Transmission of Knowledge and Practice between Cultures: A Case Study of Chinese Medicine Integration in the United States : Chinese Medicine and Culture

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Transmission of Knowledge and Practice between Cultures: A Case Study of Chinese Medicine Integration in the United States

Morris, William✉,

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Chinese Medicine and Culture 5(4):p 202-207, December 2022. | DOI: 10.1097/MC9.0000000000000030
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Abstract

1 Introduction

Integrative medicine describes the whole systems of care. The verb “integrate” means to render something as a whole. The idea of integration provides a wholeness perspective, where there is integrity within and throughout systems. Thus, systems-based care is a core competency for all forms of medicine.1

Integration occurs among individuals, municipalities, counties, states, and federal and global zones, and will include exopolitics. Practitioners integrate methods of thought and procedures. For a Chinese medicine practitioner, integration can also occur between knowledge gained in state-approved educational systems and family lineage forms of practice.2

Integrative medicine expresses the essence of humanity. This point of view is at the heart of Chinese medical practice. The integration takes place across cultures, time, within the person, between people, and across jurisdictions and institutions.

2 Chinese medicine in the United States

Traditional Chinese medicine (TCM) began integrating into the culture of the United States on the East Coast. Franklin Bache, MD, great-grandson of Benjamin Franklin, translated and published Morand’s Memoir on Acupuncture in 1825.1 William Osler, the father of American medical education, stated that acupuncture was good for “lumbago” while serving at Johns Hopkins University in 1892.2,3 The two scholars were the first leading advocates and researchers of TCM in the United States.

Chinese immigrants also had brought a different perspective to integrate TCM into American medical culture since the 1850s. It was palpably different from the adaptations made by conventional practitioners such as Osler and Bache. The first acupuncture and Chinese medicine laws took place along the West Coast. Of note, the East Coast focused on acupuncture to the point that the schools in that region also prioritized acupuncture over herbal medicine as part of their mission. After the first wave of acupuncture schools, in the second wave, in the late 1970s and early 1980s, schools in the West Coast developed Chinese herbal programs. During the 1990s, the Florida and Massachusetts acupuncture associations provided 2-year herbal programs to which qualified practitioners can sit for the National Certification Commissions for Acupuncture and Oriental Medicine examinations.

The cultural diaspora partly facilitated the influence of Chinese medical thought in the United States along with the build-out of the railroad systems that went through Davenport, Iowa. It was where Daniel David Palmer lived, practiced, and created Chiropractic medicine. Thus, Chiropractic may be a product of tuina integrating with scientism and European concepts of vitalism. The chiropractors survived the impact of the Flexner inquisition by claiming not to be medical practice. It is reasonable to say that the American healthcare environment has changed with the advent and firm entrenchment of Chiropracticas the discipline became part of the Medicare system in 1895.

Doc Hay (Ing Hay) practiced in Oregon. He came from a family lineage of herbalists and likely began practice in 1883.4 His presence in Oregon would have contributed partly to accepting foreign medical practices in the United States. Indeed, Oregon became one of the first states to create a practice act for acupuncture and Chinese medicine. To clarify, a practice act is a contract between the profession and the social system it serves.

3 Early integrative medicine in the United States

Abraham Flexner, a teacher by trade, was also a reformer of medical education, attempting to understand its place in society. Flexner’s 1910 report Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching shaped the medical-industrial-investment complex and scope in the current medical field.5

Flexner’s report also may have reduced the use of natural products in the US healthcare between 1910 and the 1960s. That gap became apparent to policymakers when David Eisenberg’s study, Unconventional Medicine in the United States – Prevalence, Costs, and Patterns of Use, demonstrated the amount of money Americans spent out of pocket on “complementary and alternative healthcare.”6 It showed a substantial amount of uninsured dollars Americans spent on complementary and alternative medicine.

Dr. Stephen Kanter, the editor-in-chief of Academic Medicine, reviewed the history of 100 years since Abraham Flexner wrote his industry-changing report.7 Topics ranged from curricular content and the length of medical training to the contrast between disease management and population-based health improvement. Glaringly absent were the documents that displayed the monopolizing results of the report on the medical practice and workforce.

Flexner’s collaboration with the American Medical Association and the Carnegie Foundation went beyond balancing and cleansing a corrupt medical and educational system. Schools with a preference toward botanical medicine and homeopathy were closed, as they often did not work with surgical wards and chemical laboratories. Schools with women and mixed races were also closed. One school with Afro-American medical trainees was allowed to continue in the south. With low Flexner site visit scores, homeopathic and eclectic medical school graduates were also denied admission to state medical examinations.6

4 Social closure in trans-cultural medical practices

The protection of medical worker classes was evident in the works of the Flexner site visits. The regulatory capture of education and the noosphere of the public by the pharmaco-industrial-investment complex were successful. The United States and the rest of the world purchased the idea that real medicine only used patented molecules and surgical procedures. This development caused an explosion of growth centered on profound economic gains served by processes of social closure. At the same time, virtues of not confusing the public resonated within the halls of institutions and government. The regulatory accomplishments for Traditional medicine (TM) in the United States had limits. The terms “complementary and alternative” helped sustain social closure and medical classism in the workforce.8

Closure depicts a process of domination whereby one group creates a monopoly by closing off opportunities to outsiders. There are four types of closure: exclusion, demarcation, inclusion, and dual forms.9,10

  1. Exclusion exercises the hierarchical dominance of inferior social groups by closing off access to opportunities and resources. It occurs by creating specific skill sets and credentials that protect and secure privileged access to the market.
  2. Demarcation occurs when a discipline member monitors and regulates closely related occupations defining and controlling boundaries between them. Exclusion suppresses vertically, while demarcation does so horizontally.
  3. Inclusion refers to subordinates’ attempts to access the advantages of higher-level groups. It can easily be dismissed by the more elite as usurpation.11
  4. Dual closure occurs when a demarcated group resists demarcation and establishes a new sphere of competence with notable exclusions.

A privileged worker class often holds closure to be in the interest of public safety. It is ostensibly used to prevent confusion. From another point of view, closure contributes to a political and economic environment where atomization and specialization of knowledge isolate and disconnect people, compromising best practices in care.12

For example, a doctoral program in Los Angeles gained access to Good Samaritan Hospital for training learners in the acute rehabilitation unit and the emergency room. No Chinese medical terms were permitted in the chart, but only biomedical terms, creating closure based on professional terms. Thus, learners used modern scientific medical terminology to describe TCM patterns, thought processes, and treatment plans. This cognitive form of social closure ostensibly protects the biomedical-legal practice which potentially devastates traditional practices in a trans-cultural environment.

There are other forms of social closure in medical record keeping. Medical records can be kept in different filing systems, leading to a lack of awareness among practitioners responsible for patient care. The International Classification of Disease 11 (ICD-11) code set provides a solution, as it provides a basis for best practices regarding communication and knowledge supplied by shared medical record keeping.

5 Social systems and integration

Integration throughout the strata of medical endeavor possesses great potential. The process takes place from private practice to policymaking at federal, state, and institutional levels. The economic implications and financial reform in connection with mind-body relationships pose distinct concerns relative to the redistribution of wealth and power in healthcare.

Modern roots of cognitive integration between Western medicine and TCM started in China when Chairman Mao sought to bring a premier form of care to humanity. To accomplish this goal, he brought western surgeons and TCM practitioners to Beijing, where they worked in concert with the themes used to drive the development of a superior form of medicine. Kim Taylor presented five phases designed to accomplish the goal of integration in his book Chinese Medicine in Early Communist China, 1945-63, A Medicine of Revolution.13

  • The Cooperation of Chinese and Western Medicine (1945–1950);
  • The Unification of Chinese and Western Medicine (1950–1958);
  • Chinese Medicine Studies Western Medicine (1950–1953);
  • Western Medicine Studies Chinese Medicine (1954–1958);
  • Integration of Chinese and Western Medicine (1958–present).14

The development of authentic and representative policies involves the integration of voices across the spectrum of all healthcare provider classes. All genders, styles, and races populating the licensed providers must be at the policymaking table, from institutional to state and federal, at all decision-making strata. The integration process is to possess compassionate humanism as a feature of the values.

Among the most significant papers affecting policy regarding Chinese medicine and acupuncture in the United States is the Eisenberg study, Unconventional Medicine in the United States – Prevalence, Costs, and Patterns of Use. The United States began to recover from the losses created by the interest parties supporting the Flexner report. In 1990, there were an estimated 425 million visits to providers of “unconventional” therapy, exceeding the 388 million visits to primary care physicians. Money spent was approximately $13.7 billion, three-quarters of which ($10.3 billion) was out of personal funds. In comparison, $12.8 billion was paid out of pocket annually for all hospitalizations in the United States in the same year.15

Paralleling with Eisenberg’s landmark 1998 study, the FDA reclassified acupuncture needles from Class III to class II. This 1996 decision made acupuncture needles a medical device rather than experimental equipment.16

As growth and change continued, President Clinton signed an Executive Order 13147 on March 7, 2000, forming the White House Commission on Complementary and Alternative Medicine Policy.17 As a result, medical schools began considering East Asian medical practices to be forms of integral medical practices. Insurance carriers could no longer deny coverage based on the experimental status of needles.18 The growth of TCM in the West is exemplified in the increase of related research that supports the efficacy and safety of acupuncture.19

The Institute of Medicine (IOM) President, Harvey V. Fineberg, MD, PhD, defined integrative medicine as:

“…orienting the health care process to engage patients and caregivers in the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for achieving optimal health.”

The definition was put forward at the Summit on Integrative Medicine and the Health of the Public held on February 25 to February 27, 2009 in Washington, DC.1,20 Such a definition sidesteps the reality of the medical workforce and regulatory capture that lead a nation to believe in a mono-cultural perspective on integration whereby the sophisticated approaches of traditional medical systems are made unavailable. Unlike Fineberg’s definition, the existing biomedicine definition is predicated on the known and loses traction with emergent trans-cultural concerns in medicine.

The World Federation of Chinese Medicine Societies (WFCMS) reports that as of 2021, Chinese medicine has spread to 196 countries and regions, reaching over one-third of the world’s population. More than 80,000 TCM institutions are established overseas, and there are approximately 300,000 practitioners of various types of TCM worldwide. Chinese medicine has been registered in the form of a drug in Russia, Cuba, Thailand, Vietnam, Singapore, the United Arab Emirates, and the Philippines. WFCMS also recounted data from World Health Organization (WHO), showing that among 113 member states that recognize the use of acupuncture, 29 countries have established relevant laws and regulations, and 20 countries have included acupuncture in the health insurance system. Some national health insurance systems cover other forms of TCM therapies.

Furthermore, “more than 60% of National Cancer Institute (NCI) designated comprehensive cancer centers incorporate acupuncture for cancer symptom management.”21,22 The net result is a trans-cultural ferment of acupuncture and herbal medicine practices within all these regions.23

6 The ICD-11 codes

One of the most significant developments regarding the integration of TCM in the world took place in May 2019 when the member states of the WHO adopted the ICD-11 Chapter 26 on TM.24 In response to the need for integrated reporting, the WHO member states, TM practitioners, professional TM associations, and educational institutions requested the TM Chapter. It was formalized in response to the international convention supporting healthcare for all, as articulated in the Declaration of Alma-Ata on Primary Health Care (1978) and the Declaration of Astana (2018).25,26

TM serves as primary care in many countries worldwide, especially throughout the Asia-Pacific. The TM practitioners gain licensure and training on par with medical doctors. Due to the lack of integrated reporting system, the practices are often underreported. It leads to a lack of aggregated, international data regarding TM encounters in form, frequency, effectiveness, safety, quality, outcome, and cost.

The ICD-11 TM Chapter will improve the regulation and integration of TM in mainstream healthcare and health information system. Efforts to effectively regulate TM as an integral part of the health system require standardized and evidence-based information.27 The ICD-11 codes provide compatibility and interoperability of digital health data. It contains diseases, disorders, and health conditions. Given the widespread use of TM throughout the Asia-Pacific region, including coding practices for understanding public health is a best practice. The World Health Assembly endorsed the new revision of ICD at the 72nd meeting in 2019, which came into effect globally on January 1, 2022, breaking the bind of social closure.28

As a concerted effort to influence the inclusion of TM via the ICD-11 Chapter 26 emerging, however, a perfect storm brewed. Experts abandoned scientific and policy journals.24 Peer reviews and evidence evaporated. A new locus of debate emerged in politic, business, popular science, and social media platforms, unduly influencing popular opinion. The polemics included themes of TM’s impact on endangered species, toxicity, and contaminants. The narratives possess a disturbingly unified language and conceptual frame. Who funded this effort and why?

The medical-industrial-investment conglomerates have financial interests and motives in maintaining control over the medical marketplace and workforce. The titans should be the first place to explore as they retain a near-totalizing level of regulatory capture and provide scientific biochemical methods in the halls of academia, policy, and governance.

Fortunately, the chapter in ICD-11 now makes it possible to collect and report on TM conditions in a standardized and internationally comparable manner. The scope contains terms for conditions described in ancient China and is now used in contemporary TCM practice. This formative action provides a basis for the second module, which will include Ayurveda and other TM diagnostic systems.

There are limitations in the ICD-11 codes as it is not used for mortality evaluations. The bounds include optional dual coding for the morbidity data collection, reporting, reimbursement, patient safety, and research.28

7 Toward future integral possibilities: a transdisciplinary view

The potential of the trans-disciplinary movement provides guiding principles in the discourse on medical integration, which is worthy of consideration. The root word discipline provides the basis for this discussion. In old English, a disciple follows another for learning. Discipline later became a branch of instruction or education. It is subsequently considered to be systematic rules and regulations, and features of the medical professions. Transdisciplinary study explores how the rules and knowledge systems connect and integrate.

The transdisciplinary view possesses an “included middle” that is essentially paradoxical. In Aristotelian logic, factor A cannot be Z, and Z cannot be A. The transdisciplinary view holds that A can be Z from the place of their commonalities. This zone of the “included middle” is also called isomorphism. In medicine, that isomorphism is the commonality of disease location, progression, and severity. These three features provide an underpinning for what in anthropology called structuralism. It is at this level that proper integration can take place.29–31

  • There is specialized knowledge within an overriding unity of cognitive endeavor.
  • A standard set of metaphors and concepts defines the field of inquiry.
  • There are taxonomies for structuring knowledge of the field.
  • There are particular methods of investigation and specific means for determining the truth of claims made in practice.
  • There is an idea of purpose relative to the discipline.
  • An organized group that studies the discipline trains other practitioners and forms the social mechanism for arbitrating various truth claims within the profession.

In practice, it is helpful to distinguish transdisciplinary from interdisciplinarity and multidisciplinarity. Multidisciplinary often refers to a diverse group of disciplines and their practitioners located within proximity and typically in the same facilities. Such practices are increasingly common, with Chinese medicine included as a discipline.

Interdisciplinary practices will often have more collaborations. Examples include Cedar Sinai or Good Samaritan in Los Angeles, where acupuncturists collaborate with practitioners of various disciplines to provide patient care. The author participated in an integrative, interdisciplinary project during the early 1990s in the Berkshires of Massachusetts. All the providers, including MD, and PhD biochemists in nutrition, art therapy, and movement therapy, sat together at the beginning of a 2-week retreat and explored the medical records with pictures of the patients. This process was a genuinely integrative medical project.

Transdisciplinarity is a practice that transgresses and transcends disciplinary boundaries, whereby groups of different practitioners are multidisciplinary.32 It links and integrates disciplines through the trans-media of biological, spiritual, and cultural epistemologies.

In summary, interdisciplinarity describes processes and information traveling between fields. Multi-disciplinarity is a grouping of disciplines in an effort toward a common purpose; trans-disciplinarity is information systems that move between, across, and beyond all disciplines.

8 Conclusion

Transdisciplinary practice is complex and it requires creativity to negotiate the range of psychosocial challenges. An approach of cooperative inquiry may generate sufficient trust to maintain the connections between members of the engaged.33

Cooperative dialogue brings ethical challenges to the various strata of integration. Power imbalances carry a risk of closing out dissenting or minority voices. One of the most significant risks is the loss of cultural identity and salient medical traditions in the integration process. Overcoming these challenges and risks are no small tasks, but are unavoidable if interdisciplinary and interprofessional teamwork is to have any real meaning.33

Chinese medicine has a history of providing low-cost, adequate health care. Furthermore, studies such as the GerAc (German Acupuncture) Trials show a lower cost of care than conventional medicine.34

A review of the GerAc trials and their impact on public health policy in Germany and ongoing research in other countries suggest that including acupuncture and Chinese medicine in the medicare system will lower the cost of healthcare.35 Such causes for the common good are impeded by federal healthcare budgetary resources, workforce, and monopoly of pharmaceutical conglomerates, as reducing the cost of care can adversely impact the economic interests of certain institutions, municipalities, state, national, and international agencies.

Possible solutions are available through models such as cosmopolitan power, in which acupuncture and Chinese medicine are beneficial to the Western world, resulting in an egalitarian worldview.36,37 There are systemic risks in our current state of development.38,39 An egalitarian healthcare system is not inevitable, given the economic interests of certain parties are at stake. There remains, however, a dynamically evolving set of possibilities. A pluralistic medical culture may generate some solutions for humanity.40

Integrative medicine has dimensions that focus on individual as the center. Patient-centered care is the core from which integral systems extend. The need is to create healthcare processes that provide a seamless engagement between patients and caregivers in the full range of physical, psychological, social preventive, and therapeutic factors. In short, it is about integrating approaches and systems. As for the integration of Chinese medicine, the process seems to be ongoing but at the risk of a premature conclusion.1

Funding

None.

Ethical approval

This study does not contain any studies with human or animal subjects performed by the author.

Author contributions

William Morris has done the research and the writing of the paper.

Conflicts of interest

The author declares no financial or other conflicts of interest.

References

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Keywords:

Acupuncture; Culture; ICD-11; Integrative medicine; Sociology; Traditional Chinese medicine; Transdisciplinarity

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