Guba and Lincoln explain, "The ability to tap into the experience of others in their own natural language, while utilizing their value and belief frameworks, is virtually impossible without face-to-face and verbal interaction with them" (p. 155) . Because of the paucity of research and documentation about the development of CCNM and of naturopathic medical education in Ontario and Canada, it is essential that I be able to clarify what each informant thought happened, illuminate as far as possible the stages and key events of the institution's development, and concomitantly acknowledge the lived experiences of the informants. I will be seeking to achieve in the interviews flexibility, high response rate, rapport, clarity and accuracy. That the interviews are an essential validity check for data assembled from sparse documentary analysis is a key aspect of my data collection strategy for this study. Overall during this study I shall be pressing for "understanding the complex interrelationships among all that exists" (Stake, 1995, p. 37). At the outset, then, my topical outline will skew toward chronologies rather than causes and effects. Dilthey (1976) suggests that "human actions are seldom simply caused and usually not caused in ways that can be discovered" in the qualitative researcher's attempt to "tease out the causes". I understand in advance that the complexity of the events and dynamics which led to the institutionalizing of CCNM will sometimes hide generalizable patterns in that process. It is in describing those patterns in the particularity of this case that some contribution can be made toward understanding how similar institutions in Ontario and elsewhere have developed. I must be on guard to separate out the situationality and political context for the particular subject of my case study here. Thus, I'll be on the lookout, doubling back as needed, for "patterns of unanticipated as well as expected relationships" (Stake, p. 41) and "all the while realizing [my] own consciousness".
Care has been taken in the design of the interviews to avoid bias which can turn up not only in my particular vantage point on the research questions, but also in the characteristics of the informants and their location within the chronology and history of the institution's emergence and development. The content and wording of the interview questions, for example, have required a particular focus for this investigator. I will utilize a number of strategies to assure the validity of the interview data: pilot testing, strict assurance of confidentiality, technically accurate and inclusive recording of the interview content, careful cross-checking of divergent data (especially with documentary sources, and by presenting appropriate data from one informant to another to establish cross-participant agreement on accuracy of detail).
Treating document analysis
Documentary analysis is another central aspect to the data collection process for this study. Keeping in mind Dexter's (1970) criteria for choosing a data collection strategy, I have been fortunate finally to secure preliminary, limited access to original files from among the spotty and often erratic documentary resources from the voluntary professional associations related to naturopathy in Canada and with particular reference to the development of the naturopathic college. Dexter explains that the researcher should use documents when it seems they are likely to "yield better data or more data than other tactics" (Dexter, 1970, p. 11). After a preliminary check for internal and external consistency [that is, do the documents and other data sources collide or converge?], not only have these documents already proven to be a platform from which can spring the interviews and other data sourcing, they are indeed a 'natural' source of information since they constitute the only existing, non-anecdotal data source for the research questions. The documents provided information about important aspects of the institution's inception and growth and provided a contextual richness in grounding my enquiry. I am anticipating that that grounding will settle comfortably into a matrix of informants, historical events and matters of record, all of which are fair game for this study.
e. Using documents in qualitative research There are several challenges related to the locating and authenticating of documents relevant to this study. Burgess (1982) counsels the qualitative researcher to not use documents in isolation. Merrian (1998) emphasizes that "it is the investigator's responsibility to determine as much as possible about the document, its origins and reasons for being written, its author, and the context in which it was written" (p. 121).
I shall use the list of questions provided by Guba and Lincoln (1981) about the authenticity of the various meeting minutes, correspondence, reports and memoranda which I may get access to.
What is the history of the document?
How did it come into my hands?
What guarantee is there that it is what it pretends to be?
Is the document complete, as originally constructed?
Has it been tampered with or edited?
If the document is genuine, under what circumstances and for what purposes was it produced?
Who was/is the author?
What was he trying to accomplish? For whom was the document intended?
What were the maker's sources of information? Does the document represent an eyewitness account, a secondhand account, a reconstruction of an event long prior to the writing, an interpretation?
What was or is the maker's bias?
To what extent was the writer likely to want to tell the truth?
Do other documents exist that might shed additional light on the same story, event, project, program, context? If so, are they available, accessible? Who holds them?
(Guba and Lincoln, 1981, pp. 238-239)
Merriam further recommends the adoption of a system for "codifying" and "cataloguing" documents gathered, using "basic descriptive categories" (p. 123). I will utilize a process of "content analysis" (Altheide, 1987, p. 68) not unlike the approach used by historians and literary critics for this segment of my research. As Altheide further points out, my goal will be to be "systematic and analytic, but not rigid" (p.68).
That the regional voluntary naturopathic medical professional associations are quite reluctant to give this researcher comprehensive access to files about the early naturopathic school will necessitate ingenuity and care in locating other sources of information as needed. Because there has been no systematic archiving of data about the earlier history of the institution, much of this material is scattered, incomplete and in disarray. I shall have to "reconstruct the process by which the data were originally assembled by somebody else" (Riley, 1963) and "the conditions under which these data were produced" (Riley, 1963, p. 252)
My goal, then, is to create a platform, a framework as it were, for interpreting my informants' input. Because of the immense gaps in documentary material related to the key research questions, a naturalistic or interpretive paradigm is essential for this study (Cohen & Manion, 1980; Guba & Lincoln, 1981; Smith, 1978).
f. Analysis strategies. A general review of the available literature, general review and analysis of observational field notes, interview transcriptions, and notations about a/v materials reviewed and cited will be undertaken. A focus group consisting of at least five senior members of the naturopathic provincial associations and the regulatory boards in Ontario, Alberta, B.C. and Nova Scotia will be employed at the outset of the study to enhance the snowball/chain strategies for data collection, and to qualify the strands of investigation proposed. As well, categorical aggregation, direct interpretation, naturalistic generalizations, and description will be employed appropriately as analytical and interpretive strategies.
g. Sources of information for the central and sub-questions of the study: sources:archives of the provincial and national naturopathic associations; Ontario and B.C. archives; the literature of naturopathy; the literature of the history of medical education in Canada; government health reports [federal and provincial]; interviews with naturopathic physicians; archives of National College of Naturopathic Medicine [Portland, Oregon] and Bastyr University [Seattle, Washington]; curriculum of the "history and philosophy of naturopathic medicine" from the four accredited naturopathic schools in North America; interviews with the administrators of the for-profit naturopathic colleges [non-accredited] which exist in B.C. and Quebec.
additional sources: available literature, archives of the national and provincial professional associations, archives of the provincial licensing bodies, triangulated interviews with elders and leaders of the profession, archives of the accredited naturopathic schools.
Other schools of unorthodox medicine have well-researched histories. These are excellent foundations for this work:
Wardell (1992), Moore (1993). Note too, Journal of Chiropractic History.
Significantly, Norman Gevitz' 1988 work includes essays on botanical medicine, the water cure movement, homeopathy, osteopathic medicine, chiropractic and Christian Science, but there is no mention of naturopathy. Key naturopathic writers and practitioners such as Benedict Lust and Henry Lindlahr are not mentioned in that book's index.
The few significant works about the history of nature cure are available only in German (cf. Brauchle's Naturheilkunde in Lebensbildern, 1937).
A primary source is Benedict Lust's journal Naturopath. I have found several "titles" for this journal and expect to find more as I fill in the item gaps: Amerikanische KneippBlatter, The Kneipp Water Cure Monthly and Herald of Health, Herald of Health and Naturopath, Nature's Path. In 1990 the American Association of Naturopathic Physicians launched The Journal of Naturopathic Medicine, the first such serial publication of its kind devoted to scientific research.
h. The research design process for this case study: Merriam (1988) states, "There is no standard format for reporting case study research. I expect that the major focus of the study [to document the institutional development of naturopathic medical education in Ontario by studying a single institution] will shape the overall rhetorical structure of the thesis. The study's design was chosen in order to illuminate the emergence of a unique institution with a context of higher education, the third sector, and the health professions. This contextualizing of the case, then, necessarily includes considerations of occupational formation (including supportive and negative influences on the development of naturopathy), the location of the specific institution within the spectrum of the third sector in Canada, and the particular history of the institution itself.
Thus, I anticipate two interlocking phases in the design of this study. The historical phase will zero in on assembling data illuminating the contextual origin and the specific historical record of the institution's development. In this stage I will want to identify the various components of meaning which accumulated and attached across time to the various incarnations of the school we are studying. As well, the recollections, experience and observations of participants in those manifestations with regard to organizational structure, staffing criteria, curriculum development and delivery, and clinical education will assist in clarifying the patterns emerging from the data collected.
There will follow an explanatory stage in the design. I will attempt plausible explanations for the patterns identified in the historical phase and develop the results, after appropriate revision as further data confirms or disconfirms those emergent explanations. The pattern, then, of design would include collecting data, analyzing that data, forming explanations, and then collecting more data with further analysis. In each "data collection - data analysis" rhythm, though, there would be interpretation occurring. It is the interpretation which will greatly assist in the evolution of the research design.
Glaser & Strauss (1967) emphasize that grounded theory methodology can assist the interpretive researcher's positioning in a research design because of the open-ended relation to the development and testing of theory. "Over time the … researcher … has the opportunity to check out his or her understanding of the phenomenon under study" (Hammersley & Atkinson, 1990, p. 24). The phenomena central to this study include the decisions and principles, with their attendant meanings and consequences, of choosing to establish a professional medical school at the periphery of higher education and mainstream scientific medicine. Grounded theory inquiry focuses on the roles people have, their behaviours, and their motivations. It can help demystify people's beliefs, motivations, theories, values and behaviours, and is especially sensitive to how these all may change across time and situationally. (Woods, 1991).
It is important, given my location in this study, to acknowledge my actions, judgments, and positioning while interviewing informants. Wolcott (1990) explains:
What one looks at and writes about depends on the nature of the problem that
sends one into the field in the first place: on the personality of the … researcher;
on the course of events during fieldwork; on the process of sorting, analyzing, and
writing that transforms the fieldwork experience into the completed account; and on
expectations for the final account. (p. 191).
Thus, an interpretive (Erickson, 1986) case-study approach will help to balance the components of this research. Of course, I would wish to achieve a reasonable balance in favour of description, given the historical record component of the study. As well, I will want to verify the data and resulting report using triangulation of information [essentially, searching for convergence of information].
2. A theoretical framework for this study: the literature of the professions, higher education, and the third sector. So much about the professional education arrangements for the naturopathic profession in Canada is more easily observed than explained. An initial concern that "the explanations given for the rise and decline or survival of [groups like naturopaths] were not necessarily generalizable to different groups, to different historical periods, or to different countries" (Gort, 1986, p. 23) has led to an interest in understanding the evolution of the naturopathic profession against a backdrop of scholarship on the characteristics of institutions in the nonprofit and public sectors, on the public policy and regulatory environment in which the naturopathic profession established its educational arrangements, and on the health professions generally.
As a starting point, readily available have been briefs to the Ontario Government's Health Professions Advisory Council (easily comparable to earlier and similar documents, for example, from the Royal Commission on Health Services, 1962, from the Committee on the Healing Arts, 1970, the Health Professions Legislation Review, 1982). Ontario Ministry of Health documents located in the Ontario Archives have also been helpful, despite the thirty year closed file rule.
While we can turn to Gidney and Millar's 1984 study of the origins of organized medicine in Ontario [since it was in Ontario that the first and longest standing naturopathic medical education institution emerged in Canada] to set the stage for our seeing more clearly how naturopathy took root here, it is the literature of the nonprofit and public sectors (Quarter, 1992; Snaith, 1991; Defourny, 1992; Monzon Campos, 1992; Saloman, 1987; Mayne, 1999; Rifkin, 1996; Milofsky, 1987; Phillips, 1999; Putman, 1993; Smith, 1999; Welton, 1998; O'Connell, 2000) and of the professions (Hughes, 1959; Schein, 1973; Schon, 1983; Shils, 1978; Duncan, 1996; Donaldson, 1979; Penfold, 1998; Townsend, 1998; Fosdick, 1952; Good, 1993; Petersdorf, 1992; Sokoloff, 1992; Noddings, 1990, Witz, 1992; Muzzin, 1993) which can give us a more comprehensive, deeper context and theoretical framework for this study.
The literature of the nonprofit and public sector [the third sector] helps us to understand the characteristics that distinguish organizations in the social economy from public sector organizations and private firms in terms of their membership, revenue sources, structure and governance. The naturopathic medical education institution set up by a group of Ontario NDs and DCs utilized the incorporation routes available at the time. Those pathways were affected by the determination of the Ontario government to require affiliation with universities or separate legislation for an institution to award professional degrees. This was not the case in American jurisdictions.
As well, and particularly in the early stages of its institutional development, the Canadian College of Naturopathic Medicine relied heavily on volunteer work in order to operate. As the institution took shape in its first decade it became part of the important nonprofit sector in Canada. CCNM's "use value" was far more indicative of its mission than the "market value' of a number of for-profit institutions in similar markets in the United States. At the same time, CCNM's earlier efforts to affiliate and partner with public sector institutions [e.g. The University of Waterloo] quickly generated awareness of how nonprofit and public sector institutions, although apparently compatible in their intent, are different in important ways in their institutional and operational realities. The critical participation of the naturopathic profession in the institution's development shaped the institution's mission, mandate, policies and operations for most of its first two decades. Attribution of outcomes (Mayne, 1999) becomes an important tool for understanding the institutional complexity of nonprofit institutions such as CCNM.
For example, Glazer's term "minor professions" (1974) can be applied to naturopathy in North America, and specifically in Canada where until recently there were fewer than five hundred registered, licensed naturopathic doctors in the entire country. Certainly, Canada's naturopathic profession has been divided and challenged by the very same "yearning" which many of the "minor professions" experience in their professional schools, namely, a "yearning for the rigor of science-based knowledge and the power of science-based technique" (Schon, p. 9). Against this backdrop of literature about the evolution and development of the professions, the particular choices made by naturopathic doctors in terms of defining their educational paradigm and how that educational experience influences the development of the profession itself come more sharply into focus. For example, Bastyr University proudly advertises its commitment to science-based medicine with its motto "where nature and science meet". However, Bastyr University's institutional parent, a one-hour flight to the south, National College, laments the demise of nature-cure in the evolving training paradigm of the naturopathic physician. C.D. Howell's work (1984) describing mainstream medical doctors as elite largely because of the development of scientific medicine is helpful to our understanding of this tension in the naturopathic community.
Many naturopathic doctors cite the "naturism" of Rousseau (1712-1778) and his leitmotif call for a "return to nature" as a touchstone and ideological basis for the nature cure movement on which naturopathic medicine is established. Vegetarianism, hydropathy (also known as hydrotherapy), nudism and the rejection of drugs characterized this perspective on how to achieve optimum health. The naturopathic practitioner will look to the whole person for answers to a particular pathology. The allopathic doctor has been trained to be reductionist in her approach to understanding disease. She would most certainly know the classic descriptions: Addison on the adrenals and pernicious anemia, Sydenham on chorea, and Bell on facial palsy. At the core of scientific medicine, however, are techniques not anathema to naturopathic medicine such as inspection, palpation, percussion, and auscultation.
The allopathic and the naturopathic doctor each look, touch and listen. Each has lab tests and instruments to do the work of physical and clinical diagnosis. Indeed, these similarities have been true from the days of Frederick Gates and William Osler who anticipated a time when all medicine, natural or scientific, could be "reduced to an exact science" (Bliss, 1999). Osler made it clear in his The Principles and Practice of Medicine (1892), though, that the rigour which must accompany scientific medicine was frequently not present in such fields as naturopathy, homeopathy and osteopathy.
Osler "knew" that "medicine must rest on science" (Bliss, 1999). Osler as a clinical physician wanted a scientific underpinning to "working at the bedside", focused on the "whole patient" not unlike the naturopathic physician who is trained to develop a relationship with the patient which includes a comprehensive awareness of the person's complete physical, spiritual and mental makeup. Boon (1996) and Gort (1988) before her have identified the contemporary manifestations of this tension between holistic and scientific practitioners, and indeed between holistic and scientific naturopathic practitioners. The holistic practitioner's spiritual and physical words are "not separate, but manifestations of a single life force" (Boon, 1996). Consequently, symptoms, whether physical or spiritual, command the same attention. Their scientific counterparts, however, practice based on a biomedical model, which reduces all pathology to a cellular or molecular level. For the latter, the scientific method is the route to curing a disease. For the former, environment and spiritual balance are key factors in a treatment protocol.
As Schon reports (1994), "the greater one's proximity to basic science, the higher one's academic status". Professional schools of medicine, in such a context, would strive to train healers and socialize them as biotechnical problem solvers. Routinely, they would follow a sequence that immersed the student in medical science and then in supervised clinical practice. Glazer (1974) describes this approach as a "yearning for the rigor of science-based knowledge and the power of science-based technique". This fascinating polarity hugely influenced the development of naturopathic medical education in Canada. The existence of a distinct tension between professional orientation [itself not consistent across the profession and often regionally diverse] and student socialization has been discussed from a somewhat different perspective by Boon (1996) in her analysis of the scientific and holistic world views of both students and practitioners.
Gieryn's (1983) discussion about the practical problem of constructing some kind of boundary between science and "varieties of non-science" is an important theoretical discussion about the claims to authority which science insists upon. Naturopathic physicians and their teachers seem attracted to such a source of authority, but define their eclectic professional therapies inside and outside such boundaries. This latter phenomenon has influenced the development of the profession and its educational institutions.
Information about the roots of naturopathic medicine as a primary health care discipline is not abundant. Information about the medical education arrangements supporting that profession in Ontario and in Canada is even less available. Whereas students of higher education have been interested in the development of health sciences education programs in the metropolitan Toronto area (Preszat, 1979), it was not until Gort's landmark study in 1986 that some attention was focused on naturopathic medical education, even though her study is a social history and analysis of naturopathy's development in Ontario. Although limited to an examination of the five colleges of applied arts and technology in the metropolitan Toronto area, Preszat's study of factors affecting the development of health sciences education is helpful in understanding the context and background of health education at the critical point when the Ontario College of Naturopathic Medicine (OCNM) was first established in 1978. As well, Stone's study of the Toronto Institute of Medical Technology (1984) also surveys the broader field of health education offerings located outside the "big players" of university medical faculties in southern Ontario where OCNM took root.
Also part of the landscape in this period were several provincial studies and one larger federal study (Royal Commission on Health Services, 1965) which assisted federal political leaders to create the Medical Care Act of 1968, and Ontario to generate its provincial version, the Ontario Health Insurance Plan, in 1969. The literature about this period is devoid of reference to what is now called the "complementary and alternative medicine" field. Higher education facilities rapidly expanded during this period but did not include the peripheral fields of naturopathic medicine and related groups such as homeopathic practitioners, osteopaths and chiropractors. There is no mention of a naturopathic educational institution or school in any of a variety of reports which were published during this period (e.g. Health Manpower in Ontario, 1980; Canadian Hospital Directory, 1982; the Ministry of Colleges and Universities' Directory of Registered private Vocational Schools, 1981; the Ontario Hospital Association's Health Careers: Educational Requirements and Program Locations, 1982; the Ontario Council of Health's 1969 study, Education of the Health Disciplines and its 1971 report, Future Arrangements for Health Education.) Significantly, however, the federal minister of health, Marc Lalonde, issued in 1974, just four years prior to the establishment of OCNM, a document, A New Perspective on the Health of Canadians which not only contemplated a "prevention" focus in primary health care (a revolutionary concept at the time, at least in terms of public policy), but promoted collaboration among the many health care professional groups and individuals in Canada. Mustard's 1974 report from Ontario also spoke to the need for such collaboration (Report of the Ontario Health Planning Task Force, 1974) Baer (1992) and others (Rosengren, 1980; Twaddle and Hessler, 1987; Roth, 1976; Maretzski and Seidler, 1985; Maretzki, 1987; Gort and Coburn, 1988; and Boon, 1996) specifically document this dearth of attention given to naturopathy in critical academic study in North America. Against a backdrop of the "hegemony of biomedicine" (Baer, 1989), systematic analysis of the field of naturopathic medicine has been limited, narrow and intermittent. Related examination of the development of naturopathic medical education activity in Canada and the United States has occurred in part (Cody, 1985; Gort, 1986; Boon, 1996) focusing, however, on aspects of the profession itself and not on the creation and development of the institution responsible for the professional training of naturopaths. Especially relevant to this study is that while there has been a type of what Altbach calls a "gray literature" (Altbach, 1996) in higher education, there is a very gray literature about the history of naturopathic medicine, of the educational institutions supporting its development, and of the relationship of those naturopathic schools and colleges to the nonprofit and higher education public sectors.
Consequently, very little work on naturopathic medical education has accumulated to date within the literature about medical education in Canada, about health professionals and health occupations (Coburn, 1991) and about the intersection of both of these with nonprofit and public sector organizations, including universities (Quarter, 1992; Defourny, 1992; Martin, 1985; Day, K., & Devlin, 1997, Cameron and Royce, 1996; Jones, 1994, 1996,1997; Skolnik, 1987, 1991,1995; Watson, 1992; Gregor and Jasmin, 1992). Helpful, too, is Brubacher's study of higher education in transition at about the same time as a group of chiropractors established Canada's first naturopathic college two thousand miles from the only other one of consequence at the time (Brubacher, 1977).