Dear Peter Deadman,
thank you for your response to my article — and thank you for publishing my article in the first place. There are plenty of people, some of whom are my friends, who feel that this kind of exchange is pointless, but I don’t agree. I think our conversation is getting more productive all the time.
We don’t know each other as individuals, which probably helps, because I don’t think this is just a debate between individuals. You and I represent two different generations of acupuncturists in the West. There’s a lot going on and not all of it has been put into words yet. This is a good opportunity to articulate the conflicts more clearly, which is what I’m going to try to do in this letter. You kindly described what I do as “bravely and vigorously addressing the elephant in the room”, meaning, the dismal economic reality of the acupuncture profession in the West — both for practitioners and for patients of ordinary incomes. However, that’s not the only elephant in this particular room. After reading your response, I realized I missed a couple. OK, a few. You know the joke —
Q: How can you tell that you have elephants in your refrigerator?
A: Their footprints are all over the butter.
A close reading of your response reveals elephant footprints on every page, as well as a couple of paragraphs that were trampled flat. I’m going to work backwards from the footprints to identify the elephants.
Elephant #2: Proof, or the lack thereof.
We have absolutely no evidence that any type of acupuncture — including sham acupuncture — works substantially better than any other kind. This elephant peeks out of one of your footnotes: “Acupuncture — as a complex intervention — seems to benefit from an unusually strong placebo effect. It appears that a high proportion of patients — at least fifty percent — will get clear improvement whatever system of acupuncture is used (including sham treatment). This means that all acupuncturists, whatever style they use, are able to report positive results, and whichever kind of needling they do, they can claim that ‘the needle does all the work’. However it also means that the challenge for practitioners is how best to benefit those patients who are not such easy responders.”
But let’s get that elephant all the way out in the open. There are no rigorous studies comparing the efficacy of different styles of acupuncture. You have absolutely no proof that the style of acupuncture that you promote will, in reality, offer more benefits to the “patients who are not such easy responders” than the style of acupuncture that I promote. You claim that spending more time on pattern differentiation, needling points on the torso and on the back, and talking to patients about their lifestyles yields better results; I claim that offering simple, possibly repetitive distal treatments with frequency and regularity yields better results. Neither of us can back our claims with anything but anecdotes. And unless you deployed a team of researchers to my clinic and I didn’t notice them, like those elephants in the refrigerator, you don’t know anything at all about who benefits from community acupuncture, and to what degree.
There’s an immense amount that we don’t know about acupuncture, and even more that we can’t prove. I think acupuncturists in the West have historically avoided this elephant because we are afraid of conceding anything to “quackbusters” like Edzard Ernst. But it doesn’t help us, collectively, to refuse to know all that we don’t know. My generation needs to face this elephant and talk about what it means to practice acupuncture in the West, to be in a profession that trusts in so much that is invisible and unproven while living in a culture that demands proof. Pure research in any field is chronically underfunded, and since there is no patent on acupuncture and no prospects for it to benefit any pharmaceutical companies, we should not expect the mysteries about what we do to get cleared up for us anytime soon.
While I was charmed to learn that I can consider myself the spiritual descendent of itinerant tooth-pullers and worm-expellers (who wouldn’t be?), I’m also a little skeptical. “(W)hile (the itinerant doctors) may have provided some level of medical care to a population that had no alternative, there were many kinds of disorders they were unable to treat effectively.” Can you document their failures? Is there a list of names, dates, specific conditions treated, and outcomes? With a control group treated by the scholar physicians? If I were to insist that the itinerant doctors were simply given a bad name thanks to the classist discrimination of the scholar physicians who wrote the histories, could you prove me wrong? How? These aren’t rhetorical questions. If you have genuine proof that one type of acupuncture has ever worked better for certain conditions (which ones?), everybody in the profession needs to see it.
In referring to acupuncturists that you approve of, you write: “they used the concepts and theories of Chinese medicine, interwoven with their vast experience, to offer patients invaluable information about why they were ill and what they might — in their own lives — do to help themselves. For they knew that in many cases, unless life habits or mental attitudes changed, treatment would only have a short-lived effect, and over time more serious disease would arise. Footnote: Hence the Nei Jing Su Wen’s famous statement that the wise doctor treats/helps at the earliest possible stage..” This sounds wonderful, but there are elephant footprints all over it.
Acupuncturists in the West are taught to treat the Nei Jing Su Wen with the same reverence that fundamentalist Christians treat the Bible — and to take it just as literally. Many acupuncturists, like fundamentalists, uncritically apply a sacred text/ historical document to the problems of an entirely different culture thousands of years later. The Nei Jing Su Wen was written at a time when few acupuncture patients could take for granted access to clean water and adequate food; forget about toilets, central heating, emergency rooms, and antibiotics. The context of the Nei Jing is profoundly different from our context; our patients have different problems. Yet in my modern Chinese medical education, nobody ever talked about what these differences might mean, clinically. I graduated knowing exactly how to treat dysentery and running piglet syndrome, and knowing exactly nothing about how to treat patients with real-world limitations of time and money. Holding up classical literature as gospel truth is not a good way to handle the proof elephant.
The concept of being able to provide treatment before disease actually arises sounds fabulous, but can you prove that it works? In which cases, precisely, do life habits and mental attitudes cause more serious disease over time, and what diseases do they cause? That’s not a rhetorical question, either. Certainly there are diseases like diabetes which (sometimes) can be reversed by changes in diet and exercise, but does the Nei Jing’s famous statement apply to schizophrenia? How about rheumatoid arthritis? Parkinson’s?
This idea, that serious disease could have been prevented if a patient had only cleaned up his diet and his thinking, can cause a great deal of distress for patients with chronic or terminal illnesses. I’ve met dozens of patients who believed passionately in natural healing, who made every conceivable lifestyle improvement and mental adjustment, and who suffered and died anyway. Some of them died feeling they had failed. I’m not saying that lifestyle changes are always pointless, or that they don’t help people sometimes. I’m saying, everybody dies of something. Have you done a 10 year follow up study on the patients who changed their life habits and their mental attitudes, and determined that they are all alive and disease-free?
Elephant #3: Authority.
You are speaking with a lot of authority when you write: “So it wasn’t until the twentieth century that some kind of ideal of best practice was established — in both Western and Chinese medicine. By that I mean that every patient, no matter what their financial status or where they lived, would receive the best possible care from doctors trained to the same level in specialist schools. We modern practitioners of Chinese medicine benefit from this best practice education — a mix of basic Western medicine, the theory and practice of acupuncture and Chinese medicine derived from the scholarly tradition of the literati, and a whole range of new and old techniques — many of them empirical and intensely practical.”
Let’s set aside, for now, the fact that many of us who were trained in Western acupuncture schools would strenuously beg to differ about the actual quality of this “best practice” education, especially the basic Western medicine and the practical techniques. Who established the ideals of best practice for Chinese medicine in the West, how, and on what basis?
Please forgive me: having questioned the Nei Jing’s authority, I’m going to question yours. And the authority of the generation that you represent. Those of us who have been acupuncturists for a long time are painfully aware that acupuncture in the West owes a great deal to murky traditions, questionable academic degrees, and self-appointed experts. It’s hard to know whether or not anyone ever really knows what they’re talking about, because so many people just make things up. You can justify almost anything with “my teacher said” or “my teacher did it this way”. That’s another elephant in the room.
In your response to me, you wrote that after having spent time working in a multi-bed clinic in China, you recreated it at home. “When I returned to the UK I set about trying to copy this model as best I could, with three curtained-off couches in my treatment room and an acupuncture student as an assistant. I operated a flexible sliding fee scale and did my best to get patients to come at least twice a week. Following Dr. Xiao's example, most patients received full-body treatment on the front and back, alongside moxibustion and cupping.” You didn’t say how long you operated this model, how satisfied you or your patients were with it, why you stopped doing it, and what happened to your patients when they could no longer receive care from you. Did someone take over your practice? How is the clinic you founded doing today? For those of us practicing community acupuncture currently, this is crucial information. Was your example of “best practice” in a sliding scale community clinic sustainable, or not? In your interview with Eric Grey of Deepest Health, you said that you stopped practicing after your book became successful. In the context of that interview, where you referred to practice as “hard slog”, it sounded as if you were glad to replace your clinical work with playing in a klezmer band.
Many of the authorities of your generation have been happy to replace their clinical work — if they ever did any at all — with scholarship, teaching positions, consulting, and various forms of acupuncture entrepreneurship. In all of these occupations it’s possible to avoid the troubling gulf between how acupuncture is described in textbooks and how it works in the real world, with real people. Unless that gulf is addressed honestly, however, those of us who treat hundreds or thousands of patients a year in the West are not likely to readily accept your advice about how we should practice.
Q: What’s the difference between an elephant and a dozen eggs?
A: If you don’t know, I’m not going to send you to the store for a dozen eggs.
You suggested I’m brave for thinking the needles do all the work. Maybe we mean different things by “work”, and also, “brave”. What do you think acupuncture does, really? What are realistic expectations for patients receiving acupuncture in the West, and for practitioners providing it? Intoning passages from the Nei Jing doesn’t help.
I’d like to suggest that it’s quite brave – no, reckless — to think, in the real world, that you can help prevent garden variety Liver Qi Stagnation from turning into inflammatory breast cancer — just to choose one example of pattern differentiation that I heard a lot about in acupuncture school. My last patient with inflammatory breast cancer contracted TB as a child and had dozens of chest X-rays before she was 18. Should I be implying to patients like her that my lifestyle counseling, based on the wisdom of Chinese medicine, could have saved her from serious disease, if only she had consulted me in time? Never mind all those years of radiation. Should I be warning patients with premenstrual moodiness that if they don’t learn to relax — maybe run and sing a little — they’ll get breast cancer? Never mind that some of them are single mothers with grueling minimum wage jobs who only relax while they’re getting acupuncture. Is that truly best practice in the real world? Is it even useful at all? How about just making sure the patient got enough acupuncture to control her nausea and anxiety so that she could get through her course of chemotherapy?
Which is what we did, and it worked; she’s in remission. But just making it possible for her to get acupuncture as a palliative treatment was a challenge, since she lost her job and her income when she got sick. Community acupuncturists encounter patients like her all the time. The luminaries in our profession have not had much to say about them that has been helpful to us. Sometimes, in fact, the luminaries end up sounding like heartless jerks. Is that because the luminaries didn’t treat as many people as we do?
Elephant #4: Privilege.
This isn’t just one elephant, it’s a herd.
Q: What’s the difference between a herd of elephants and a bunch of grapes?
A: Grapes are purple, elephants are grey.
Scholars of elephant jokes claim that they are basically about dissestablishment, and rooted in the counterculture of the 1960s. Some believe that they are a flimsy disguise for anxiety about both the sexual revolution and the civil rights movement. I love elephant jokes, and it’s sad to think that they might be one more way for white people to avoid dealing with race. It’s not like we needed another one.
White acupuncturists in the West don’t talk about the fact that for most of us, studying acupuncture was basic and unapologetic cultural appropriation. That’s a function of white privilege, of course. We can adopt cultural practices that appeal to us, while remaining blissfully unaffected by — and even unaware of — the history of vicious racism directed at Asian people in the West. For example, 51 years before I enrolled in the Oregon College of Oriental Medicine — not even one person’s lifetime — 4,500 Oregonians of Japanese descent were rounded up and put in internment camps. While I studied Japanese acupuncture and self-cultivation through calligraphy at my modern acupuncture school, nobody ever mentioned the problematic historical backdrop to my studies, and I never thought about it. I never had to.
White acupuncturists in the West don’t talk about Orientalism, or the way that the West likes to fetishize and objectify Asian cultures and Asian people. Why does acupuncture in the West so often look like something to display — a diploma hanging on a wall — rather than something a person uses to help her neighbors? Why do so many acupuncturists in the West seem so concerned with cultivating themselves, and so uninterested in actually treating patients? Also, are you trying to fetishize my bucket?
Race is one aspect of privilege; then there’s class. My colleague Larry Gatti wrote an excellent blog post about the class cultures on display in this exchange between you and me. I think it explains a great deal, and I’d be thrilled if you — or anybody else in your generation of practitioners — read it.
My generation needs to face the privilege elephants, just like we need to face the proof and authority elephants, because they have so much invisible impact on our relationships to patients. Every day in the clinic we encounter patients who have less privilege than we do. We white acupuncturists took something from another culture, and we have a responsibility to look at all of the issues around that: particularly the responsibility that falls on us because we possess a technology that could help so many people who have few other resources.
In your response to me, you cited a criticism of community acupuncture — and especially my writing — that I’ve heard frequently. “The implication and sometimes overt statement that runs through the article is that community acupuncture's way is the right, the only way, to practise.” Actually, I didn’t say that in my article and I’ve never said that anywhere else. In fact, I said “turning off acupuncturists who think they share our values is a conscious goal for us: we do not want to persuade people to do what we do.” I did say that community acupuncturists are passionate about rooting acupuncture in the West. It’s worth looking at how privilege functions to turn our passion into accusations of being dogmatic, absolutist, and dictatorial.
Community acupuncture IS the only way to practice if you want to treat working-class patients consistently, sustainably, and without making them the objects of charity. For a lot of us, that means it is the only way to practice, period — because we can’t stand to exclude those patients, who are often our neighbors, friends, and family. We believe that acupuncture can’t be genuinely rooted in the West when it excludes the majority of people of ordinary incomes. The reality, however, is that many acupuncturists in the West don’t want to treat working class patients. It’s simply not a priority. If it were, the entire profession would look utterly different. Many acupuncturists are perfectly comfortable with their class privilege and how it plays out in their practices. We acupunks are not saying that everyone should practice the way we do. We are saying if you practice conventionally, you tolerate a lot of exclusion in your practice. Everyone tolerates exclusion in their practices; the community acupuncture model, for instance, does not include indigent people who depend on public assistance. Instead of complaining that I am imposing a rigid blueprint on “our shared acupuncture future”, you could simply acknowledge that you and your generation of practitioners have had other priorities than including working-class patients. That would be honest.
It’s a function of privilege, however, to refuse to acknowledge your privilege. It’s a function of privilege to believe that your viewpoint, circumscribed by class and race, is objective and impartial. And it’s a function of a lot of privilege to end your article the way you did: to call for a practice model that transcends the limitations of community acupuncture and presumably allows “every patient, no matter their financial status” to receive the kind of care you think they should have. Those are the emptiest words I’ve ever heard in my two decades as an acupuncturist. Who is going to create and implement this model? How will it be funded? Would you be willing to stake your livelihood and access to care for patients in your community on its success, as we have?
The effect of your article in the real world, for people who can’t see elephants, will probably be to discourage acupuncturists from practicing community acupuncture. Of course, part of my goal in writing my original article was to do the same thing, as I said, but I have to object to the way you have joined me. I’m trying to discourage acupuncturists from practicing community acupuncture if they don’t accept the sacrifices and limitations that it involves. You are discouraging acupuncturists from practicing community acupuncture by holding up a better alternative — the only problem is, it doesn’t exist. Are you trying to be whimsical?
Q: Why do elephants wear shoes with yellow soles?
A: So you can’t see them when they float upside down in a bowl of custard.
Q: Have you ever seen an elephant floating upside down in a bowl of custard?
A: Of course not. It works!
Your generation of acupuncturists in the West brought the four elephants of the acupuncture profession into the room: economic dysfunction, the problem of proof, self-appointed authorities, and unexamined privilege. My generation can’t send them back. The community acupuncture model is a creative way to live with them. (So is making jokes.) We don’t make promises about what acupuncture can do that we can’t prove; we let patients use acupuncture however they want to, and decide for themselves. We don’t claim to be authorities. We try to include as many people as we possibly can. We make ourselves accountable to our communities by depending on them for our livelihood.
When your comments on community acupuncture in the Deepest Health interview surfaced, several of us wrote responses on Prick, Prod and Provoke, which is POCA’s blog:
As I wrote in one of those posts, this exchange with you has helped me see more work that the community acupuncture movement needs to do. Most importantly, we need to define “best practices” for community acupuncture — because your best practices are not ours. We particularly need best practices that address the four elephants. After a certain point, we shouldn’t be defending ourselves against charges of betraying and diminishing the medicine. We should be defining the terms in the first place.
Thank you for the stimulating conversation.