Social Justice, Medical Aid, and Acupuncture Part 2: Sustainability.

How does acupuncture fit into the medical voluntourism spectrum? I would argue that some of the problems posed by Part One of this topic can be eliminated or adequately addressed by the use of acupuncture and associated therapeutic modalities. The nature of this medicine allows greater mobility, ease of information sharing, and lower overhead cost than allopathic medicine. I also argue that it can be more easily integrated into the social structures of diverse cultures than the technology-heavy and iconized allopathic medicine. This is not to say that acupuncture and associated modalities can completely replace allopathic medicine, but its practical application may create a more positive cost-benefit picture.

From the Acupuncture Without Borders (AWB) website:

While modern medical treatment remains indispensable in a great number of the conditions encountered in developing countries, the cost of medication and the lack of medical supplies mean that any efficient way of replacing prescriptions provides a welcome element in healthcare management.

AWB is therefore dedicated to offering a complementary therapeutic tool for existing local medical practice, whether modern or traditional. Acupuncture very often makes the prescription of drugs redundant, and only indispensable medications need be paid for.

Statistical data collected by AWB have shown that acupuncture could efficiently treat some 60% of the pathologies seen in dispensaries (this figure does not include minor surgery or dressing of wounds).

All Acupuncture Without Borders Centers are thus committed to collaborating and promoting exchanges with any organization sharing similar objectives. The benefits of collaboration and complementary actions in the field of humanitarian work are self-evident.

AWB aims to contribute to the development of greater self-reliance in the field of healthcare for disadvantaged peoples, by offering healthcare practitioners training and therapeutic practice in acupuncture. AWB acts in a spirit of solidarity, respecting the culture and the dignity of the populations concerned, and is committed to a policy of non-interference.

Acupuncture Without Borders in Burkina Faso

To this end, AWB sponsors missions in developing countries by volunteer acupuncture practitioners, with the aims of:

– sharing their knowledge with local medical practitioners (doctors, nurses, midwives, medical assistants, and so on), by imparting a theoretical and practical grounding in acupuncture.
– providing teaching media: books, manuals, acupuncture charts, etc.
– providing essential acupuncture equipment: needles, moxas, sterilizers, etc.
– ensuring delivery and correct use of the equipment.
– maintaining a long-term follow-up and evaluation of the training as part of a primary healthcare program.

Acupuncture Without Borders works solidly within the recommended guidelines for creating socially just and ethical medical aid. Acupuncture presents several areas in which it can excel as compared to allopathic medical aid, and a few areas which face the same problems as allopathic medical aid. I will outline my understanding of these below, using the guidelines set forth in Perceptions of short-term medical volunteer work: a qualitative study in Guatemala.

Danger areas in which acupuncture excels as complementary medical aid abroad:

1. The risk of medical interns and volunteers practicing beyond their scope of practice, which can occur for a variety of reasons (lack of proper oversight, lack of communication, initiative on the part of the volunteer, medical research):
Acupuncture poses very little risk of being used in a way that is beyond the practitioner’s scope of practice. The main types of risk management involved in acupuncture training include how to recognize emergencies that should be referred to a surgeon or ICU, and how to prevent a pneumothorax or syncope from acupuncture. Acupuncture is understood to be a low-risk profession, as evidenced by our relatively low rate for malpractice insurance in the U.S.

2. Lack of follow-up care:
Acupuncture for long-term, chronic illnesses can be taught to family members in many countries, so they can treat the patient over a long period of time for a very low cost.

Certificate of Completion for Acupuncture Training Course in Burkina Faso

Acupuncture protocols can be taught for particular diseases or afflictions that may be prevalent in one region (such as arthritis or asthma). Many types of self-care can be transmitted easily, involving the use of hydrotherapy, herbal teas and poultices, moxibustion, cupping, and simple self-acupuncture protocols. Most organizations include some kind of training certification that local community members can participate in, to further the care when they leave.

3. Volunteers taking advantage of lax laws or absence of supervision to experiment with procedures or medicines rather than simply provide necessary health care:
Since acupuncture has been practiced in a very similar way for over a thousand years, there is very little concern with using dangerous or new procedures.

The National Acupuncture Detoxification Association (NADA) expresses their intent to aid Gaza civilians concisely, in Guidepoints January 2011 by Greg Schnabel:


The NADA Gaza Strip project was designed to help civilian residents cope psychologically with the traumas of war and everyday life. For this project, teams of local health care professionals are trained in the NADA protocol for a period of 2 weeks.  After receiving training, members of these teams provide ongoing care within their communities.  This model empowers members of a community to help themselves and their neighbours and provides continuity of care in a region that is often difficult or impossible for international medical aid to access.

5 Needle Detox Protocol

…The potential for the application of the NADA protocol within Gaza is vast. The NADA Gaza group hopes to collaborate with other clinics inside Gaza that offer more traditional psychological support services. If they succeed in doing so there will be a need for more trainings and more needles in clinics throughout Gaza.

In a country that has seen war and conflict for so many decades, the incidence of trauma can span generations. It is the sincere hope of all members of the NADA Gaza group that the relief NADA brings to individuals may have a ripple effect, helping to ease the burden of care placed upon families and society. We hope that by easing these burdens we contribute, in some small way, to peace.

NADA practitioners are clearly positioning themselves within a collaborative care framework, with the stated goal of helping to aid in the creation of peace and autonomy of the Gaza community. The simple, clear, transparent process of this organization shows how acupuncture can be used to enhance the quality of life of a community without creating any burden or disadvantageous power dynamic. However I’m not trying to say that acupuncture is completely free from the problems that plague any medical aid organization. For the rest of the article I will explore the aspects of acupuncture that may be slightly better or no different from those of allopathic medicine in a foreign aid setting.

Dangers of medical voluntourism that pose less of a problem for acupuncturists than for allopathic practitioners:

4. Cultural assumptions and values inherent in the type of medical care provided may affect the recipients in a negative way (i.e. colonial mindset).
Acupuncture and its effectiveness as a healing modality can be seen through several lenses (see similarities with traditional Native American, Mayan, Tibetan, and Ayurvedic medicine among others) and does not necessarily reflect the traditional colonialist religion-affiliated-hospital association. Acupuncture could be practiced in a religious setting, but the medicine itself doesn’t currently create an imperialist dynamic in the same way that “Western” medicine sometimes does. The closest association may be that of the communist “barefoot doctors” of Maoist China, but interestingly when practiced by people from other countries than China, this association becomes diluted or dispelled.

Health worker in Liberia, from Merlin's Hands Up For Health Workers website

5. Language and cultural barriers leading to less effective treatment and medical errors.
Acupuncture uses a sophisticated system of objective and subjective diagnosis to understand the condition of the entire body. This theoretically does not require the patient to say anything, although a clear patient history is preferred. Acupuncture also does not usually require the removal of clothing other than socks. The patient maintains a fairly high level of autonomy during the treatments, easing the power dynamic between doctor/patient and allowing a more open and comfortable environment.

Challenges that all foreign medical aid NGOs face:

6.Understanding local medical needs.
Acupuncturists fortunately don’t rely on a set of specific and limited medicines; rather, this flexible medicine can respond easily and in a similar way to a large spectrum of medical needs as they are presented. However, local medicine needs must be clearly understood, since there may be times when a different type of medicine would benefit the majority of the local population. The knowledge may already be in the community but the technology might not be available. Possibly a broader structural change in the society or economy would solve the health crisis more thoroughly than any kind of health care aid. Acupuncture still has the potential to delay a crisis in such a way as to prevent real structural change from being spurred into action.

7. Identifying all stakeholders.
Acupuncture aid organizations function in a less institutional and more individualized way than many allopathic medical organizations at the grassroots level, and consequently they have greater ability to be flexible in practice. This leads to the possibility for closer communication with the full spectrum of social structures, from government offices to religious centers and schools to local business owners associations and individual community members. Hopefully this flexibility and communication translates to higher level of awareness of the stakeholders, but each organization differs. This is the responsibility of the personnel involved in the organization rather than something inherent to the medicine.

Moxafrica's Health Care Worker Trainees

8. Undermining the livelihood of local medical providers.
This may be unavoidable, but this prospect is hopefully offset by the opportunity for those local medical providers to learn acupuncture themselves if the clinic becomes threatening to their practice. Acupuncture is a complementary therapy in general, and it is generally seen as a way to help prevent illness. Specialists may not be undermined by acupuncture, since more serious illnesses requiring surgery or pharmaceuticals will be referred out of the acupuncture clinic. At the same time, a tendency to use acupuncturists as a general practitioner could emerge and undermine local health care providers.

9. Brain drain due to training and new opportunities abroad.
Training preference is usually given to community members that already provide health care to their community in some way and are looking to expand their current practice. However, the opportunities available for trainees would undoubtedly expand as their knowledge base and exposure to English improves. The aid organization has no control over what the trainees ultimately do with their knowledge. Hopefully the organization would keep track of the long-term effects of their training program and take steps to encourage the stability of the community.

Image credit Image Focus Australia on Flickr

Well that concludes my long-winded two cents regarding the challenges of creating sustainable acupuncture aid abroad. Much more research and documentation needs to be done as these projects mature and expand their reach. I am excited about the potential for sustainable aid using acupuncture and Chinese herbalism.

A few focused NGO Non-Profits are already providing effective and sustainable health care abroad using acupuncture and Traditional Chinese Medicine. The Acupuncture Relief Project is one outstanding foreign medical aid organization which uses Traditional Chinese Medicine and Massage to bring free health care to people in Nepal. They also summarize the above points nicely:

“Community acupuncture is a highly effective and efficient way of treating a variety of individual and community conditions in areas of conflict, disaster or devastation. Clients are treated in a group, sitting up in chairs, fully clothed. Acupuncture does not rely on the availability of expensive medications and can be extremely effective in treating pain, anxiety, depression and post traumatic stress disorders in areas of disaster or conflict.

  • Acupuncture addresses physical and mental health conditions simultaneously.
  • Effects are immediate, but can also be long lasting, well beyond the time the treatment is being given.
  • While the treatment alleviates symptoms, it is also a general balancing treatment, which treats not only symptoms, but also the root cause of the symptoms. It addresses the whole person and has a comprehensive effect.
  • There are almost no side effects or contraindications. It is non-addictive.
  • Equally effective when there are language or cultural barriers.
  • Healing in a community environment is especially beneficial when a disaster, trauma, or conflict has affected the whole community.
  • Acupuncture in a group setting allows the community as well as the individuals to experience healing.

In addition to providing aid to this besieged community abroad our practitioners will gain valuable experience that will aid in their personal development and compassionate treatment of their patients back home.”

In a similar vein, Mindful Medicine Worldwide provides acupuncture and massage in three clinics in Nepal, including more rural areas. They provide a stronger year-round presence and are also collaborating with a hospital in the Thai-Burmese border region to provide integrative care to refugees using acupuncture, naturopathy, and other healing modalities to address trauma, drug use, and communicable diseases such as HIV and tuberculosis.

Another inspiring international NGO/NP is Moxafrica, an organization that teaches people in Uganda and South Africa to use moxibustion for the treatment of symptoms associated with Tuberculosis:

MOXAfrica

“Are we seeing moxa as being an alternative to existing drugs?

No.
We seriously see it, however, as being potentially helpful when drugs are available, particularly so if they are in inadequate supply as is currently the case.

We also seriously see possible benefits in connection with any one of the following: reduced periods of infection if moxa supports the patient to enable the drugs to work more effectively; possible resultant reduction in disease spread; shorter drug regimes resulting in improved rates of overall recovery; potential reduced rates of mortality; better tolerance to drugs and reduced side effects; possibleimproved results with DR-TB when appropriate diagnostics are absent; consequent possible reduction in the growing incidence of drug resistance; indications for innovative possible approaches to treat patients co-infected with TB and HIV/AIDS.
However, in circumstances in which drugs are unavailable (as is also often currently the case) we also speculate that moxa may be helpful and may even provide the possibility of an emergency “barefoot” treatment when nothing else is available.

Why aren’t we proposing conducting our investigation in the UK in premier research establishments?

We’ve tried.
We have been asked why such an investigation as we propose is necessary given that effective treatments already exist. Whilst this is true for those of us living in the affluent world, for most of those living in Africa where this disease is so dangerous this is obviously far from the case.
Individual responses from the medical status quo have varied. In some cases they have been basically dismissive. In some cases they have been cautiously encouraging, this encouragement often being accompanied by what might best be described as a kind of worried pat on the back. In some cases we have received simple honest encouragement. Institutionally, however, in every case to date there has been clear and consistent disassociation from direct support for any investigation we might suggest.
The bottom line, of course, is that conducting research on any disease like TB which is out of control in one particular environment (the develoiping world), but doing this in another discrete environment (the “first” world) in which it is basically already controlled tends to point towards relevant research results.

Do we think moxa offers an answer to TB?

No, no and no.
We do believe that it just might have a part to play, however, in the campaign against this dreadful disease, particularly in those environments where the might of scientific medicine is as remote as a clean supply of drinking water.
The TB plague has been identified by Dr Paul Farmer of Partners in Health as a symptom of a global blind spot towards one particular human right – the universal right to decent health care. This is such an important concept, and our proposals do nothing to challenge it. It has become perhaps an even more challenging idea in a world which is now engulfed in economic recession, and the last thing we would wish to offer in association with our project is an idea that TB can be controlled by moxa “on the cheap”.

TB cannot be controlled on the cheap, it can only be controlled by concerted effort and investment .
In the meantime we wonder whether moxa may offer at least a much needed rest-stop on the roadmap to better global health care.”

Video of personal testimony from South African hospice workers collaborating with Moxafrica.

As further proof that acupuncture can be very useful in resource-scarce regions, acupuncture is being used to relieve anxiety, pain, depression, stress, and reduce the amount of medications required in Intensive Care Units in the US. This shows that not only can acupuncture flexibly respond to various conditions on the ground, but it can also help mitigate emergency situations which will then be treated by allopathic practitioners.

From the American College of Chest Physicians website:Integrative Oncology and the Memorial Sloan-Kettering Cancer Center Critical Care Experience:

Acupuncture reduces many symptoms experienced by cancer patients in all stages of treatment, including dyspnea, fatigue, hot flashes, sexual dysfunction, urinary problems, osteoarthritis, neuropathy, xerostomia, and more. Most relevant to patients in the ICU, acupuncture can relieve anxiety, depression, stress, and pain, and it can reduce the amount of opioids required to maintain patient comfort. Randomized clinical trials show that relief offered by acupuncture is not a placebo effect. A phase III MSKCC trial reported that acupuncture reduced pain and dysfunction in cancer patients with a history of neck dissection. In addition, acupuncture relieved xerostomia in this population (Pfister et al. J Clin Oncol. 2010;28[15]:2565). A companion functional MRI (fMRI) study illustrated that true vs sham acupuncture produced neuronal activation associated with increased saliva production. Signal changes on neuroimaging were correlated with changes in the appropriate cortical areas (Deng et al. BMC Complement Altern Med. 2008; 8:37).

-Barrie R. Cassileth, PhD. Chief, Integrative Medicine Service, Laurance S. Rockefeller Chair in Integrative Medicine, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY

As usual, since you’ve made it this far, I would like to end with a video…

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