Hierarchy of Needs: Poor People’s Priorities

Comrades, I’m kind of obsessed with this hierarchy of needs. I keep thinking, if this particular tool had appeared circa 2005, about half of the writing, speaking, and video-making we’ve all done over the last 14 years wouldn’t have been necessary. When punks have complained, over and over, that conventional acupuncturists don’t “get it” — while also not being able to articulate what “it” is, to everyone’s ongoing frustration — most of the time, I think what we meant was, the hierarchy of needs.

Here’s to discussions being less frustrating, going forward.

It’s both difficult and emotional to communicate about what we can take for granted, especially relative to what other people can take for granted. Part of why I was thinking about Ellyn Satter’s pyramid was that I’ve always thought that I never had any issues around food insecurity, because there was always enough food in my house when I was growing up. Recently I realized that’s not entirely true. Having enough food in the house was accompanied by my father telling stories about what it was like for him as a child to not have enough food, to have to steal food, to eat the same foods over and over to the point that he never wanted to see them again which meant we never had them. (Mayonnaise on white bread.) And then I realized — I might not have experienced food insecurity myself, but it was a vivid reality to me nonetheless. I grew up not being able to take that first level of Ellyn Satter’s food pyramid for granted, and that remains a difference between me and people who never had to think about it.

If you can take something for granted, it means you don’t have to put effort into maintaining it. If you can take something for granted, it means it doesn’t require focus and perseverance. You don’t have to be grateful for it; heck, you don’t even have to be aware of it. And if you have to admit that you can’t take something for granted, especially relative to other people who can, you’re acknowledging that you’re a have-not and they’re the haves, that you lack social power. You’re admitting vulnerability.

I started writing about community acupuncture because I was finally able to admit that economic access to acupuncture, and economic stability in practicing acupuncture, weren’t things I could take for granted. The acupuncture profession had told me that I could and I should, but the enduring reality was that I couldn’t, which had everything to do with who I was and where I came from, but also the state of the acupuncture profession itself. And boy, was I mad about it, and boy, did my writing strike a nerve. Because of course I wasn’t the only one.

Remember the buckets and Ming vases article, and Peter Deadman’s response to it? In hindsight, there could have been a lot fewer words in that exchange (though I had fun with the metaphors) and a lot less emotion, because all we were really talking about was the hierarchy of needs.

In his response, Peter Deadman starts out by acknowledging: a lot of people can’t afford acupuncture and a lot of people can’t make a living at it. BUT — the rest of the article is BUT, (plus something really interesting at the end, that I’ll get to in a minute) a model that prioritizes access over theory risks impoverishing Chinese medicine. Our model isn’t best practice, and we’re not complete practitioners, and to the extent that we’re successful in propagating our model, it’s a loss for Chinese medicine as a whole.  One of his major problems with us is that we don’t make patients take off their clothes, and as a result, “a swathe of acupuncture points is largely consigned to oblivion”. In 2012 I was too mad to love this line, but I love it now, and I wish I’d remembered it during POCA Tech’s last site visit. POCA Tech, consigning back shu points to oblivion since 2014.

In other words: the acupuncture theory level of the pyramid deserves much more attention and focus than the economic access level. Yes, the economic access level is arguably a huge mess, but that doesn’t matter as much as getting the theory right. And if you prioritize the levels the way punks do, with economic access being more foundational than theory, you will impoverish the entire field of Chinese medicine. You could rephrase that as: the priorities of Chinese medicine will look like poor people's priorities.

And that’s why we call what we do Liberation Acupuncture.

And that’s where you get punks waving their hands in the air, stomping their feet and yelling Fuck yeah — that’s what we want! and you get conventional acupuncturists being like, What? no, that’s exactly what we don’t want! So even when you take the emotion out of the argument, we’re still disagreeing about fundamentals. Because of course, everybody would like to take economic access (to everything) for granted. What we’re saying is: that’s great that you can, but we can’t.

The end of Peter Deadman’s article is the most interesting part, to me. He writes that every patient, regardless of income or social status, deserves access to the best possible practice (which he defines as back-shu points, TCM differential diagnosis, and lifestyle counseling — we’ll skip the discussion about social safety for purposes of this post). The reason that community acupuncture shouldn’t succeed is that there has to be a better model, where you could treat just as many people, but you could still make theory your first priority. I think you could rephrase that as: what actually exists, and is providing relief to humans who need it right now, is less valuable than something that doesn’t exist but is ideologically purer. Or, you should be able to do better than that — which is something people with my background are used to hearing, about everything.

That particular argument doesn’t belong only to Peter Deadman and the people from his side of the aisle, so to speak. POCA gets that argument from all sides.

This many years into this work, I’m inclined to respond to that differently than I used to. The hierarchy of needs represents everything I don’t feel like arguing about anymore, so I’m inclined to respond: Okay. You’re probably right, that we should be able to do better than this.

The thing is, though — speaking for myself and WCA at least —  just doing what we’re doing, the way we’re doing it right now, takes everything we’ve got. We’re not talking about the difference between what we have now and a better version, we’re talking about what we have now vs. burnout and giving up, or what we have now vs. nothing. Because what we have now wasn’t easy to create, and it isn’t easy to maintain.

If you can take something for granted, it means you don’t have to put effort into maintaining it. If you can take something for granted, it means it doesn’t require focus and perseverance. You don’t have to be grateful for it; heck, you don’t even have to be aware of it. The people telling us we should be able to do better, are taking what we’re already doing for granted as a baseline to be improved on. It’s not fun to admit that we can’t take what we’re doing for granted, and that we don’t have the energy for improvement on top of maintenance; it involves admitting weakness, fatigue, vulnerability. There’s also no indication that anybody else is up for maintaining anything that looks remotely like our baseline.

Making acupuncture economically accessible to the number of people that we do is, all by itself, a lot, because it involves small business, and small business is very difficult. Doing small business for a decade or more means that it gets easier in some ways, but in other ways, it really doesn’t. (See: stamina.) It’s funny, I feel like I have to keep outing myself as somebody with low-class priorities: if it exists, and I can afford it/make it happen/keep it up, it’s more valuable to me than something “better” that doesn’t yet exist, and I'm even grateful to have it.

I can’t forget about the first level of the pyramid, physical safety, where it matters that acupuncture is so much safer than other forms of pain management. In 2016, more than 46 people died each day from overdoses involving prescription opioids. How many of them might never have tried prescription opioids at all if they had had access to acupuncture? Acupuncture that isn’t happening is acupuncture that can't save anybody’s life, as opposed to acupuncture that IS happening, and can.

But if somebody can make the better version of what I do actually exist, and people without a lot of resources can actually afford it, I’d love to take notes. That’s the purpose of POCA, to share the details of what works in reality. But until the better version has crossed the difficult barrier from ideal into reality, I’m just not interested in debating its merits, with Peter Deadman or anybody else. Make it real, and then we can talk.

Poor people’s priorities are actually pretty ambitious — who knew?

Author: lisafer

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Conference Keynote: Breaking the Ceiling

The theme for this conference is “Breaking Barriers”. You know, there are so many barriers to break in acupuncture that it was really hard to choose which ones to talk about for this speech. But since I’ve spent so much time talking about classism as a barrier, I thought it might be fun to shift gears a little and talk about numbers.


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  1. Thanks, thanks, thanks for this! I’ve been feeling the stamina pressures after re-locating our clinic and the great needle scare of 2018. Burn-out is stalking me, so these blogs really help me keep the faith and remind me that such difficulties are just part of it. I need to recalibrate my response to them. Yes, small business is hard, and sometimes it’s too easy for me to focus on what’s going wrong and not on the 100s of treatments we give each week that ripple out from individual lives into their communities to soothe and support others.

    Unsure of the Tan and Tung, but Deadman is clearly deep in the TCM mold, and still wants his massive, costly tome to be used in schools and absolutely essential to any “legit” practitioners education. Great example of the system assuring you that YOU NEED THEM to survive, to know. How freeing to realize you DONT!

  2. this reminds me of when a former acupuncture teacher told me that Community Acupuncture is okay but not suitable for anyone who has cancer. Fast forward a few years and then my co-workers and I find out that we get referrals from a local cancer treatment center. Lots of oncologists know that acupuncture helps people who are in treatment, but cancer treatment is very expensive. So again, safety and access win over theory and back-shu points.

  3. The whole thing with “purity” or superior acupuncture just cracks me up. How would anyone ever be able to actually decide the most valuable “style” of putting needles in someone? <> I was amazed at the various different styles of “superior” and super esoteric acu that I was able to observe. And they all worked. Even when their theories of how to stick tiny needles in people were diametrically opposed.

    Our rooms full of healing folks that leave with a bit more ease make me feel like we doing damn good.

  4. My only experiences with acupuncture since I was licensed has been CA and now my hybrid. I practice TCM theory- Zang-Fu, 5E and I do it distally, clothes on and it WORKS. I don’t use Tan or Tung, I add more theory when patients want and need it- and I do it all in an affordable clinic $20-$40. The idea that theory is lost in a CA clinic just isn’t accurate.