3 Key Concepts of Liberation Acupuncture
Dr. Paul Farmer, one of the founders of the global health organization Partners in Health, wrote an essay, "How Liberation Theology Can Inform Public Health", about applying the key concepts of liberation theology to medicine. These key concepts – Preferential Option for the Poor, Structural Violence and Accompaniment – are illuminating for those of us trying to define how liberation acupuncture functions as a school of thought.
Preferential Option for the Poor
“The first notion is the preferential option for the poor. Any serious examination of epidemic disease has always shown that microbes also make a preferential option for the poor. But medicine and its practitioners, even in public health, do so all too rarely. Imagine how much unnecessary suffering we might collectively avert if our health care and educational systems, foundations, and nongovernmental organizations genuinely made a preferential option for the poor?”
One of acupuncture’s most striking aspects is its sheer simplicity. Its basic requirements, as POCA acupuncturists like to say, are needles, cotton balls, and stillness. None of those elements costs much. Acupuncture could be a particularly beautiful therapy for marginalized people because it is possible not only for them to afford it, but even to own the means of production. The preferential option for the poor requires us to ask ourselves what stands in the way of acupuncture in North America belonging to people who have little or nothing.
It seems that what acupuncturists tell themselves that they are doing and why (and the structures they create as a result) are what makes acupuncture expensive and out of reach for the marginalized.
According to Paul Unschuld’s Medicine in China: a History of Ideas, “the origin of acupuncture in China is not clear.”( p.94) It is described for the first time in a document dated to 90 BC. Equally unclear is where the knowledge of acupuncture points originated. How those points were chosen and used undoubtedly changed over time; at some point “a system of cosmological correspondences” was apparently suddenly imposed over practices based on empirical use.( p.96). This system of correspondences was developed by unknown authors in the course of the last three centuries BC, and its theoretical principles closely tracked those of the socio-political order promoted by Confucian political ideology.( p.67)
The philosopher Confucius responded to the widespread social and political conflicts of the Spring and Autumn period of Chinese history by creating a system of ethics (sometimes referred to as a nontheistic religion) based on precisely defined social roles and mutual obligations. Some of his principles are universal and timeless: for instance, he formulated a version of the Golden Rule. Many, however, are very specific to the society of his time, such as loyalty to a morally upright ruler, filial piety, and observance of a set of rituals including ancestor worship. Confucius envisioned a perfectly harmonious society based on a firmly established hierarchy. Similarly, the cosmological correspondences imposed on the practice of acupuncture were based on principles of how human beings could live in harmonious relationships with natural phenomena. For example, the image of acupuncture meridians transporting nourishment throughout the human organism in the form of qi “...reflects a transfer of the vital importance of waterways to the state.” ( p.83) Irrigation engineering was a major responsibility of the government throughout Chinese history; similarly, the principles of clearing blockages and draining flooding, of balancing excess and deficiency and regulating the flow of qi in the meridians, became central to the theory of acupuncture practice.
Confucius was certainly progressive relative to the feudal society he was trying to improve. For example, he championed the previously unheard of concept of meritocracy and he insisted on the obligations of the rulers to those that they ruled. For our purposes, however, it would be hard to claim that his philosophy reflects a preferential option for the poor. The transfer of Confucian political ideology to an understanding of how healing functions and how acupuncture works must be seen within the context of a particular society at a particular time, rather than universally helpful in all situations, particularly those involving illness and inequality.
If Unschuld is correct, acupuncture practice existed before acupuncture theory, and the theory we have now did not arise out of the practice. There is daylight between them. We should make use of that daylight for critical reflection on our current practice.
The text that Unschuld describes as “the classic scripture of acupuncture treatment” is the Yellow Emperor’s Classic of Internal Medicine or the Nei Jing. Parts of it may date from the second century BC. It is composed of 81 “heterogeneous and partly antagonistic texts” ( p.78) which, Unschuld says, “should not be approached as a classic from which one may distill a homogeneous set of ideas based on stringent concepts and terminology.” ( p.58) The Nei Jing is the source of most of the acupuncture theory that is taught in North America today and unfortunately, Unschuld’s recommendation seems to be mostly unheeded. Many schools and acupuncturists approach the theories found in the Nei Jing as if they were scripture – sacred, irrefutable, ahistorical wisdom, free of political bias and social context.
A prominent feature of the acupuncture profession in North America, particularly the US, is turf warfare. Licensed acupuncturists spend a lot of time being indignant about physical therapists, chiropractors, and MDs doing acupuncture, or so-called “dry needling”, without training in the theories laid out in the Nei Jing which constitute a large portion of acupuncture education. They claim that acupuncture is part of a complete system of (Confucian) medicine, not merely a modality or an intervention that can be safely practiced without those theories. The history of acupuncture itself would seem to contradict this position.
The question is: to whom does acupuncture belong? Can anyone now living own it, or assert the right to control its parameters?
Given that no one can claim to have invented acupuncture, and its origins are altogether mysterious, it is reasonable to make the case that the practice of acupuncture is part of the commons – something that cannot be privately owned or controlled. As one advocate of the commons wrote, “The common can be built and expanded, and it can never be fully enclosed because there are parts of human experience that cannot be turned into property and have to be held in common. Compassion, ideas, social relationships, and the planet itself must be held in common." Acupuncture has proven its adaptability and mutability across centuries and continents; it would be a mistake to try to enclose it.
It would seem that modern-day practitioners of acupuncture have made a choice to define the practice of acupuncture as something complicated, something to fight over. We could also choose to define it as something simple, something to share. Approaching these issues from the perspective of a preferential option for the poor instead of from the perspective of turf warfare, we could – with equal justification – claim that if acupuncture belongs to anyone, it belongs to the people who need it the most, the people with the fewest resources, the people for whom its simplicity makes it uniquely accessible. In short, the preferential option for the poor represents a compelling moral argument that poor people have first claim on acupuncture and whatever method gets it to them, in a way that they can use it, should be embraced.
“The second (key concept) is the notion of structural violence. Sure, bad things happen. But they don’t often happen randomly. Violence is done to some people in this world by poverty, racism, gender inequality, homophobia, and xenophobia. Just as this violence, which Gutiérrez and others term structural violence or “structural sin,” can be institutionalized through unjust social arrangements, so too can it be undone with the help of more just ones.
The secular world needs to understand that what would “free us from all anxiety” is opening up to the poor and otherwise marginalized the chance to flourish. This cannot happen if there is hunger, unfair political arrangements, ongoing assaults on the environment, and no safety net to protect the sick, the unemployed, and the frail. The current rules of modern capitalism cannot rid us of structural violence any more than wars or other forms of “event violence” can. But understanding how the social worlds in which we live are constructed might help us to do so, as can the mystery of hope.”
As one acupuncturist observed about working in a community acupuncture clinic, “What you see is how the violence of our current economic system is written on our patients' bodies and minds.” Structural violence is made visible in repetitive strain injuries from grueling minimum wage jobs; in back and neck pain from standing all day long in service industries; in migraines and irritable bowel syndrome caused by financial anxiety; in chronic pain from years of overwork; in depression and addiction triggered by hopelessness. While much of “alternative medicine” strives to locate the cause of disease and distress within the individual, making it a matter of individual choice and control, liberation acupuncture's perspective arises out of years of work in low-cost, high-volume clinics where the overwhelming impact of social factors on suffering is inescapable.
The concept of structural violence also requires us to interrogate how unjust social arrangements are institutionalized in acupuncture practice in North America and how these arrangements might be undone. It also requires us to reflect on the role and the state of our professional institutions, particularly their relationship to the vulnerable and excluded in society.
Obviously, acupuncture predates capitalism. The practice of acupuncture in a capitalist society is not a topic on which the Nei Jing is going to be able to advise us, and will require not only critical reflection but resilience and creativity. We have to take an honest look at the way acupuncture — and the acupuncture profession in North America — functions in capitalism, because capitalism is continually shaping our social arrangements and our institutions.
Acupuncture in the US is profoundly influenced by two major forces represented by third parties outside of the acupuncture profession itself: the insurance industry as a pillar of the for-profit healthcare system, and the federal government which provides the student loan funding that most acupuncture schools depend on. These third parties are deeply involved as a consequence of the cost of both acupuncture treatment and acupuncture education being much too high for most people to pay out of pocket. Acupuncturists accept their involvement since it is framed as making both acupuncture treatment and acupuncture education “more accessible”; the reality, however, is not so simple.
Insurance coverage for acupuncture is very limited, highly variable, and for the most part, closely tracks the socio-economic status of the insurance consumer. People with more resources have better insurance, which is both more likely to cover acupuncture and to cover more treatments for a wider range of conditions. In Oregon, Medicaid “covers” acupuncture, but for an extremely limited range of conditions that periodically change according to state policy. People on Medicaid are required first to get their primary care provider to approve their acupuncture treatment; this gets them three treatments. By jumping through more bureaucratic hoops, they may be able to access a maximum of ten treatments. In contrast, people in Oregon with more expensive insurance may access an unlimited amount of acupuncture treatments for a wide range of conditions for a $30 co-pay, with no prior approval needed. Given that people on Medicaid probably need acupuncture treatment more than people who have enough disposable income to buy good insurance, “insurance coverage” does not change the reality that access to acupuncture is mostly based on socioeconomic status.
Most of the treatment protocols that US acupuncturists learned from Asia rely on courses of treatment, and a course of treatment can be anywhere from 10 to 100, delivered not less than a week apart, depending on the condition. Using one treatment when ten are called for is like taking one pill out of a course of antibiotics and expecting it to work. Many insurance companies, even if they “cover acupuncture”, will not pay for a full course of treatment.  Acupuncture is uniquely useful in the treatment of chronic conditions such as diabetes, which can require multiple treatments per week for as long as the condition exists. If the cost of treatment is so high that most people can only be expected to access it through third party payers, and if those third parties will not pay for enough treatment to be clinically effective, the structure of the profession is arguably harmful as well as self-defeating.
Liberation acupuncture demands that its practitioners both confront and create institutions. We desperately need new social and economic structures that are based on inclusion. Individual efforts by individual practitioners are not enough to address structural violence in our sphere. Creating new social and economic structures is a collective project and it is not separate from healing.
“The third notion is accompaniment. The power of this simple idea, a staple in liberation theology, came to me in contemplating patients facing both poverty and chronic disease. They missed appointments, didn’t fill prescriptions, didn’t “comply” with our counsel. And this was true in every country in which I’ve worked. But when we began working with community-health workers to take care to patients, the outcomes we all sought were much more likely to happen. Instead of asking “why don’t patients comply with our treatments?” we began to ask, “How can we accompany our patients on the road to cure or wellness or a life with less suffering due to disease?” Again, the notion would be welcome in the world beyond the church: How many institutions, including those responsible for foreign aid, desperately need to replace time-limited, contractual, and almost invariably inegalitarian arrangements—the aid worker and the aid recipient—with genuine accompaniment and solidarity? My guess: almost all of them.”
Liberation acupuncture is interested in how power, and the lack thereof, affects people’s health – particularly social power. Alongside the question of social power is the question of power over illness and disease. The most common question that people ask about acupuncture is, Does it work for ______? Does it work for arthritis, for migraines, for fertility? The reality of clinical practice is that it depends on the person. Often acupuncture works for arthritis, for migraines, for fertility – for any of the conditions on the long list that the World Health Organization created for the purpose of answering that question. [See page 29 of the PDF.] But sometimes it doesn’t, and we don’t know why. This is true of all medical interventions, not just acupuncture: nothing works for everybody and nothing works all the time. Sometimes the question people ask about acupuncture is simply, does it work? Either way, it’s a question about power: does acupuncture have power over illness and disease?
Much of the success of modern biomedicine has to do with its ability to answer the power question in an absolute (or mostly absolute) way. There is a reason that China embraced biomedicine so enthusiastically despite its long cultural tradition of acupuncture: biomedicine is spectacularly effective. Vaccines have all but eradicated polio; antiretrovirals transform HIV from a terminal disease into a manageable chronic illness. Power has its downside, of course. Antibiotics work – they work so well we’re dangerously overusing them. Opiates work – they work so well we’re facing an epidemic of overdoses.
Sometimes acupuncture acts like a powerful biomedical intervention. For some individuals it inarguably works better than drugs or surgery. There are people who will tell you that they tried both acupuncture and conventional biomedicine for a certain problem, and acupuncture worked for them while biomedicine didn’t. More often, though, acupuncture is not more powerful than opiates or antibiotics or surgery. It just isn’t. (This is why acupuncture doesn’t have side effects – that’s the trade off.) Liberation acupuncture holds that conventional power over illness and disease is not why acupuncture is valuable to modern society.
Physical, mental and emotional suffering in modern society is not identical with conditions that biomedicine can reliably overpower and dismiss. Nor are they identical with conditions that acupuncture can resolve; however, there is a large overlap with conditions that acupuncture can relieve either in a direct or an indirect way. Furthermore, acupuncture can often change someone’s relationship to their illness or disease. The issue of placebo and liberation acupuncture is a topic for another essay, but the point is that in real people’s lives, as opposed to in a lab, everything can’t be reduced to “it works” or “it doesn’t work”. The question is more often, does the person feel better, and does acupuncture help them bear what can’t be fixed? Does it help them enough that they consider it significant? This is where the concept of accompaniment becomes useful.
As much as many acupuncturists want to claim the social power that doctors hold, we can’t claim an equivalent power over the functions of the human body. Drugs and surgery can force change. Acupuncture can only gently encourage it. It’s an elegant, ancient form of palliative care that every suffering person deserves access to – but it’s not an equivalent to biomedicine. And that’s not a bad thing.
Many people come to acupuncture after frustrating experiences with biomedicine. These experiences include: being told there is nothing that can be done for a particular problem, so you’ll just have to live with it; being told a problem is psychosomatic or “a stress response” so it’s all in your head; being labeled as a difficult patient for balking at a suggested treatment with questionable outcomes and serious side effects. If your problems are not a good fit with the categories of biomedicine – and many, many people’s problems aren’t, no matter where they fall on the spectrum of “psychosomatic” to “terminal” – biomedicine has little to offer you. Meanwhile, you still have your problem; just because biomedicine dismisses it doesn’t mean that it goes away for you.
Liberation acupuncture holds that people should not be left alone with their suffering, because isolation will compound it. It is likely that the epidemic of overtreatment in biomedicine has a lot to do with people’s need to do something – something that resembles help even if it actually makes the condition in question worse than it would have been without treatment. Doing something seems better than being left alone to suffer.
The role of a liberation acupuncturist is to accompany people in their experience of stress, pain, disease, and illness. Even when there is no power-over to be claimed – and especially when there isn’t – acupuncture can offer relief, support, comfort, and clarity. Our capitalist society tends to reject and isolate people who are suffering. A liberation acupuncturist chooses to be in relationship, in solidarity, with them. The capitalist healthcare system seeks not only to marginalize those people but to profit from their pain. Liberation acupuncture rejects the profit and claims the relationship. This kind of accompaniment re-humanizes not only the patient but the practitioner as well.
Perhaps the most crucial aspect of accompaniment in liberation acupuncture, though, is the way that delivering acupuncture in a social context creates the opportunity for people who are suffering to offer accompaniment to each other. People who receive acupuncture in a community context are not passive recipients; they are helping to create an environment of healing for other people to tap into. Everyone’s presence is a contribution, and the patients’ contribution is as essential as the practitioner’s. Liberation acupuncture holds that acupuncture’s value to modern society lies not in having some special power over illness or disease, but in the power to re-humanize each other through relationship.