Sociology of Health & Illness Vol. 27 No. 1 2005 ISSN 0141–9889, pp.

20–43
Nissim
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Oxford,
Sociology
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January
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Judith
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Sky GrossBoard 2005
/Editorial

Boundary at work: alternative medicine in

biomedical settings
Nissim Mizrachi1, Judith T. Shuval2 and
Sky Gross2
1
Department of Sociology and Anthropology, Tel Aviv University
2
Department of Sociology and Anthropology, Hebrew University

Abstract The study explores the process of boundary demarcation within

hospital settings by examining a new phenomenon in modern
medicine: collaboration between alternative and biomedical
practitioners (primarily physicians) working together in
biomedical settings. The study uses qualitative methods to
examine the nature of this collaboration by calling attention
to the ways in which the biomedical profession manages to
secure its boundaries and to protect its hard-core professional
knowledge. It identifies the processes of exclusion and
marginalization as the main mechanisms by which symbolic
boundaries are marked daily in the professional field. These
processes enable the biomedical profession to contain its
competitors and at the same time to avoid overt confrontations
and mitigate potential tensions between the two medical systems.

Keywords: alternative medicine, marginalization, exclusion, boundaries,

field, demarcation

Introduction

The notion of boundaries has become an organising theme in recent years

for various sociological approaches to social inequality, collective and national
identity, class, gender and ethnic relations, as well as for the sociology of
science, knowledge and professions (Lamont and Molnar 2002). Sociolo-
gists of science, medicine and professions have paid considerable attention
to the processes of boundary demarcation by which scientific disciplines and
modern professions seek to secure their autonomous position, gain legiti-
macy, mark and defend their turf, and expand their jurisdiction (Gieryn
1983, 1999, Freidson 1988, Abbott 1988). Although these studies have high-
lighted the link between boundary demarcation and social domination and
© Blackwell Publishing Ltd/Editorial Board 2005. Published by Blackwell Publishing, 9600 Garsington
Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden MA 02148, USA
 Alternative medicine in biomedical settings 21

emphasised the dynamic nature of boundary formation1, they have not

anchored their research in mundane arenas in which social actors negotiate
social and symbolic boundaries daily.
Recent studies in medical sociology have called attention to microprocesses
by which professional boundaries are demarcated in biomedical settings.
These studies examine the ways in which the division of labour in healthcare
settings is constructed, maintained, negotiated and challenged by the actors’
daily rhetoric and action (Allen 2000, 2001, Hak 1994). In the same vein,
microanalyses of boundary demarcation and healthcare settings have high-
lighted the ways the actors’ professional, structural and spatial positions in
the hospital setting shape their epistemological, ideological and ethical views
of their daily work. These diverse viewpoints acquire visible expressions in
daily processes of boundary negotiations among different medical profes-
sions (Anspach 1987, 1993, Chambliss 1997, Mizrachi 2001, Mizrachi and
Shuval 2005). From a micro-perspective, Freidson’s view of a physician-
dominated biomedical field has been challenged by various studies that
found professions like nursing and clinical pharmacy capable of negotiating
and expanding their professional jurisdiction into new managerial and
clinical territories (Hughes 1988, Mesler 1991, Allen 1997).
In line with these studies, the present work examines the micromecha-
nisms by which boundaries are marked daily and professional domination
maintained in the hospital setting. It is part of a broader inquiry by the
authors into various facets of the coexistence between biomedicine and
alternative medicine in Israel2. By ‘alternative medicine’ we refer to a ‘heter-
ogeneous set of practices that are offered as an alternative to conventional
medicine for the preservation of health and the diagnosis and treatment of
health-related problems’3 (Murray and Rubel 1992: 61).
Whereas most microanalyses of boundary negotiation in healthcare set-
tings have focused primarily on inter-occupational symbolic negotiations
over division of labour (Allen 1997, 2001, Mesler 1991), where all participat-
ing occupations were subordinated to the logic of the biomedical field, the
present case explores micro-mechanisms of boundary demarcation between
the biomedical field as a whole and alternative practitioners who are
perceived as ‘aliens’ to the entire field. Other than identifying settlements of
jurisdictional disputes (Abbott 1988), the present study explores changes in
the contours of boundaries accomplished without disputes or expressions of
overt conflict, by a responsive strategy on the part of the biomedical field.
We show that by changing the contours of boundaries, closed and open
areas are tacitly marked in the field, enabling the biomedical discourse to
contain and exclude its competitor at the same time.
Drawing on Larson’s notion of ‘discursive field’, which incorporates
Bourdieu’s and Foucault’s approaches to the sociology of professions (Larson
1990), we consider a wide variety of formal and informal daily and ceremo-
nial phenomena as inter-related and embedded within one professional field
(Larson 1990) subjected to the logic of biomedical discourse (Foucault
© Blackwell Publishing Ltd/Editorial Board 2005
22 Nissim Mizrachi, Judith T. Shuval and Sky Gross

1994). The phenomena under consideration are the division into areas of
expertise, patterns of recruitment and remuneration, decision-making pro-
cesses, actors’ positioning in the social and spatial structure, daily rituals and
forms of interaction. We view the hospital’s social and spatial structures,
forms of knowledge and practice, and modes of social behaviour and pro-
fessional conduct as interconnected constituents of the hospital field (Prior
1988, Geogropoulos and Mann, 1983, Mizrachi 2001).

The hospital as a discursive field

In The Birth of the Clinic, Foucault describes the discursive forms in evidence
in the clinical field:

For clinical experience to become possible as a form of knowledge, a

reorganization of the hospital field, a new definition of the status of the
patient in society, and the establishment of a certain relationship between
public assistance and medical experience, between help and knowledge,
became necessary; the patient has to be enveloped in a collective,
homogeneous space. It was necessary to open up language to a whole new
domain: that of a perpetual and objectively based correlation of the
visible and the expressible. An absolutely new use of scientific discourse
was then defined: a use involving fidelity and unconditional subservience
to the coloured content of experience – to say what one sees; but also a
use involving the foundation and constitution of experience – showing by
saying what one sees (1994: 196).

Thus, the hospital space is not merely a site for medical knowledge and
practice. The variety of forms and practices taking place in the hospital
arena is viewed by Foucault as part of the same discourse, which ‘is constituted
through its rules of formation, its condition of emergence and its correlation
with other practices’ (Prior 1988: 92). Historically, the rise of the modern
hospital coincides with the rise of the medical profession, knowledge and
ethos, all of which are given visible expressions in the space of the modern
hospital since its inception (Rosenberg 1996). The epistemological founda-
tion of modern scientific medicine has been embedded within the hospital
architecture (Prior 1988) and its organisational structure (Georgopoulos and
Mann 1983).
Magali Larson’s attempt to incorporate the Foucauldian notion of
discourse into the sociology of professions helps the examination of the
daily management of professional jurisdiction (Larson 1990). Drawing on
Foucault’s notion of discourse, Larson has pointed out the adjacency
between power and knowledge and its pertinence to the theory of profes-
sions. Two major forms of professional discourse are particularly germane
to the present analysis: (a) procedures of exclusion, primarily interdictions
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 23

and the distinction between true and false and the ways in which they tacitly
mark closed and soft areas in professional fields; and (b) the ways in which
‘the control of knowledge always ultimately depends on controlling the
subjects who know’ (Larson 1990: 32).
The first refers to the hard-core truth values of professional knowledge
and practice. For example, in view of the great emphasis that biomedical
discourse places on the nature of ‘disease’, it is less likely to find alternative
practitioners in strategic diagnostic areas of the hospital, such as the Emer-
gency Room, offering a preliminary medical verdict. The second discursive
form refers to behavioural and interactive procedures, both formal and
informal, by which the actors are lined up along the ‘proper’ paths of the
professional boundaries in the field. This discursive type relates to forms of
daily interaction as well as to the formal structure by which symbolic and
social boundaries are constructed daily. But although these two discursive
forms are analytically separable they are empirically interwoven within the
professional field. The presentation of these two forms in isolation is merely
an initial heuristic strategy pursued solely for the sake of clarity.
Combining Foucault’s notion of discourse with Bourdieu’s sociological
concept of the scientific field, Larson proposes a helpful theoretical frame-
work for examining the issues at hand. While Bourdieu’s notion of scientific
field emphasises the relative power position of different authorised actors,
the term discursive field, according to Larson, represents ‘something broader
than a scientific field, since discourses are produced in areas of social prac-
tice that include both unauthorised and non-authoritative speakers’ (1990:
34). Larson’s integrative approach suggests the role of human agency in
shaping the professional field (see also Vallas 2001). We examine the process
of boundary formation by highlighting the actors’ strategic behaviour on
a daily basis.
Agency is viewed within a set of elements (positions and actions) arrayed
in a particular field in which actors ‘frame their action vis-à-vis one another’
(Martin 2003: 42). Actor reactions and interactions in the field are viewed
in relation ‘to [actors’] field position as every position in the field induces
a set of motivations that are subjectively experienced as “what should be
done”’ (Martin 2003: 42). In our case, structural positions, conditions and
constraints, as well as individuals’ actions, reactions, interactions and
behavioural strategies are all regarded as various manifestations of field
relations.

Boundary at work in the hospital field

The broader meaning of discursive versus scientific field sheds light on the
way in which, in the biomedical profession the supreme epistemological
authority of science, embodied in the ethos of evidence-based medicine,
plays a major role as a boundary marker in the field. Therefore, Gieryn’s
© Blackwell Publishing Ltd/Editorial Board 2005
24 Nissim Mizrachi, Judith T. Shuval and Sky Gross

notion of ‘boundary-work’ becomes particularly germane to the present

analysis. According to Gieryn, boundary-work is ‘the discursive attribution
of selected qualities to scientists, scientific methods, and scientific claims for
the purpose of drawing a rhetorical boundary between science and some less
authoritative residual non-science’ (Gieryn 1999: 4–5).
Drawing on Gieryn’s notion of boundary-work, the study examines
‘boundary at work’ by exploring a variety of expressions in the field by
which the biomedical discourse as a whole marks its boundaries. Emphasis
is placed on the dynamic nature of processes of demarcation in the field by
which boundaries are maintained, perpetuated and reshaped.
We pose the following research questions: What are the overt and veiled
mechanisms by which a dominant biomedical discourse secures its position
or relaxes its boundaries? What are its mechanisms of exclusion? What are
the overt and veiled behavioural strategies of different actors in the field?
What are the professional areas in which biomedical discourse admits
alternative practitioners? And finally, what are the areas of biomedical
knowledge that remain closed to outsiders?

Epistemological hegemony in a changing environment

The ‘invasion’ of alternative practitioners into the biomedical fortress4 has

become possible after economic conditions and market competition have
created an environment in which collaboration between biomedical and
alternative practitioners could take place. A survey published in the May
2000 issue of Consumer Report, which included 46,000 of the journal’s readers,
provides a good illustration of some of the recent trends in the healthcare
market:

. . . more that 16,000 – almost 35 per cent [of readers] – had used such
alternative therapies as megavitamins and nutritional supplements
(herbals and natural body compounds); deep-tissue massage (rolfing,
myofascial release, neuromuscular massage); chiropractic manipulation
and acupressure; and mind-body treatments such as meditation and
relaxation therapy. Some got these treatments through their regular
doctors or an alternative practitioner.

This survey is indicative of the increasing use of alternative therapy in the

general population. Ten to 25 per cent of the adult population in Western
European countries and approximately 40 per cent of a similar population
in the US have utilised alternative therapy (Aldridge 1990, Cooper and
Stoflet 1996, Siahpush 1999, Eisenberg et al. 1993, Lewith and Aldridge
1991).
The growing public demand for alternative therapy (Shuval 1999) has
been closely related to increasing questioning of the unlimited authority of
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 Alternative medicine in biomedical settings 25

biomedicine. Various social conditions and processes have been associated

with this trend:

. . . growing disillusionment with the technology and bureaucracy of

biomedicine and increased questioning of its excessive invasiveness;
heightened consumer awareness of iatrogenic effects of modern medicine
and growth in expectations for quality service including structural
changes in the physician-patients relationship as well as widespread
demystification which have led to considerable erosion of confidence in
Big Science as a means of solving problems (Shuval 1999: 311).

Over the past three decades, these social processes and market constraints
have gradually changed the attitudes of biomedical practitioners regarding
alternative medicine (Grandinetti 2000, Jobst 1998, Shuval et al. 2002). To
clarify these changes, a brief recapitulation of the fundamental contrast
between the two medical systems is in order.
In Wardwell’s account, alternative practitioners were perceived by the
biomedical establishment as outsiders ‘. . . who challenge some of the basic
assumptions of orthodox medicine’ (1976: 63). Biomedicine has been char-
acterised by prioritising the soma, identifying nature with the physical, and
reducing the concept of disease to a visible entity (Kleinman 1995, Foucault
1994, Rosenberg 1992). While such reductionism has played a role in con-
solidating the cognitive foundation of biomedicine (Freidson 1988, Larson
1977), it was also the source of continuous social discomfort and tension
associated with what has been characterised as de-humanisation and de-
personalisation of the patient (Anspach 1990, Mishler 1981). The distinction
between disease and illness, common in medical sociology, captures this pro-
found epistemological divide. Disease refers to an objective, physical, visible
and universal entity, while illness refers to the subjective experience of the
suffering individual (Conrad and Kern 1990). ‘. . . Not that experiential or
behavioral matters are ignored, certainly not by good clinicians, but that
these matters are separate from the real objects of medical practice . . . The
fundamental reality is human biology’ (Good 1994: 186).
Alternative medicine represents a fundamental institutional challenge to
biomedicine by its lack of a unified, formalised and standardised body of
knowledge as well as by its underlying epistemological assumptions. Alter-
native practitioners often view the great mind-body divide in biomedical
theory and practice as an obstacle to reaching a cure. They ‘often maintain
explanations of health and illness that are based on causal factors that differ
from those of orthodox medicine, e.g. that illness is caused by an imbalance
between opposing energy forces, and usually claim an holistic orientation
as part of their paradigm of health knowledge’ (Clavarino and Yates 1995:
254).
The reaction of biomedicine to emerging social and economic constraints
can be divided into the following types: Negation and denigration: characteristic
© Blackwell Publishing Ltd/Editorial Board 2005
26 Nissim Mizrachi, Judith T. Shuval and Sky Gross

of a large number of biomedical practitioners who question the reliability

of alternative medicine (Anyinam 1990, Dacher 1999, Launso 1989, Radley
1994, Turner 1996). The American Medical Association, for example, has
consistently viewed alternative practitioners as unscientific and profession-
ally unreliable as far as biomedical professional standards are concerned.
Cautious approval: a partial recognition among biomedical practitioners of
the usefulness of some forms of alternative medicine for particular types of
illness. Such approval does not necessarily mean embracing the theoretical
underpinning of alternative medicine, but rather recognition of its effective-
ness, which is likened to the placebo effect (Rees 1997, Sharma 1992). Bio-
medical practitioners who refer patients to alternative medicine generally
believe that it is an appropriate alternative if there is a good reason to believe
that it ‘could do no harm’ (in May and Sirur’s terms 1998: 175, see also
Shuval 1999, Shuval et al. 2001). Reconciliation: a relatively recent pheno-
menon of biomedical practitioners embracing alternative medicine either in
conjunction with their biomedical practice or by attempting to integrate the
two systems (Rees and Weil 2001).
Negation reflects the refusal to seek any tangential point between the two
systems. Alternative medicine is excluded from the biomedical discourse
as a whole not as a consequence of deliberative consideration but by its
placement, ipso facto, outside the biomedical parlance.
Cautious approval reflects recognition of the problem-solving capacity
of alternative medicine. Such recognition is generally restricted to the area
of illness rather than disease, and it is often associated with the wisdom of
practice rather than the logic of science. In other words, there is some room
for alternative medicine in the neglected area of illness, which has been
excluded from biomedicine in the first place and has often been a burden on
the biomedical profession rather than being an integral part of the medical
procedure. Such cautious recognition becomes possible when the logic of
science can be separated from the wisdom of practice – the grey areas of
mind-body interaction where placebo effects transcend the logic of bioscience.
Reconciliation is manifest in attempts to integrate the two systems. It
includes manifestations of cautious approval in the recognition of the posi-
tive effects of alternative medicine, albeit restricted to the area of illness and
the wisdom of practice. But even this most collaborative form of reaction
maintains clear boundaries of negotiation. Along these boundaries, the
hard-core logic of bioscience, which has been the most fundamental charac-
teristic of the biomedical profession, remains largely untouched.
In Israel, as in most Western countries, the biomedical system enjoys
prestige, legitimacy and exclusivity as the provider of medical care. However,
a significant increase in the use of alternative medicine has been recorded
from 1994 to 2000 (Bernstein et al. 1994, Bernstein and Shuval 1997, Israel
National Center for Disease Control 2000, Ronnen 1998), and a growing
number of patients have been referred to alternative practitioners by physi-
cians during the 1990s (Borkan et al. 1994, Schachter et al. 1993). Over the
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 27

past decade, changes in the status and influence of alternative medicine have
taken place in Israel against a background of shifting values that have
prompted important changes in the healthcare system in general. In this
process, Israel is following a pattern seen in several other Western countries
(Shuval 1992, Shuval and Anson 2000).
The National Health Insurance Law (NHIL) of 1995 provides universal
access to comprehensive health insurance, which includes curative and
preventive ambulatory care as well as hospitalisation. The NHIL emphasises
the importance of reducing costs and encouraging competition among the
hospitals and among the four sick funds (Chinitz and Rosen 1993).
It was economic conditions and market competition that shaped the
growing collaboration between biomedicine and alternative medicine in Israel.
The establishment of alternative clinics within publicly-sponsored biomedi-
cal settings has been a gradual process that began in 1991 when the first
alternative clinic was opened within one of the government hospitals in Tel
Aviv. The accommodation of alternative practitioners within the biomedical
fortress has coincided with the increasing market value and growing clientele
of alternative medicine (Shuval 1999). However, the accommodation has,
in Shuval’s words (Shuval 1999), proved to be a ‘bear hug’, allowing the
biomedical profession to control and monitor the practice of alternative
medicine within the hospitals while sharing its clientele. At the same time,
alternative practitioners have gained professional legitimacy from biomedical
sponsorship (Shuval et al. 2002).

Methodology

The data for the present study are based on formal and informal interviews
as well as in situ observations in the field conducted by a graduate student
in anthropology at an internal medicine department of a large university-
affiliated government hospital in Tel Aviv over a seven-month period in 2001.
The observations were made during routine activity, meetings, formal and
informal interviews, and social encounters in the field.
The initial contact of our research assistant with the team of alternative
practitioners working at the hospital was made with the head of the team,
Dr. M, an MD, trained also in acupuncture, who symbolically represents the
conjunction of the two knowledge systems. In his intermediary symbolic
position at the hospital, he occasionally crossed the lines between the two
systems. This bridging position plays a mediating role in daily encounters of
alternative practitioners with physicians and hospitalised patients.
Observations in the field were focused on Dr M and his team of alter-
native practitioners during their routine work with hospitalised patients. The
research focused on the two teams of alternative practitioners working in
the internal medicine ward in the hospital. Dr M was the head of both teams.
The table below summarises the main characteristics of the alternative
© Blackwell Publishing Ltd/Editorial Board 2005
28 Nissim Mizrachi, Judith T. Shuval and Sky Gross

Table 1 Characteristics of alternative practitioners

Team Practitioner Gender Complementary practice Trained MD

A 1 F Acupuncture No
2 F Acupuncture No
3 M Acupuncture No
B 1 F Acupuncture Yes
2 M Acupuncture No
3 M Expert in Chinese medicine Yes
(guest from China)

practitioners who participated in the study, all of whom were practising

acupuncture and over half of whom did not have biomedical training.
Every visit was planned in advance and authorised by Dr M. In this respect,
the observations were limited in scope and designed to emphasise highly-
structured interactions. Other documented observations and ethnographic
evidence were collected during interviews in the field, which were scheduled
in advance. These structural constraints affected the nature of the available
ethnographic data and restricted it to particular events and interviews. Thus,
data collection was focused on specific sites in the course of professional
practices rather than by unrestricted participant observation in the field. At
the same time we sought to reach a balance between our a priori theoretical
concerns and the observed reality in the field.
The analysis is based on carefully recorded observations as well as on
formal and informal interviews with biomedical and alternative practitioners
and with hospitalised patients. It is a result of numerous processes of
interpretation, framing and reframing of the rich qualitative data (Atkinson
1992), which was mined by the researcher in the field and guided and super-
vised by the two senior researchers. Our presuppositions and views have
reshaped themselves dynamically throughout our ongoing discussion before
and after every visit in the field.
The interviewer took notes during the interviews, which covered various
general subjects such as socio-demographic and occupational background,
including gender, age, country of origin, area of expertise, formal training
and occupational experience. Other general subjects focused on occupational
role and included: specialty, work schedules, remuneration, previous experi-
ence, additional work outside the clinic or hospital, job status and evaluation
of the work site, including economic and other considerations. Finally, a
group of general questions focused on attitudes about work: reason for the
choice of work site, views on the place of alternative practice in a biomedical
setting, advantages and disadvantages, mode of interaction with colleagues
and attitudes regarding the place of alternative healthcare in Israel.
In addition to informal discussions with various participants in the field
during observations, in-depth interviews with key actors provided insight
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 29

into the participants’ work experience. Special attention was paid to their
beliefs, underlying assumptions and fundamental perceptions regarding
the nature of medical knowledge and the appropriate forms of collaboration
between the two medical systems, their boundaries and restrictions. The
narratives provided information about the decision-making processes as well
as the nature of daily interactions and practice (see Denzin and Lincoln
1994, Erlandson et al. 1993, Polkinghorne 1988, Silverman 1997, Strauss
and Corbin 1990, Yin 1994).
Finally, the present work is part of a broader research project encompass-
ing a number of separate, inter-related studies on the relations between alter-
native and orthodox medicine in Israel. Focusing on the rise of alternative
medicine, these studies examine the historical context of the new trend,
describe changes in public attitudes, and explore new institutional and
organisational processes involving the growing collaboration between the
two medical systems. This broader research context in which the present
study is situated has a double effect on the process of data collection and
analysis. On the one hand, it restricts the selection of research questions and
the nature of subject matters under investigation, and thereby precludes
other possibly noteworthy issues from being explored. On the other hand,
the present study expands upon findings already reported in related Israeli
studies and validates some structural characteristics such as patterns of
remuneration, recruitment and accreditation (Shuval et al. 2002, Shuval
et al. 2004, Mizrachi et al. 2005), which enhance its reliability.
Within this context of the related studies on the subject, the empirical site
studied here is the only one of its kind that has ever been studied. It is the
first site where alternative practitioners were observed and interviewed dur-
ing their work with hospitalised patients collaborating with their biomedical
colleagues. It provided us with a salient case for exploring biomedicine’s
reactive and interactive strategies toward the alternative ‘invaders’ in the
field. The following analysis seeks to sketch the highlights of various inter-
active and institutional forms of boundary demarcation and negotiation
involving both hard-core and soft areas tacitly marked in the biomedical field.

Analysis of the data

Procedures of exclusion

The gatekeepers
The field is demarcated in advance by the gatekeepers who introduce alter-
native medicine into a biomedical setting on the one hand and restrict its
jurisdiction within the hospital on the other. The study specifically identified
two key actors. The first is Dr M (male MD), head of the outpatient
complementary5 unit at the hospital; the other is Prof K (female MD), head
© Blackwell Publishing Ltd/Editorial Board 2005
30 Nissim Mizrachi, Judith T. Shuval and Sky Gross

of the hosting internal medicine department. Dr M offers his unit’s services

to different departments within the hospital. As a medical doctor trained
in alternative medicine, he can translate the alternative terminology into
biomedical terms and can anticipate potential professional tensions between
the two systems. His role as the negotiator with biomedical authorities
places him in a gate-keeping position where he seeks to avoid unsafe
intrusions of alternative practitioners and to reduce potential tensions. He
thereby sets the terms by which the nature of collaboration takes shape and
its boundaries are demarcated.
Dr M demarcates the areas of practice of alternative practitioners in the
hospital along the disease-illness lines. He states: ‘Complementary medicine6
can be helpful in cases of pain in general and in post-operative pain in
particular, in cases of depression, rheumatism, chronic illness and breathing
difficulties. You cannot introduce complementary medicine to other fields
such as intensive care units for example’. In Dr M’s view, therefore, alterna-
tive medicine is restricted to the patients’ experience of illness or to their
functioning during illness.
In Dr M’s view, a more thorough integration between the two systems
depends upon further research validating the positive effects of alternative
treatment through incontrovertible scientific methods. ‘This is the only way
to integrate the two medical systems’ he stated decisively. The reduction of
alternative knowledge to biomedical terms appears to him as the only means
of real integration. He explains the dominance of acupuncture among alter-
native specialties practised at the hospital in the same vein: ‘Acupuncture is
known to be effective and therefore it has become dominant. Like biomed-
icine, it has a clear physiology, diagnosis, pathology and treatment. Physicians
can grasp this kind of logic. It speaks to them. It is much harder for them
to accept homeopathy, for example’. The logic of alternative medicine
appears to be reduced to the terms of the hegemonic epistemology of bio-
medicine. This demarcation takes place before the alternative practitioners
arrive at the hospital. The screening process, therefore, marks the profes-
sional jurisdiction and shapes the selection of the ‘appropriate’ alternative
specialty. It is not by chance that the choice was acupuncture, the most
mainstreamed of alternative specialties (Grandinetti 2000). The Israel
Medical Association itself stated (1997) that acupuncture can be useful if
practised by a physician, thus providing it with rare biomedical legitimation
among the alternative fields of practice (offered additionally only to chiro-
practice) (Israel Medical Association 1997).
Prof K’s view of alternative medicine is indicative of the way in which
the boundaries of knowledge between the two systems are perceived by the
biomedical staff. As a department head known for her open-minded approach
to alternative medicine and for her pleasant hospitality, she has become
the inner mediator between alternative and biomedical practitioners. The
following statement about the reactions of biomedical practitioners to alter-
native practitioners attests to her collaborative spirit: ‘Intelligent people
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 31

[referring to biomedical practitioners] talk about alternative medicine as if it

were the enemy, a big threat, as if something is taken from them’. She then
goes on to describe her view of alternative care: ‘Conservative medicine
[referring to biomedicine] is not capable of answering a lot of questions.
It [biomedicine] can sometimes do harm rather than help the patient.
Complementary7 medicine can help patients although the way in which it
works is unknown to me’. Prof K points to another important incentive for
the current collaboration: ‘We are understaffed, and complementary practi-
tioners can dedicate more time to patients. A good word from a practitioner
can make the patient feel better. They can spend time with the patients, time
that we don’t have’. She continues by emphasising the success of comple-
mentary practitioners in alleviating pain.
Again, the neglected realm of illness appears to be the designated place for
alternative practitioners. As to the real value of their medical knowledge, she
thinks that ‘a real objective research, using double blind methodology is needed’
to establish the validity of alternative treatment beyond the placebo effect.

The ‘clinical gaze’ at work

Both gatekeepers present a similar generic picture. There is only one science.
Its methodology, functional value and objectivity are beyond question even
though it may not provide all the answers and it may often fail to relieve
human suffering. As Gieryn notes: ‘So secure is the epistemic authority of
science these days, that even those who would dispute another’s scientific
understanding of nature must ordinarily rely on science to muster a persua-
sive challenge’ (1999: 3). Dr M, clearly more familiar than Prof K with the
theory of alternative medicine, considers the need for scientific verification a
matter of cardinal importance, necessary for any prospective integration of
the two systems. For Prof K, unless alternative knowledge is scientifically
validated, its nature and logic remain unknown. From both perspectives,
alternative medicine is restricted to the realm of illness and patient care rather
than diagnosis and therapy.
The focus of biomedicine on the human body and the identification of
evidence-based medicine with somatic, visible and predictable evidence has
provided the biomedical profession with the epistemological infrastructure
that shapes professional conduct and ethos of biomedicine. ‘I believe only
what I can actually see . . .’ stated one physician referring to alternative care.
His statement captures the gist of Foucault’s well-known equation, seeing =
knowing, describing the ethos of the ‘clinical gaze’ (Foucault 1994). ‘Scientific
facts’ normally associated with visible evidence provide the epistemological
foundation of evidence-based medicine (Kleinman 1995). Prof K (the head
of internal medicine mentioned above) stated: ‘Alternative medicine may
work in cases where we fail. I do not understand how it works but there
is definitely no harm in using it’. The determination of what constitutes
‘medical harm’ remains exclusively within the domain of biomedicine. This
attitude is shaped to a great extent by the nature of the physicians’ knowledge
© Blackwell Publishing Ltd/Editorial Board 2005
32 Nissim Mizrachi, Judith T. Shuval and Sky Gross

about the knowledge base and practice of alternative medicine. This know-
ledge is not systematically acquired within an academic setting but is based
on personal experiences, which at times act to decrease their resistance to
alternative medicine (May and Sirur 1998). The related Israeli studies
(Shuval et al. 2002, Shuval et al. 2002a) indicate that reactions of biomedical
practitioners to alternative medicine range from complete rejection to
cautious recognition. In the latter case, alternative knowledge is placed in
the realm of beliefs rather than scientific facts.
Physicians who favour collaboration with alternative practitioners express
cautious recognition of the possible positive effects of alternative treatment,
but always exclude the knowledge base from their discussion. They regard
the knowledge base of alternative medicine as an unknown or a matter of
personal belief. Hospitalised patients often acquiesce in this division. For
example, a patient who refused to be treated by an alternative practitioner
said: ‘Thank you, but I don’t believe in it’. The alternative practitioner
accepted it. Another patient, who had just been treated by an alternative
practitioner, when asked whether it had helped, replied: ‘I don’t know if it
helps but it’s soothing’. In another episode, Dr M approached a patient
during a case presentation: ‘I was just told that you have been suffering a
great deal and I wonder whether you are willing to try it. Ofer and Tali [two
alternative practitioners] will be able to help you’. The patient looked
surprised and responded suspiciously yet sheepishly: ‘I don’t know if I
believe in it. Do you think it might work?’. In this case, Dr M’s biomedical
training bestowed legitimacy and provided the symbolic link between the
two medical systems.

Social manifestations of an epistemological divide

The traditional distinction between disease and illness (see Conrad and Kern
1990) is particularly helpful in tracing the boundaries of practice between
biomedical and alternative practitioners. The evidence points to a strict divi-
sion of labour between the two: alternative practitioners are restricted to the
realm of illness, while their biomedical colleagues are in charge of diseases.
Thus, alternative practitioners focus on the patient’s personal experience
of pain and suffering, while biomedical practitioners concentrate on the
diagnosis and cure of the disease, although they do not necessarily ignore
the patients’ experience of illness.
Medical intervention of alternative practitioners was to be restricted to
the patients’ experience of illness: feelings, affective states, the alleviation of
pain and suffering, and efforts to improve the quality of life. This restriction
demarcates strategic areas within the hospital where alternative practitioners
were not found to be practising. These areas include, emergency rooms (where
initial diagnosis is made), labs, radiology and imaging units (where biomed-
ical evidence is created and interpreted). This demarcation is accepted by all
participants in the study (physicians, alternative practitioners and patients
alike) and manifests itself in the decision-making process as well.
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 33

Various forms of knowledge are present in a hospital, biomedical as well

as other non-medical professional forms of knowledge such as administrative,
legal, technical and so on. Although the knowledge base of each area is
different in nature, it is embedded within the bureaucratic hospital system
that divides the healthcare system into sub-units of operation (Geogropoulos
and Mann 1983). None of these forms suffers from ambiguity as to the
nature of its knowledge base and its social and symbolic boundaries. They
are all part of a rational hospital system within which the health care service
is organised by the assembly line rationale (Geogropoulos and Mann 1983,
Shenhav 1999). Alternative knowledge alone is placed outside the hospital
knowledge system. Patterns of recruitment, employment conditions and the
accreditation system are all visible expressions of social boundaries drawing
the line between ‘in’ and ‘out’ in the hospital system.

Controlling knowledgeable agents

Lamont and Molnar (2002) distinguish between symbolic and social bound-
aries cutting across different sociological sub-fields and cases. The first refers
to ‘. . . conceptual distinctions made by social actors to categorize objects,
people, practices, and even time and space’; the latter to ‘. . . objectified
forms of social differences manifested in unequal access to and unequal
distribution of resources (material and nonmaterial) social opportunities’
(2002: 168). Drawing on Lamont and Molnar’s distinction, we divide the
ways by which alternative practitioners are controlled in the field into formal
and structural procedures versus interactive and symbolic.

Social boundaries and the meaning of informal legitimacy

The related Israeli studies (Shuval et al. 2002, Shuval et al. 2002a) indicate
that alternative practitioners have gained entrance to hospitals by informal
rather than formal bureaucratic processes. There are no public announce-
ments of vacant positions, or invitations to qualified persons to submit their
credentials. Personal contacts and networking appear to be the principal
mechanisms of recruitment. Biomedical practitioners were found to know
little about the professional training and knowledge of their alternative
colleagues, even when they work together (Shuval et al. 2002).
In the present case, Dr M’s personal ties enabled him to introduce alter-
native medicine to biomedical authorities in the hospital. It was his profes-
sional identity as an MD rather than his reputation or credentials as an
alternative practitioner that provided him with a legitimate entry point. This
informal form of contact is typically followed by the formal recognition of
the services provided by alternative medicine in attracting patients. All the
hospitals that have outpatient clinics for alternative medicine make use of
the alternative specialties to attract patients, and advertise their presence in
leaflets describing their services (Shuval et al. 2002). Nevertheless, while
© Blackwell Publishing Ltd/Editorial Board 2005
34 Nissim Mizrachi, Judith T. Shuval and Sky Gross

accepted as a new service, the knowledge base of alternative medicine

remains outside the biomedical parlance. When asked what were the criteria
for selecting the ‘right’ alternative specialty, Prof K answered: ‘I simply
accepted what Dr M had to offer’.
Alternative practitioners working in hospitals and other biomedical clinics
in Israel do not hold formal positions. They often volunteer or work on an
ad hoc, individual contractual basis. All work part time, mostly one or two
but as many as four days a week. The fees paid by patients to hospital
practitioners are a fraction of the fees charged in private practice (Shuval
et al. 2002). All the alternative practitioners in this study work at the hospital
as volunteers. One of the alternative practitioners working at the hospital as
a volunteer noted: ‘I see myself as a pioneer. It is important to me to enter
the hospital and to gain legitimacy and prestige. I would like to see alterna-
tive medicine as part of the medical establishment’.
Exclusion of alternative practitioners from remuneration, recruitment
and accreditation enables the biomedical discourse to avoid placing alter-
native knowledge and practice within the professional field of the hospital.
While other sub-medical fields and para-medical professionals such as
nurses, technicians, physiotherapists and others might differ in the nature of
their practice, the length of their training, the degree of abstraction of their
knowledge and the level of academic education (Abbott 1988), they are all
inherently related to the scientific biomedical system of knowledge. In some
form or other, they all provide supportive services to physicians. The exclu-
sion of alternative practitioners from the formal institutional structure,
enables biomedical authorities to keep alternative practitioners outside the
professional field in which the nature of knowledge plays a role in determining
its market value (Derber, Schwartz and Magrass 1990).
In practice, the epistemological hierarchy manifests itself in the formal
decision making process. The diagnostic process is always initiated by a
physician who decides which patients should see an alternative practitioner.
‘First we ascertain that there is no medical problem, then we refer the patient
to alternative medicine’, said Dr M. At this diagnostic stage, if doctor and
patient decide to use alternative medicine, the patient must sign a consent
form and obtain the doctor’s approval.

Ceremonial behaviour and boundary demarcation

Rituals of case presentation provide a valuable site for exploring the mech-
anisms of power (Anspach 1990). In cases where alternative practitioners join
the routine rituals of case presentation, the division between the two groups
of practitioners invariably emerges. The ritual is conducted by a physician
who makes the diagnosis and in some cases refers the patient to an alterna-
tive practitioner. In one case, after the diagnosis had already been made, the
physician approached the alternative practitioner: ‘Do you have something
for a sore neck?’. She replied positively. He proceeded to address the patient:
‘If her treatment with needles makes you feel better you will go home today’.
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 35

This was said after the decision had already been made by the physician.
(Interaction of this kind between physician and medical practitioner during
case presentation is exceptional; the typical role of alternative practitioners
during case presentation is described in the section Spatial marginalisation
below.)
This and similar cases point to two ways in which the hierarchy of knowl-
edge manifests itself. First, it indicates the dominant position of physicians
in the decision-making structure, which is accepted by all participants.
Second, it highlights the division into disease and illness, which marks the
professional jurisdiction of the two medical systems.

Deference and demeanour

Marginalisation within the hospital field can also be observed in the level
of social encounters, daily rituals, and professional interactions. Goffman’s
(1967) notion of deference and demeanour provides a helpful analytical frame-
work for observing daily hospital activities. Demeanour as a social phenom-
enon refers to ‘that element of the individual’s ceremonial behavior, typically
conveyed through deportment, dress, and bearing, which serves to express
to those in his immediate presence that he is a person of certain desirable or
undesirable qualities’ (1967: 77). The term deference refers to ‘that compon-
ent of activity which functions as a symbolic means by which appreciation
is regularly conveyed to a recipient. . . .’ (1967: 56).
Case presentations as a professional ceremonial routine (Anspach 1990)
are also a good site for exploring the nature of collaboration between
practitioners of the two medical systems. Alternative practitioners regularly
joined biomedical doctors’ routine case presentations during their shifts. But
they appeared voiceless, compliant and accepting of their marginalised posi-
tion. Usually, during case presentations, alternative practitioners were part
of the group of residents following the senior physician, moving from one
patient to another and presenting their medical condition. In these rituals,
the hierarchy of power is visible in the participants’ manifestations of defer-
ence and demeanour. Residents present medical case histories before their
senior supervisors as part of their training. The bedside rituals appear to be
essential for the residents’ professional and self image (Anspach 1990).
Senior physicians are situated in a control position in the middle of the
circle, right by the presenter and close to the patient. Their central position
is marked by their confident possession of space and evident control over
the course of discussion, its form and contents (Goffman 1967). Control
over the professional conduct attests to the doctors’ dominant position. Their
demeanour is underscored by the complimentary deference on the part of
their professional subordinates, who usually take the position of the audience
around the outer circle. In one case, when an alternative practitioner who
was chatting with a patient noticed that a group of doctors was heading
toward the patient’s bed, she abruptly stopped her interaction with the
patient, moved away, and placed herself in the outer circle.
© Blackwell Publishing Ltd/Editorial Board 2005
36 Nissim Mizrachi, Judith T. Shuval and Sky Gross

Nevertheless, residents and medical students participating in the group are

expected to stay alert and occasionally participate in the group discussion,
primarily when a question addressed to the presenter was not fully
answered. Alternative practitioners usually position themselves outside the
group, occasionally close to the exit. During six months of observation, they
were never observed asking questions, voicing concerns, or participating in
any other way in the group discussion. While participating in the group
bestows legitimacy, their position away from the group marks their place as
outsiders.
Deference and demeanour, therefore, are visible expressions of symbolic and
social boundaries maintaining and perpetuating the hierarchy of power and
knowledge can be explored. Through these conceptual lenses, one can examine
the behavioural strategies of other actors in the field in relation to alternative
practitioners. The related Israeli studies (Shuval et al. 2002, Shuval and
Mizrachi 2002a) and our observations revealed an overall mutual respect
between para-medical and alternative practitioners. Nevertheless, both related
Israeli studies (Shuval et al. 2002, Shuval et al. 2002a) and the present study
showed that paramedics take precedence over alternative practitioners. On
several occasions, a physiotherapist, a nurse or a dietitian intruded upon an
alternative practitioner’s territory during a treatment session. These inter-
ruptions were accepted by all actors. Since paramedical practice is part
of the biomedical system of knowledge, its precedence over alternative
medicine is taken for granted by all actors in the hospital.

Behavioural isomorphism as a boundary-maintenance mechanism

A mimetic pattern of behaviour by which alternative practitioners copy the
structure and symbols of the dominant professional group in the hospital
further reinforces their legitimacy. The propensity of professionally subordin-
ate groups to follow organisational and behavioural patterns of the domin-
ant groups in their field is part of their attempt to achieve recognition and
legitimacy. Isomorphism is a form of behaviour often adopted by challengers
who seek to gain legitimacy in an organisation (Scott 1992)8.
Another manifestation of micro-isomorphic behaviour by alternative
practitioners is the way they follow the physicians’ ceremonial behaviour when
approaching hospitalised patients. During such encounters with patients,
they discuss the patient as a medical case, and refer to patients in the third
person (see Anspach 1990). The encounter between the patient and the
group of alternative practitioners appears to be a typical biomedical ritual
of case presentation (Anspach 1990). The senior practitioner presents the
case to the junior ones, as part of the professional socialisation process. The
structure of the conversation is typical of a biomedical intake in which
the senior physician monitors the question/answer form of conversation,
controls its content, and manages its course (see Mishler 1990).
Isomorphism is embedded in the division of labour as well. Despite the
fact that most alternative practitioners, whatever their field, take a holistic
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 37

approach to health-care, the biomedical setting in which they find them-

selves causes them to model their practice on the dominant structure of the
biomedical role, that is, specialisation in a narrow, clearly defined area of
practice (DiMaggio and Powell 1991).
Isomorphism is also present in the dress code of alternative practitioners,
which resembles that of physicians or nurses, and in the furnishings and
decor of their clinical settings, which are generally similar to those of their
biomedical colleagues. Their professional conduct is shaped by typical hos-
pital forms and practices. The medical records of patients are organised in
files to which alternative practitioners often refer as ‘cases’. The rhetorical
reduction of the patient to a medical case may be indicative of the effort of
alternative practitioners to emulate biomedical practice, which ironically
contradicts their fundamental holistic premise. Moreover, alternative practi-
tioners interact with patients in the hospital in forms that appear similar to
those of biomedical practitioners. On a micro level, these isomorphic pro-
cesses are part of a macro process of professionalisation that some alternative
specialties have undergone (Cant and Sharma 1996). The related Israeli
studies (Shuval et al. 2002, Shuval and Mizrachi 2002a) also indicate that
when there is more than one alternative practitioner working in the outpa-
tient alternative clinic, they are likely to have regular case conferences
modelled after biomedical clinical conferences (Shuval et al. 2002, DiMaggio
and Powell 1991, Meyer and Rowan 1991).
Through isomorphic forms and practices, alternative practitioners avoid
marking a visible territory within the biomedical field. These processes play
a role in mitigating the potential threat of the alternative medical system,
which in its pure holistic form may undermine the knowledge foundation of
biomedicine and its institutional division into different units of operation.

Spatial marginalisation
As the related Israeli studies (Shuval et al. 2002, Shuval and Mizrachi 2002a)
show, none of the clinics providing alternative care were located in the
physical centre of the hospital facility. All were placed either on the external
boundaries of a department, for example, at the end of a corridor, or at the
margins of the hospital, as in an outside building on the periphery of the
hospital complex. Goffman (1961) and more recently Fox (1992), Mizrachi
(2001b) and Shuval (1999) have pointed out the importance of space in
structuring interaction processes and relations, in both forming and reflect-
ing the prevailing power structure (Prior 1988, Mizrachi 2001b). In a sym-
bolic sense, the alternative practitioners may be said to be inside the hospital
and outside its central social and geographic space at the same time.
In the present case, the spatial marginalisation of the alternative medicine
team provides a visible expression to their symbolic status as aliens. Nurses’
stations are normally located in the middle of the hospital wards and doctors
have their rooms within the department: such geographic locations provide
visible expressions of the ‘inness’ of these actors within the bio-medical
© Blackwell Publishing Ltd/Editorial Board 2005
38 Nissim Mizrachi, Judith T. Shuval and Sky Gross

field. It is striking that the lack of a space of their own marks alternative
practitioners as being ‘out of space’ (see Mizrachi 2001).
In the same manner, the ‘spacelessness’ of the alternative practitioners
manifests itself in the storage place of their practice instruments. There is no
provision for the storage of devices used by alternative practitioners and
they are not stored in properly designated places in the hospital; space in
non-clinical, administrative offices is used for storing their equipment. The
tools of alternative medicine, symbolic icons of all medical practice, are kept
apart from other biomedical devices in the hospital, further contributing to
placing alternative medicine outside the hospital field.

Conclusions

The combined effects of growing consumer demand, economic factors and

market competition have provided the conditions for the entry of alternative
practitioners into the biomedical fortress. How does the biomedical profes-
sion contain its competitor within its own territory and at the same time
avoid overt conflict between the two systems? On the face of it, a competitor
has invaded the professional turf of a dominant profession. Alternative out-
patient clinics operated under the auspices of biomedical institutions and
alternative practitioners working with hospitalised patients are a relatively
recent phenomenon in Israel. The potential tension between two medical
systems sharing the same institutional space appears inevitable. Nevertheless,
there is no evidence of overt conflict between the two medical systems. The study
found no substantive debates at the epistemological level over the ultimate
truth-value of each system. Moreover, the physicians interviewed (all of whom
worked in collaboration with an alternative practitioner) expressed support
and respect for the alternative practitioners with whom they were associated.
By identifying the multi-dimensional, inter-relational and dynamic nature
of social and symbolic boundaries in the biomedical professional field, the
present study sheds light on the ways in which the medical discourse has
managed to exclude and include alternative medicine at the same time with-
out overt conflict or confrontation. It explores the tacit ways in which power
is exercised within a professional field by marking the boundaries of ‘truth’,
drawing boundaries between different forms of medical practice, and
controlling the ‘subjects who know’ (see Larson 1990: 32), namely the social
actors in the field. The study uses the term ‘boundary at-work’ to identify
these multi-dimensional processes of boundary demarcation by which
marginalisation and exclusion in the field enabled the biomedical discourse to
absorb the invaders while avoiding conflict or tension between the two systems.
Although these processes do not stem from a coherent viewpoint or a con-
scious decision made by authoritative figures in the field, they are dynamically
negotiated by social actors in the field. Nevertheless, their behavioural strat-
egies appear to be highly restricted by the boundary constraints in the field.
© Blackwell Publishing Ltd/Editorial Board 2005
 Alternative medicine in biomedical settings 39

During the tacit processes of boundary demarcation, the presence of

alternative practitioners has not required any overt process of negotiation
over the nature of alternative knowledge, or a precise definition of the scope
of its professional jurisdiction within the hospital. Similarly, biomedical
authorities have not been compelled to place alternative practitioners within
the formal structure or to define their position in relation to physicians and
other para-medical practitioners. These processes of exclusion are especially
striking in view of the fact that the practitioners under study were all
specialists in acupuncture, the most mainstreamed and legitimised of the
alternative specialties.
While economic factors and market conditions enabled the entrance of
alternative practitioners into the biomedical fortress, they did not provide
adequate conditions for a thorough epistemological integration of the two
medical systems, or even for negotiation over the hard-core professional
doctrines of biomedicine in the hospital setting. Scientific medicine contin-
ues to fuel the professional ethos of biomedicine by exercising its power
through tacit, multi-dimensional processes of boundary demarcation within
the professional field.
Address for corresponding: Nissim Mizrachi, The Gershon H. Gordon Faculty
of Social Science, Department of Sociology and Anthropology, Tel Aviv Uni-
versity, POB 390–40, Tel Aviv 69978 Israel.
e-mail: nissim@post.tau.ac.il

Notes

1 Primarily Abbott’s and Gieryn’s works.

2 In the other components of the inquiry, the authors focus on the historical
context and the organisational dimensions shaping the particular institutional and
organisational forms of collaboration in various clinical setting in Israel (Shuval,
Mizrachi and Smetannikov 2002, Shuval and Mizrachi 2005).
3 Alternative practitioners have been referred to as complementary, holistic, un-
orthodox, unconventional, natural and fringe (Bombardieri and Easthope 2000: 480).
4 See Shuval 1999.
5 The formal definition of the unit as ‘complementary’ can be regarded as a visible
institutional expression of the secondary epistemological rate of alternative
medicine.
6 See footnote 4.
7 This is Prof K’s terminology.
8 Isomorphism is associated primarily with DiMaggio and Powell (1990) who
referred to a widespread organisational phenomenon in the contemporary indus-
trialised world: organisations often reproduce similar organisational forms and
practices. The key term for this organisational behaviour is ‘institutional iso-
morphism’, which is defined by Hawley as the constraining process that forces one
unit in a population to resemble other units that face the same set of environmental
conditions (DiMaggio and Powell 1991: 66). This phenomenon was also described
© Blackwell Publishing Ltd/Editorial Board 2005
40 Nissim Mizrachi, Judith T. Shuval and Sky Gross

by Meyer and Rowan (1991: 41) who proposed that institutionalised products,
services, techniques, policies and programmes function as powerful myths, and
many organisations adopt them ceremonially. In this manner they practice ritual
conformity to the norms of the culture they seek to enter.

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