The Roots of Inequity in CAM

When I think of the potential that CAM (complementary and alternative medicine) has in a truly integrative model of medicine, where CAM can be used not only to treat subjective complaints that have no real biomedical basis, but also to help those with medical trauma or who are reluctant to engage with a conventional care provider, I find myself simultaneously believing in the possibility whole-heartedly, and stumbling when I think of the reality. CAM is not a medicine built on equity, from the barriers to access built into our insurance system, right on down to how providers are educated. To truly extend our scope to all patient populations, we in CAM have much to reckon with.

The first thing I stumble on is healthism, originally defined by Robert Crawford as a “preoccupation with personal health as a primary — often the primary — focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of lifestyles.” Though healthism occurs in conventional medicine, it is endemic in CAM. In practice, this manifests with CAM providers often making a slew of lifestyle recommendations without considering whether or not our patient is ready or willing to make that change. We gloss over the very real sociological barriers that these recommendations present to many people. Even a basic dietary recommendation of eating primarily based whole foods can be tremendously difficult for many due to access, time and education. There is also the prescription of supplements, none of which are covered by insurance, and the time and money it takes to maintain regular acupuncture appointments or yoga classes. Crawford put it this way: “To the extent that healthism shapes popular beliefs, we will continue to have a non-political, and therefore, ultimately ineffective conception and strategy of health promotion. Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well-being.”

I’ve made this mistake myself repeatedly in my acupuncture practice. It’s part of our education as providers. We’re taught that if the patient really wants to get better, that they should comply with the very practical suggestions we give them. It’s all too easy to gloss over what’s behind these benign seeming recommendations, which is not simply confined to the above. They also contain within them the seeds of paternalism and perfectionism, as if we CAM providers are somehow a step above others in our evolution as human beings, and creating the opportunity to confuse our role as healthcare ally with that of lifestyle guru.

Indeed, the pressure we put on ourselves as CAM providers here in the US is subtle but myriad. Holism becomes a coded perfectionism. We’re supposed to have a deep spiritual practice, meditate, mindfully exercise and keep fit, eat a diet so pure that even our perfectly formed shit is organic, abstain from anything more than moderate drinking or drug usage, avoid prescription drug dependency, and know what herbal tonics and supplements keep us from ever being ill for more than a day or two. Our lifestyles should keep us glowing with natural vitality. It’s taken me years to be at peace with the fact that my life doesn’t look like this, and that beyond that, that this is an expectation that reinforces inequity on a fundamental level. It’s as if we’re saying that those who can afford to keep such a lifestyle are somehow more worthy of good health than those who cannot, which is exactly what Robert Crawford was getting at.

How I see CAM as being able to bust out of this paradigm is by releasing any such expectations of our patients and ourselves. We have a unique placement in the healthcare system that has languished too long. Our very status of outsiders in mainstream healthcare give us the opportunity to work with people who fall through the cracks due to their reluctance to engage with conventional medical or behavioral health providers. Our training in looking at the individual as a whole is incredibly valuable, as is our ability to work with and treat conditions that may or may not have a biomedical diagnosis.

To do this, however, our education needs to change. For those with medical trauma or who distrust conventional care providers, having a CAM provider to talk to while undergoing treatment for a major medical condition can be enormously therapeutic. This involves a rethinking of CAM as an entire field. We’re taught that our primary therapeutic purpose is to give an alternative treatment, but the reality may be that the alternative treatment is the relationship itself with someone who is sympathetic and trained to look at the whole person. With this as a potential goal, we need to educate CAM providers to work with all people, not just the middle and upper classes. Students must learn to work with and value difficult patients as much as compliant patients, and we need better education regarding mental and behavioral health. Additionally, we need to know how to navigate and work with conventional healthcare systems and providers. Supplements, food therapy, and lifestyle recommendations should either take a backseat to training or be seen as equal in value to interpersonal skills such as reflective listening, motivational interviewing, anti-bias training, harm reduction, suicide prevention, and trauma-informed communication methods. If we emphasize the latter, we’ll be able to do the former with more skill and discernment than if the “Alternative” part of CAM is prioritized.

Going to step down from my soapbox now…FYI, this post has not been thoroughly edited, and may contain typos. Apologies.

Why do we sideline our medicine?

Why do we put ourselves as acupuncturists and EAMPs in such a tight career bracket? After school, it feels like we have one option: to open our own practice and do acupuncture and herbs, or else leave the medicine.

I’ve sought to expand this by trying to get another conventional medical degree, but that isn’t working out. So I’ve been asking myself: if I don’t want to be a small business owner and I want to work with underserved and marginalized populations, what can I do as an EAMP?

Last year, I had the good fortune and networking prowess to make a volunteer position I was doing turn into a paid position at the Seattle Institute of East Asian Medicine. The future of this position is uncertain, but for the past year, we’ve been able to provide free acupuncture to low income seniors affiliated with Pike Market Senior Center, while I as an acupuncturist get paid. This is wonderful, but not enough.

Two weeks ago, I got a job at DESC, an organization that helps people who’ve lived in chronic homelessness. My new position is support and resource people who have received housing so that they can maintain stability in their lives.

This is medicine, and it is fully in the scope of the role we have as EAMPs.

As CAM providers, it seems like we feel that we need to practice the most literal interpretation of our medicine to be practicing. In order to do that, we’re reliant on people being able to pay out of pocket or have excellent insurance plans that cover CAM without too many restrictions. This limits access to our services to many people, and in this way we perpetuate inequity. It’s as if we’re saying that only middle and upper income level people deserve holistic healthcare. Services like community acupuncture seek to address this, but in a way that is incredibly difficult for anyone but the owner of the clinic to make a living wage working there.

By doing this, we’re sending a message, and that message is that our medicine isn’t essential, and that practitioners of our medicine shouldn’t expect the financial stability of conventional medical providers.

It’s been my experience that CAM providers are incredibly idealistic about their medicine–it’s part of what makes us accept the far lower wages and uncertain employment. We become holistic care evangelists, perpetuating a dichotomy of us versus them in the “allopathic” medical community. This only serves to further the above message that we’re not essential, and we are cut off from being a part of larger medical systems that would allow us access to more patients that could benefit from our care. We lag behind in addressing social inequity and trauma-informed care, despite being in a great position to be a part of that movement.

We need to start getting ourselves into these systems in whatever way we can if we’re going to change this. We have something extremely valuable to offer–validation of people’s subjective feelings of being unwell. If we’re to do this, we need to learn to get over ourselves. The forms we currently utilize in our practice is limited. If we’re in medicine because we wish to be healers–something you hear a lot of from CAM providers–we must be able to make our medicine work for all people, including ourselves.

I have my first job with guaranteed income and benefits for the first time in years. No, I won’t be sticking needles in people or recommending herbs, but I’m still working to benefit people and help them live to the best of their potential. Isn’t this what we’re trying to do in medicine?

I have a theory that I’m putting into practice by taking this job that if I put in my dues, I can find my way back to working under the capacity of a licensed acupuncturist. I believe that what we have is of value to underserved people, and that we can be an ally to them in receiving the full range of care they need. I think our scope is broader than we think, if only we’re willing to extend ourselves.

The power of subjective experience.

As an acupuncturist applying to medical and nursing school, I find myself sitting in an unusual space. I love science, and do not believe that there is any inherit superiority in natural medicine. Yet neither am I going to dismiss the positive effects I see in my acupuncture patients simply because I don’t know how it works, or if the modality is scientifically valid.

The space I reside in mentally regarding my profession has clarified in recent years as I delve into my hobby interest of ecology. Studying the works of such scientists and historians such as Robin Wall Kimmerer and Bathsheba Demuth, and philosophers such as David Abram, I’ve come to have a new appreciation for the subjective. Often called by the belittling title: “the placebo effect”, I think we as a species do ourselves a disservice by downplaying the power of subjectivity. Scientific, so-called objective reality being the norm is a very recent phenomena, and one that comes with a fair amount of baggage in its own right. By distancing ourselves from the natural world, putting a microscope between us at it, we often fail to see ourselves as a part of it.

For most of our existence, humanity has worked to define its place on earth and in the cosmos. Various subjective religious and spiritual experiences and frameworks gave us a way to integrate ourselves into something larger than ourselves. The more we compartmentalize and dissect, the harder it can be to see and identify with the whole. Ways of thinking that allow us to tap back into that may not be scientific, but they may still be necessary. Research is coming back that having faith, a belief in the intangible, helps people live happier, more fulfilling lives. What they believe in may not be scientifically true, but that doesn’t detract from the benefit they receive from it.

The shamanic worldview that Traditional Chinese Medicine (TCM) was born from has been with humanity for centuries. Nature-based religions such as shamanism played an important part in the development of our species. While we may no longer believe in spirits and ghosts, I believe there is a part of us that still longs to connect with the land and the earth in an elemental, almost mystical way. The phenomena and popularity of the idea of “forest bathing” shows us a little of that. TCM, with its method of looking at the body as a dynamic network of systems that all play off of each other and root back to various elements of the Earth, also strives to do that in its way.

There is a notion that science can explain everything if we throw enough time, energy, and money at a problem, and that an understanding of the world built on science is superior to an uninformed, subjective view. I know I’ve often thought that way, even as an acupuncturist. Yet I can’t help but wonder if the recent pushback we’ve seen in this era of “alternative facts” has been some misguided attempt at reclaiming power in our subjective reality. When I think of it in this light, I develop more sympathy for those that wish to claim the world is flat and the like. Perhaps if we gave more credence to the subjective in addition to the scientific, we would find ourselves at less at loggerheads, and we could work at channeling this need for subjective validity into repairing our relationship with the Earth.

Robin Wall Kimmerer posits that there there is a healing that can happen if we are able to develop a sense of having a reciprocal relationship with the Earth. Founded on an indigenous worldview where the land is imbued with animacy, she and other academics who are looking into this worldview question why we are so quick to dismiss it if it leads us to have more reverence and respect for the world around us.

Coming from the field of CAM, my curiosity about this question has gone one step further. Could the popularity of “natural” medicine come from a subconscious urge to be more in sync with the Earth? Within the CAM field, I find that there can be an unexamined tendency to believe “natural” medicine is superior in some way, even if its outcomes are often less certain or studied. I don’t personally hold this view, and am just as likely to take a prescription and talk to my allopathic doctor as I am to use herbal medicine or another complementary modality. Yet the feverishness that some cling to this, such as in the movement that questions vaccines, has lingered despite the evidence that should reassure. If this is the case, might we, instead of dismissing people with these concerns as

Coming from the field of CAM, my curiosity about this question has gone one step further. Could the popularity of “natural” medicine come from a subconscious urge to be more in sync with the Earth? Within the CAM field, I find that there can be an unexamined tendency to believe “natural” medicine is superior in some way, even if its outcomes are often less certain or studied. I don’t personally hold this view, and am just as likely to take a prescription, get a flu shot and talk to my allopathic doctor as I am to use herbal medicine or another complementary modality. Yet the feverishness that some cling to this, such as in the movement that questions vaccines, has lingered despite the evidence that should reassure. If this is the case, might we, instead of dismissing people with these concerns as recalcitrant, look at what lies below the surface? If we take them seriously, and work to reassure them that their subjective concerns are valid, might we slowly earn the trust we need to assuage their fears?