Acupuncture in California
Acupuncture in California During the 1970s
CALIFORNIA GETS THE POINT
by Colin Elbasani
Special thanks to:
Paul West
Linda Barnes, PhD
Joel Harvey Schreck, LAc
Susan Johnson, LAc
Benson You, LAc
Contents
1. Introduction
2. Acupuncture Enters the American Mainstream
3. The Evolution of Acupuncture in China
4. Approving Acupuncture Research in California
5. Medical Issues in the Regulation of Acupuncture
6. Health Care Delivery Issues in Acupuncture Regulation
7. Criticism of Acupuncture Regulation
8. Conclusion
Appendix. The Practice of Acupuncture: A Legislative Position Paper
1. Introduction
Geographically, California is the last stop in the continental United States before Asia. It is not surprising, then, that the medicine, philosophy, and other aspects of Asian culture constitute such a prominent part of the California experience. Although acupuncture is portrayed by some academics—perhaps because of their perspective from the East Coast—as having resulted in a tremendous culture clash between established Western medicine and Eastern exotic medicine, the historical record shows that their differences were more easily reconciled than these critics would have us believe; over the course of the last forty years, acupuncture has been completely integrated into California’s medical delivery system.
While it may be true that “professions institutionalize control over social capital by establishing licensing procedures, internally run educational institutions, and self-regulation,” they do not exist first and foremost to do so. This is especially the case in the medical profession, where incompetence, carelessness, or plain ignorance can and sometimes does result in the injury or even death of a patient. Rather, these structures are in place to provide standards and safeguards that insure quality patient care. In fact, the evolving legislation regarding acupuncture in California reveals a steady progression from cautious, close scrutiny by the medical profession to its current state, which integrates acupuncture into mainstream healthcare while providing for autonomy of the government’s oversight of the acupuncture profession.
Given how little scientific basis there was for the argument that acupuncture was effective at all, the medical community was actually quite tolerant, accommodating, and even encouraging of incorporating it into mainstream medical practice. Many members of the California Medical Association (CMA) and the American Medical Association (AMA) shared with laypeople the same curiosity and enthusiasm about the potential benefits of acupuncture to Western medicine in the early 1970s. Nevertheless, they hesitated to accept it as an effective form of therapy. Their reasons for doing so were well-founded, and their concerns over numerous issues raised by the public’s fascination with acupuncture were warranted.
This thesis will explore the tensions between Western medicine and acupuncture in California, and how the latter came to be accepted as a form of alternative medicine and granted a great degree of professional independence and autonomy by the state. The chronology of acupuncture legislation will provide the framework for the narrative, drawing on the original legislative documents from the California State Archives in Sacramento, articles in newspapers and magazines, articles from the AMA, and the secondary literature available on the history of acupuncture and on the authority structure of established Western medicine.
2. Acupuncture Enters the American Mainstream
During the Cultural Revolution under Mao Tse Tung in the 1960s, diplomatic, cultural, and scientific relations between China and the United States relations were all but cut off completely. At this time, American fears of Communist hegemony overshadowed the public’s curiosity about Chinese culture. These Cold War tensions were finally eased by Ping-Pong Diplomacy in April of 1971, and Nixon’s subsequent meeting with Mao Tse Tung in late February of 1972, ultimately lifting the Bamboo Curtain (the Asian equivalent of the Iron Curtain), and opening up a flood of Chinese culture into America. Shortly after the Nixon visit in 1972, a sudden warming of relations between “red” China and the “imperialist” United States caused a surge in American public interest and fascination with many things Chinese.
The two decades of Chinese isolation from the West only increased American curiosity about all things Asian. Acupuncture, a mysterious healing art that was that bore no relation whatsoever to Western medicine, piqued the curiosity of Americans more than most other subjects. The renewed interest Americans maintained for a seemingly exotic Chinese “other” was quite unlike what Edward Said calls Orientalism; the form of their interest was not imperialist, but anti-imperialist, taking place in a context that followed America’s own Cultural Revolution: the Civil Rights Movement. Many Americans, especially in academia, were revisiting the exoticness of the Chinese, not only with heightened curiosity, but with humility and a new appreciation and respect for non-Western cultures, political ideologies, and even medicine.
This new China craze led to an avalanche of enquiries for travel visas from Chinese embassies in the United States. In the Bay Area, the San Francisco-based Women for International Understanding, the Asian Art Commission of San Francisco, and local 771 of the American Federation of Teachers, with the support of the California Federation of Teachers State Council in Oakland, Berkeley, and San Francisco, rushed to organize large group trips. In many universities, enrollment in Chinese language courses as much as doubled, numerous seminars and symposia on China were scheduled, and a survey of 165 universities found that the vast majority of students favored exchange programs with China. The New York Times reported, “Scientists are falling all over themselves wanting to go to China even those who know nothing about China.” One professional group particularly affected by the China craze was medical researchers.
In 1971, the New York Times reporter James Reston’s article, “Now, About My Operation in Peking,” marked a turning point in the acceptance of Chinese medicine in America. Reston and his wife were invited to visit Beijing by the Chinese Government. On July 15, at 10:30 A.M., while speaking to foreign ministers at the Peking International Club, Reston suddenly felt a stab of pain go through his groin. Later that evening, he was bedridden with a temperature of one hundred and three degrees. The next day he was admitted to the Anti-Imperialist Hospital for examination. An hour later, consultants summoned by Premier Chou En Lai gathered around Reston to listen to a troubling irregular heartbeat pointed out by one of the doctors. After a moment’s deliberation the eleven leading medical specialists in Peking returned with their assessment: “Acute appendicitis. Should be operated on as soon as possible.” The two-and-a-half hour surgery was successfully carried out with the use of the anesthetics Xylocaine and Benzocaine. However, later that evening, as Reston lay in bed recovering, he began to experience abdominal discomfort from postoperative gas pains. Li Changyuan, a doctor of acupuncture at the Anti-Imperialist Hospital, inserted three long, thin needles into the outer part of his elbow and below his knees in order to stimulate the intestine and relieve pressure and distension of the stomach. Reston writes of the procedure,
[it] sent ripples of pain racing through my limbs and, at least, had the effect of diverting my attention from the distress in my stomach. Meanwhile, Doctor Li lit two pieces of an herb called “ai,” which looked like the burning stump of a cheap cigar, and held them close to my abdomen while occasionally twirling the needles into action. All this took about twenty minutes, during which I remember thinking it was a rather complicated way of getting rid of gas on the stomach, but there was a noticeable relaxation of the pressure and distension within an hour and no recurrence of the problem thereafter.
Reston goes on to assure his readers that his condition was genuine, and not some ‘journalistic trick’ to do investigative reporting of the Chinese medical system, quipping, “This is not only untrue, but greatly overrates my gifts of imagination, courage, and self-sacrifice. There are many things I will do for a good story, but getting slit open in the night or offering myself up as an experimental porcupine is not among them.”
Although his account of Chinese medicine was met with skepticism, Reston’s personal experience as a patient of acupuncture anesthesia made him living, Western proof to physicians and the American public that acupuncture might be more than propaganda and hype. For the first time, academics and legislators were compelled to seriously consider investigating its potential as a tool in American operating rooms. Given the excitement in the media and curiosity of the public concerning acupuncture that followed, it is generally agreed that Reston’s article for the Times introduced the West to modern acupuncture. As Assemblyman Gordon Duffy, author of the first piece of acupuncture legislation, remarked the following year, “Especially since the self-recorded treatment of Mr. James Reston’s appendicitis by acupuncturists, we have been bombarded with stories about traditional Chinese medicine.” Though it is commonly believed President Nixon’s trip was responsible for introducing acupuncture to the United States in 1972, scholars such as Dr. Li Yongming, president of the Traditional Chinese Medicine Association in the United States have argued otherwise. The China Daily, China’s largest English-language newspaper, has quoted Dr. Li as saying that “acupuncture fever” really began with James Reston a year earlier in 1971.
3. The Evolution of Acupuncture in China
American citizens were unknowingly embracing a form of acupuncture that was not a 5,000-year old science, as many believed it to be, but a modern adaptation that was still in an experimental phase of development. Their enthusiasm was partly based on the mystique associated with all things Oriental, but was also due to most coverage in the media describing it as ancient, with the rare exception of the occasional newspaper article that drew the distinction between traditional Chinese medicine and the modern version of it that was now being practiced in China. It is important at this point to give a brief overview of the recent history of acupuncture in China.
China’s sovereignty became severely compromised by British aggression throughout the nineteenth century. As a result, the shattered perception of cultural superiority that she had maintained for over two millennia led many Chinese, for the first time in the nation’s history, to reevaluate their traditional cultural traditions, especially in regard to science and medicine. It quickly became apparent to the Mandarins that China would have to embrace Western technologies to compete militarily and economically in the modern world. Western medicine was spread by Christian missionaries, who established 340 hospitals in China between 1828 and 1949.
In the 1920s, following the overthrow of the Emperor, traditional Chinese medicine came under fire by the liberal intellectuals as a vestige of the backwards, failed regime and as having no real benefit compared to the medicine practiced in Europe and the United States. Western medicine was soon referred to as the “new medicine” and traditional Chinese medicine as the “old medicine.” Chen Kuo-fu, a nationalist ideologue aligned with Chiang Kai-shek, condemned the radicals’ seeming renunciation of all things Chinese in favor of all things foreign as unpatriotic. Aware that traditional Chinese medicine had many shortcomings in comparison with modern medicine, Chen advocated a vision of a scientificized version of it, blending Eastern and Western knowledge into a new and superior discipline. Chen’s vision, however, would never come to fruition, as the conservative old and leftist new schools of medicine were too politically and ideologically polarized to reconcile their differences.
Acupuncture and herbal medicine began to be favored once more with the rise of the People’s Republic of China (PRC) in 1949. While making use of the national resources in the numerous traditionally trained doctors was in line with Mao Tse Tung’s philosophy of self reliance and served to bolster national pride, it was also a necessary measure to address the problem of drastic shortages in Western medicine and trained physicians. Unlike earlier versions, acupuncture in the PRC was stripped of any religious or folkloric overtones, and revisited as something to be applied in the field of paramedicine, and as a subject worthy of research within China.
By 1963, the PRC had an estimated one trained physician for every ten thousand people (compared to one per nine hundred people in the United States). This considerable gap was addressed by implementing a program of paramedicine, in which traditional healers would provide basic care to their local communities after receiving an elementary education in the fundamentals of first aid. Western-trained physicians were encouraged to “broaden their knowledge” in traditional healing and to create a new scientificized Chinese medicine, ironically echoing Chen Kuo-fu’s proposal decades earlier. By 1966, China boasted twenty institutions of traditional Chinese medicine with an enrollment of over ten thousand students, and an estimated sixty thousand apprentices training under practicing doctors. Apart from the immediate need to address the health care crisis in the countryside, experiments were being done with traditional Chinese medicine, especially acupuncture hypalgesia.
“Acupuncture hypalgesia,” the proper medical term for pain management by acupuncture, was discussed in the findings of a study group sponsored by the Committee on Scholarly Communication with the People’s Republic of China of the American Council of Learned Societies, the National Academy of Sciences, and the Social Science Research Council, who made a three-week visit to the People’s Republic of China in May of 1974 to witness forty-eight operations involving acupuncture-based pain management in sixteen hospitals. The group concluded “it must be clearly understood that acupuncture does not produce conventional surgical anesthesia. In no instance is sensation totally abolished or consciousness disturbed; thus ‘acupuncture anesthesia’ is a misnomer. There is considerable evidence, however, that acupuncture does affect the pain experience, although our observations suggest complete analgesia may not occur. Therefore the term ‘acupuncture analgesia’ is similarly inappropriate. In view of these limitations, it seems more reasonable to refer to the phenomenon as ‘acupuncture hypalgesia’.” Hypalgesia refers to diminishment of sensitivity to pain, rather than pain itself.
It is in the context of pain management that acupuncture came to be introduced to mainstream medicine in the United States. In the 1970s, acupuncture was still very new as a mechanism of hypalgesia even in China, with its earliest successful use in this capacity dating back only to 1958 in a tooth extraction in Chansi Province. The first assertions that acupuncture was a science still in its experimental stages were not made by elite members of the American medical profession in the United States in some sort of effort to wrest medical authority from Chinese-Americans who had been practicing acupuncture in insular Chinatown communities, but by Chinese physicians such as Dr. Wei-Jan Wu, the deputy chief of surgery at Capital Hospital of the Chinese Academy of Sciences in Beijing and leader of a Chinese medical delegation to the United States. In November of 1972, Wu told a press conference in San Francisco that acupuncture was still fraught with numerous unanswered questions that had to be addressed, that acupuncture could not replace other methods of hypalgesia, and was not indicated for every patient or every operation in China. “On the other hand,” Wu added, “we couldn’t say it is useless. We can say it is a new kind of anesthesia that can be added to conventional methods with promising prospects.” Wu’s clarification, that acupuncture as an hypalgesic was still experimental, was echoed in reports from American and Canadian delegations returning from China, who had been similarly informed by Chinese physicians during their visits.
Dr. Samuel Rosen, an otologist at Mt. Sinai Hospital in New York, was one of the first American physicians permitted into China to witness major operations performed using acupuncture hypalgesia. In September of 1971, Rosen, accompanied by cardiologists Paul Dudley White of the University of Boston and E. Grey Dimond of the University of Kansas School of Medicine, were present at fifteen such operations at the Kwangtung Provincial People’s Hospital in Canton and later at the Third Teaching Hospital of the Peking Medical College. They witnessed brain operations, thyroid adenomas, gastrectomies, laryngectomies, and tonsillectomies being performed with acupuncture hypalgesia. The most striking case, for Rosen, was that of a victim of pulmonary tuberculosis. The operating room was much like one would find in any Western hospital and procedures for asepsis and preparation of the patient were consistent with those of Europe and the United States. The only difference, Rosen reported, was the presence of an acupuncturist who placed one needle in the patient’s forearm midway between the elbow and the wrist before surgery. After twirling the needles for twenty minutes to induce the desired effect, the surgeon began to cut into an awake and alert patient. The first incision was made from near the spine across the left side of the chest wall to the sternum. Then, with the use of surgical scissors, each rib was snipped away. Finally, with the use of a thoracic retractor, the chest cavity was exposed, revealing the patients beating heart and the patient’s collapsed lung. All the while the patient sipped tea and conversed with the surgeon, apparently in no pain whatsoever. This was only one of many impressive examples of acupuncture hypalgesia witnessed by Rosen. Others included teeth extractions that appeared to cause no pain to the patient.
Thomas C. Elmendorf, President-elect of the California Medical Association, experimented with acupuncture treatment at the hands of Drs. B. C. Pien, of San Francisco, and Leung Kok-Yuen, a pain specialist and head of the North American College of Acupuncture in Vancouver, at a meeting of the San Francisco Medical Society on May 9, 1972. He had hoped to find relief from severe arthritis pain in his hip, from which he had suffered for over four years. As soon as the treatment was finished, Elmendorf rose to his feet and declared “there’s no question there is considerable relief of pain in my hip – the pain that I had when I came in is essentially and literally gone.” The treatment was repeated a month later by the same doctors at the California State Capitol building in front of an audience of curious legislators. When all was said and done, Elmendorf popped off the improvised operating table, saying to the onlookers, “it hurts, but it feels good.” Later, Elmendorf was flooded with inquiries about acupuncture and where to find similar treatment for pain relief. Regretting what he later considered a bit of a misleading overstatement, Elmendorf addressed the public with this generic letter:
…The problem is simply this: acupuncture itself is a procedure in which the skin is penetrated, and as such must qualify as a medical, or perhaps, even surgical procedure. The Chinese physicians do not have licenses to practice medicine in the state of California or for that matter, anywhere in the United States or North America. Therefore, they are not licensed to practice acupuncture here, although acupuncture is not in itself illegal. A physician who had a license to practice medicine and surgery in the state of California, or in any of the states, who learned the procedure of acupuncture and wished to use it in his practice, could legally do so as long as he observed the ordinary prudence required of all medical practice.
I personally believe that acupuncture has some potential as a technique to relieve pain or even, perhaps, to induce anesthesia for surgical procedures. The truth of the matter is that Western medicine knows very little about acupuncture, and I believe that we should attempt to learn about it. Accordingly, university centers are being encouraged to attempt a scientific evaluation of acupuncture treatment. It may even be possible that enabling legislation will be required; however, we are exploring the situation in depth, and no doubt you will be reading about it in the not too distant future.
I want to make it perfectly clear, that I do not endorse acupuncture at this time. I am sorry that some of the newspaper articles gave this impression. It is only fair to report to you that a Chinese nurse, also part of the demonstration and who was reported to have multiple disc disease with two surgeries, tells me that she has had complete relief of her pain for a period of four weeks.
I am immensely pleased that the medical profession here in California has such an open-minded attitude regarding this technique, about which we know very little; nor do we understand the traditional methods of Chinese medical practice.
I should mention that there are no physicians’ names that I can give to you in the United States who practice acupuncture, although I have heard rumors that there are such physicians in Los Angeles, New York and Philadelphia. I want to emphasize that this is rumor only.
My heart goes out to you, because I cannot do more for you; but if there is any value to the acupuncture treatment, we intend to find out.
4. Approving Acupuncture Research in California
On August 14, 1972, the state legislature passed Assembly Bill 1500 in a 57-0 vote in the assembly and a 35-0 vote in the Senate. It authorized unlicensed practitioners to practice acupuncture under the direct supervision of a licensed physician in an approved medical school in California for the sole purpose of scientific investigation and research. The bill also required medical schools that conducted research on acupuncture to report their research findings to the legislature annually. Finally, it extended the same authority to supervise such experimentation to surgeons and dentists.
There were several reasons why early research focused chiefly on acupuncture’s effectiveness in the area of pain management. The main reason for this is the way it was first introduced by the media as a miraculous anesthetic that bypassed all methods used by Western medicine. The main demonstrations of acupuncture to Western doctors were in this context. To test the effectiveness of acupuncture as a hypalgesic was to test its veracity, and it goes without saying that many western doctors were skeptical specifically about its application in this regard. Pain was a simple, easy, and timely criterion to test for.
The prospect of replacing opiates with acupuncture was also appealing to doctors concerned about a host of problems associated with conventional forms of pain management, such as addiction, legal issues with schedule II (highly restricted) drugs, and complications in young, old, allergic or otherwise contraindicated patients. To many medical professionals and politicians during the 1970s, a non-narcotic alternative to pain management drugs could not have come at a better time. On the fourth of July, 1969, President Nixon declared a “war on drugs.” That year, 5.14 percent of college students reported having tried heroin, up from 3.2 percent the previous year. The problem was recognized as not only being limited to countercultural youths; American Vietnam veterans were returning from the Golden Triangle addicted to heroin. As the Yale historian of medicine David F. Musto points out in his book Quest for Drug Control: Politics and Federal Policy in a Period of Increasing Substance Abuse, 1963-1981, the problem of heroin abuse continued to increase into the 1970s.
Lastly, physicians in the United States and China began to propose explanations for why acupuncture was working that had a scientific basis and could be understood and debated in terms of Western medical theory. Up until that point, western medicine could do nothing but dismiss the theory of qi flowing along meridians as little more than fantasy; modern, scientifically-based acupuncture was an animal with which Western medicine could finally grapple.
Such an explanation was first given in 1972 to an audience at Caltech by George Wald, a Harvard biology professor and Nobel Laureate, who had recently visited research laboratories in China. Speaking only of modern uses of acupuncture in pain management, and not of traditional Chinese acupuncture for the treatment of disease, which he dismissed as “probably (having) no scientific grounds,” Wald assured the audience that modern acupuncture was “absolutely real” and not the result of hypnotism or suggestion. The research Wald had witnessed on his trip at the Physiological Institute of the Academy of Sciences in Shanghai was based on the recent gate-control theory of pain advanced by the American physician Robert Melzack and the British physician Patrick D. Wall in 1962.
The gate-control theory challenged a more widely accepted and simpler theory of pain known as the specificity theory, which suggests signals are transmitted along nerves from a site of injury from receptors to the brain, where they are finally processed as pain. Gate-control theory, on the other hand, suggests that pain is less straightforward. According to gate-control theory, a gate-like mechanism exists in the pain-signaling system, which may be opened, partly opened, or completely closed. In the last two cases, pain is either reduced or non-existent. In 1973, Melzack hypothesized that acupuncture might close the gate by stimulating large nerve fibers, which in turn override activity in the small nerve fibers responsible for carrying pain signals to the brain.
A debate began in 1972 in the letters to the editor section of the Journal of the American Medical Association about the best way to test the effectiveness of acupuncture in pain management. Bernard C. Adler first wrote to the editor proposing a double-blind study be carried out in which acupuncturists treat one group of patients with the proper set of acupuncture points and a control group using points slightly removed from the proper ones. Lester C. Mark responded that Mark’s suggestion of deceiving the patient by using false points would be inappropriate, as the patient is an active participant in the acupuncturist’s attempt to illicit paresthesis by reporting to the doctor if manually twirling the needles on the points is producing thé chi, a feeling of soreness or distention that indicates acupuncture hypalgesia is beginning to take effect. Doctors Chein and Shapiro responded saying that while manual stimulation might not produce the desired effect by manually twirling the needles at the wrong points, electrostimululation of acupuncture points would mimic the same soreness regardless of which points were chosen, adding that known points along meridians could be selected, making a double-blind test for placebo feasible. Mark responded, insisting once again that before any stimulation of the acupuncture points took place, whether manual or electrical, the needles would have to be correctly placed, and that this could not be counterfeited. Finally, Chein and Shapiro responded to Mark’s letter, saying that the only proposed studies up until that point were single-blind, as only the patient, and never the acupuncturist, was being deceived. They proposed a simple solution to the problem:
…Make the study double-blind by briefly training and hiring naïve technicians, instructed by an acupuncturist without direct contact to the patients. If sufficient numbers of patients are randomly assigned to the specific and non-specific treatments, anomalies, such as grossly abnormal nerve distribution, and other individual differences, would be distributed between the two groups. Since only naïve subjects and acupuncture technicians would interact, the placebo effect of the treatment would affect both groups equally. If the treatment at the presumed acupuncture point resulted in significantly more improvement than at the control or nonspecific acupuncture point, the conclusion would be that acupuncture is better than placebo in the condition under study.
Such a double-blind study was carried out as early as July of 1972 as part of the UCLA School of Medicine’s research project on the efficacy of treating rheumatoid arthritis patients with acupuncture. Candidacy for participating in the study was determined by whether or not sufferers of arthritis pain were not responding well to the latest treatments available to western medicine. Of the two dozen patients observed over the course of ten weeks, half were treated by inserting needles into prescribed acupuncture points that fell along meridians, while the other half were treated using randomly selected points.
5. Medical Issues in the Regulation of Acupuncture
Starting in the 1960s, radical social movements, beginning with the counterculture, then the antiwar movement, and then the women’s liberation movement, emerged on a vast scale in the United States and Europe. Everything that was part of the existing order was questioned and criticized. Medicine, like many other institutions, suffered a stunning loss of confidence in the 1970s. Fantastic accounts coming back from early visits to China by American doctors in 1971 and 1972 set imaginations ablaze and caused physicians as well as laypersons to entertain high hopes that where Western medicine had disappointed traditional Chinese Medicine might succeed.
Western medicine faced a unique challenge in the arena of popular opinion. Only a year after Reston’s article sparked widespread interest in acupuncture, contemporary authors such as Marc Duke were already criticizing the reception of acupuncture by the Medical profession in 1972. Responding to his question about who might practice acupuncture in the United States, Duke quotes the AMA’s science news editor, Frank Chappell, as saying “it would be the practice of medicine, so it would have to be licensed. That is, it would have to be done by licensed physicians.” Duke then goes on to conjecture:
Most physicians are dedicated, hard-working men who earn their pay – and more. If acupuncture were to become common in the United States, doctors’ incomes would fall. Surgeons and anesthesiologists would be the hardest hit if acupuncture replaced general anesthesia, as it might. The huge amount of drugs American doctors prescribe would also fall. Fewer prescriptions would mean less money for drug manufacturers, another powerful lobby in Washington. Drug companies contribute huge sums of money to medical research. They are unlikely to support research into a medical system that is not founded on the use of drugs.
Such scathing remarks about Western doctors’ sentiments about acupuncture were not uncommon in an era when mistrust of government and corporate enterprise was rife. Western medicine was distrusted as part of the ancient régime. However, the comments by Thomas N. Elmendorf, M.D., the President-elect of the California Medical Association, reveal that Chappell’s answer to Duke’s query, if taken as a single-sentence sound bite, is apt to mislead the reader.
It should come as a surprise to no one that in this initial period of regulation, concerned legislators and medical professionals called for a period of restriction and research to safeguard an eager public from engaging in a practice that posed considerable risks in the wrong hands. The California Medical Association and the California Department of Consumer Affairs responded to a seemingly unbridled acupuncture craze with demands that the state legislature pass some sort of regulation on a form of medical service which, up to that point in time, had none.
There is a considerable risk of structural damage due to insertion of acupuncture needles, the most common of which is pneumothorax (collapsed lung) . In 1973 and 1974, six cases of pneumothorax as a result of acupuncture were reported in the Journal of the American Medical Association and the New England Journal of Medicine alone. One of the cases involved a patient seeking acupuncture as a treatment for atypical migraine in August of 1973. When she sought medical attention two days later for pain in her left shoulder blade and increasing shortness of breath, doctors discovered that 35% of her left lung had collapsed, requiring re-expansion with a chest tube. When the California State Assembly was deliberating over legislation to follow AB 1500, the CMA voiced concern about such complications, presenting the legislature with an article from the Journal of the American Medical Association entitled “Complications of Acupuncture,” which dealt chiefly with the problem of pneumothorax.
Other complications leading to structural damage were known to have occurred with acupuncture, including but not limited to cardiac tamponade (an emergency condition in which fluid builds up in the sac containing the heart) caused by too deep of a penetration to an acupuncture point located below the fifth rib, spinal cord damage associated with the ya-men acupuncture point, penetration of the eye as a result of misdirection of needles inserted subpraorbitally or infraoribitally, and damage to the external middle ear.
Elmendorf’s letter gives us another very critical reason why acupuncture, unlike other traditional Chinese therapies such as herbal treatments, came under such close scrutiny: it is an invasive procedure, that is, a procedure that enters the body, by cutting or puncturing the skin or by inserting instruments into the body. Medical expertise is necessary in such an instance because the skin is the body’s first line of defense against bacterial or viral infection. Whereas HIV infection would probably constitute the chief threat to public health from contaminated needles nowadays, in the 1970s the AMA and CMA were concerned about the spread of hepatitis. Outbreaks linked to poorly sanitized, reused needles were known to have occurred in rural parts of China and while such cases were few and far between in the United States, the concern was not unwarranted. In 1984, a rash of hepatitis B infections struck thirty-five patients at an acupuncture clinic in Rhode Island.
The arrival of acupuncture in the United States did not signal the first time medicine had to put its foot down and declare a procedure invasive. The admittedly more extreme case of the lobotomist Walter Freeman sheds light on how the grey area between what is and what is not an invasive procedure can be stretched. Although Freeman was more familiar with neuroanatomy than the average psychiatrist, he was not formally trained as a neurosurgeon and therefore lacked the necessary qualifications to participate in brain surgeries as anything more than a surgeon’s assistant. Rather than put his career on hold to receive surgical training, he devised a new procedure that could be performed in a matter of minutes by anyone with an ice pick. This procedure called for entering the brain through the tear ducts, which are naturally sterile, leading him to reason that, apart from sterilizing the instrument used to perform the lobotomy, there was no need for asepsis.
Knowing he could not perform the new lobotomy in an institutional setting, Freeman began offering his transorbital lobotomy to patients in his private office. Freeman’s critics were often very vocal about how inappropriate they found it for psychiatrists to carry out the work of surgeons. One such critic, David Cleveland, remarked, “the surgeon will shudder, and rightly so, at the thought of cerebral surgery becoming an office procedure in the hands of the usually, very unsurgical psychiatrist.”
Freeman took an adversarial position, asserting that “neurosurgeons were simply trying to stake out the brain as their exclusive property.” In order to reclaim what he perceived as the surgeons’ monopoly on the right to lobotomize, he went to great lengths to proselytize that his new method was so easy, simple, and efficient that anyone from any discipline, not just surgeons, could do it.
It could be argued that Freeman’s lobotomies, although extremely invasive, in fact do not require formal training in surgery to be safe and effective. Acupuncture, too, can indeed be practiced safely and effectively without all of the training of a professional surgeon. Although acupuncture is not lobotomy, is far less invasive, and poses far fewer risks, it technically remains an invasive procedure and complications involving the practice can and have occurred.
The concern about acupuncture being an invasive procedure was not limited to licensed or unlicensed practitioners. The L.A. Times reported that along with the lifting of the Bamboo Curtain, coolie hats, Mao jackets and acupuncture kits were flying off of store shelves. At a hearing on acupuncture in the California State Assembly, legislators expressed concern that laypeople might pick up a book and attempt to practice on themselves. Bob Felt, in an interview with Boston University medical anthropologist Linda L. Barnes, a leading authority on the history of acupuncture in the United States, remarked of informally practicing acupuncture in the 1970s, “we were middle class kids, a lot of us. It was illegal as a practice, and we never thought we would make a living at it. I practiced out of a back room of the bookstore. It was something of an outlaw role. Having gone through our early adult years as outlaws with a feeling of rejection and of not belonging, we probably outlawed it more than it needed to be. But without outlaws, nothing new comes into the culture.” Felt provides an example of the young and naive who dabbled in acupuncture like outlaws in the romantic tradition of Robin Hood. As has been discussed, acupuncture is not a quaint curiosity of the Orient, but a real medical practice with real medical complications. While Felt and others like him might have been well-meaning, acupuncture has no more business being practiced in the back room of a bookstore by amateurs than does a coat hanger abortion.
The public’s disenchantment with Western medicine also made it prey to rampant charlatanism in acupuncture. The flurry of interest in traditional Chinese medicine occasionally led unwitting patients into the offices of opportunists eager to charge an arm and a leg for their seemingly exotic and cutting edge services. From a public health standpoint, what was especially alarming was that many of these “clinics” or “institutes” that seemed to crop up overnight operated more like ‘mills’, processing hundreds of patients daily. These so-called “quackupuncturists” often promised relief from minor afflictions that tend to cure themselves in time, such as headaches, to more permanent problems, such as baldness. One remarkable example of such deception is that of acupuncture ‘institutes’, and ‘centers’ claiming to cure nerve deafness within a few treatments – an experimental procedure that hadn’t shown any clinical success in China.
6. Health Care Delivery Issues in Acupuncture Regulation
AB 1500 was only ten weeks old when the Assembly Committee on Health Manpower held a hearing on acupuncture. The goals of the hearing were to balance their stated desire to help ensure that it became available to the general public to the extent proven therapeutically valuable with the need for protection of public welfare; to protect the public’s right to receive acupuncture on the one hand with the need to protect the public from those who were inadequately trained to administer acupuncture on the other. Dr. Elmendorf was present to represent the California Medical Association’s position:
...I am here to support the second objective of your committee which is really twofold, and that is to protect the public interest, number one, in the sense that if this is of value, let’s find out what that value is, so that the public may receive it, and secondly, that we see to it that they receive it in the proper way, and that they are protected from the development of cult for the exploitation of the public by those who would do so for monetary reasons or whatever.
When asked if the legislature should approach the problem of acupuncture by declaring it a medicine that only physicians could practice, Elmendorf responded:
Well, I would have to struggle with that, as I am sure you are. I would say this, that it would seem that the penetration of the skin with needles does constitute the practice of medicine, although we know of instances where this is done by other than physicians for purposes of diagnosis. We know that earlobes are punctured, for example, by jewelers for ear rings …the procedure of penetrating the skin with needles does carry the risk of infection, it carries risk of penetrating some vital structures, perhaps, and, as you pointed out earlier, it particularly carries the risk of diagnosis and treatment. As you know, we don’t advocate giving morphine for a stomach pain before we know what is causing the pain. One could see the use of acupuncture to relieve a symptom prior to the time an adequate diagnosis was made. So I do believe that the position of the California Medical Association is that this procedure should be in reliable hands. We need to have, in some way, we need to encourage, stimulate, if you would, the medical centers to give a scientific evaluation of this. This is what I think is in legislation now, if it permissive. I would rather not see it mandatory, but if there were some way that we could move this before it gets out of hand, as I think is one of your fears, I would be very much for that, and I am sure the Medical Association would be, too.
In response to questions from Assemblyman William Campbell about how he came to be temporarily relieved of arthritis pains and how acupuncture works, Elmendorf replied:
Whether it is hypnotic or not, which the Chinese vehemently deny, and there seems to be substantial evidence against that theory, as well as some evidence for it, or whether it is a type of somatic phenomenon, I really don’t care, as long as an individual has had adequate diagnosis and is not having a delay in needed treatment, I don’t care how his pain is relieved. There are many people that I have found, from letters all over this country, who are in chronic pain and would like to obtain some way to obtain relief. They will grasp at straws. It is, of course, the fear of this committee, and my fear that they may go too far in this thing. Lets [sic.] try to find out what its value is and how it does work.
A major issue that also came up at the hearing was the impact of AB 1500 on practicing acupuncturists. Dr. William Prensky, Chairman of the Board of the Institute of Taoist Studies, a non-profit organization in California, observed, “we have a major concern that acupuncture, practiced by competent practitioners, not be forced underground in the state of California, and therefore that all practitioners, both competent and incompetent, be forced into the same type of clandestine practice, so that it will forever be impossible to separate those proper practitioners from the improper practitioners.”
Indeed, for the vast majority of Chinese practitioners of acupuncture, AB 1500 effectively stripped them of any autonomy as caregivers to their communities. Whereas they were once largely ignored by the rest of the public as they practiced in the nooks and crannies of their respective Chinatowns across the state, they were now met with interested outsiders seeking relief they could not find elsewhere. Arrests under the new law followed quickly, as the California Department of Consumer Affairs and the Board of Medical Examiners cracked down to emphasize the point that acupuncture was now subject to medical regulation home.
The first such arrest occurred in December of 1972, when a client of George Long, a martial arts instructor and the owner of the George Long School of Kung Fu at 1865 Post Street, San Francisco, notified the Department of Consumer Affairs that Long was offering acupuncture treatment without the proper credentials, and that he had been doing so for quite some time. Long was released on five hundred dollars bail, potentially facing a six hundred dollar fine and up to six months in jail on charges of practicing acupuncture without a medical license.
The most well known of the early arrests of acupuncturists is that of Miriam Lee. On April 16th, 1974, as stunned patients looked on in disbelief, Lee was arrested by agents of the Department of Consumer Affairs on charges of practicing medicine in California without a license in her Palo Alto office at 555 Middlefield Road. She was later freed on five hundred dollars bail and faced an additional five hundred dollar fine and six months in jail if convicted. When Lee appeared at her hearing, over a hundred of her patients showed up as well. News of the widespread support she received drew attention from the legislature, convincing many that the subject of acupuncture was an urgent social and cultural issue as well as a medical one.
Apart from the immediate need to protect the general public from the potential side effects of acupuncture, there was also a need to integrate Chinese medicine into the existing public health model. Members of the acupuncture research project at UCLA maintained in a written statement to the California State Legislature that lifting the restrictions on acupuncture would be premature, as certain measures would have to be taken to ensure that legalization would result in the formation of a safe and ultimately legitimate profession. Their intentions were not to stifle or control acupuncture, but to facilitate a process that would guarantee acupuncturists as much independence and autonomy from the established medical community as possible. They argued, “licensed acupuncturists should operate their own offices, carry their own malpractice insurance, etc., thus allowing them a certain degree of autonomy from other medical practitioners.”
The UCLA research team’s statement summarized the conflict between medical authorities and proponents of acupuncture: the first group believed regulating acupuncture was necessary to prevent exploitation and to minimize harm to the public, while the second group believed physicians were too ignorant about acupuncture and too financially vested in maintaining a status quo to regulate it. These two perspectives, they believed, could be reconciled by legislation that provided licensing of all practitioners, qualifications for licensure, standards of practice, establishment of an Acupuncture Advisory Board, and funds for research. The requirements they believed were necessary for licensure included fluent knowledge of the English language, basic knowledge of anatomy and physiology, basic knowledge of western medicine, basic knowledge of aseptic procedure, and basic knowledge of acupuncture.
The reason they considered a knowledge of anatomy, asepsis, and Western medicine, in general, to be necessary for acupuncturists’ training was solely to prevent complications. In the case of asepsis, for instance, many practitioners of Oriental medicine did not believe in germ theory. In order to prevent the spread of diseases such as hepatitis, the UCLA researchers insisted germ theory should, at least, be respected as plausible until proven otherwise (the document is reproduced in full in the appendix). The incidences of punctured lung, although few and far between, were well known to Western doctors, and this was the chief reason for urging that a basic understanding of anatomical structures be made compulsory in training and certification. That acupuncturists should have a basic understanding of Western medicine may seem ethnocentric, but the researchers argued there were simply too many factors in patient safety, when it came to acupuncture, that Oriental medicine could not account for, such as the ramifications of sticking needles into someone who is taking anticoagulants, or is hemophilic, or the complications that can result from performing electroacupuncture on a patient who has a pacemaker.
Some of these requirements, such as fluent knowledge of the English language, may strike some as excessive or culturally biased. Foreseeing this, the UCLA team argued that it was only fair that patients be able to obtain clear answers from their caregiver, and caregivers must be able to understand the complaints of patients, adding that foreign trained physical therapists, nurses, psychologists, and other caregivers were required to pass examinations by the Medical Board in English, and that acupuncturists should share the same responsibility as there fellow caregivers.
In 1975, legislators deliberated over a new bill that was to have profound impact on acupuncturists. Senate Bill 86 was to move acupuncture from being an experimental procedure performed behind the walls of universities back to private practices. It called for the creation of a governor-appointed, seven-member Acupuncture Advisory Committee, consisting of five non-physicians with at least ten years’ experience in acupuncture and two physicians with at least two years’ experience in acupuncture to assist the California Board of Medical Examiners. It also provided, for the first time, a state certification program for acupuncturists by the Board and the automatic certification of acupuncturists upon proving they were in practice for five years or for three years on condition they participate in a designated acupuncture program. Furthermore, the bill permitted certified acupuncturists to practice on patients with a referral or diagnosis from a physician, surgeon, dentist, podiatrist, or chiropractor, and for the acupuncturist to report back to the referring doctor the nature and effects of the treatment upon its completion. Finally, it called for the dismissal of all pending cases of practicing medicine without a license for all those who met the criteria to qualify as acupuncturists under the new guidelines, and for all convictions of acupuncturists for practicing without a license pending on appeal to be remanded to trial court for the verdicts to be appealed and judgments of acquittal entered.
7. Criticism of Acupuncture by Western Doctors
Some medical anthropologists, including Paul Root Wolpe and Linda L. Barnes, have argued that the call for regulation of acupuncture by medical doctors was an attempt to assert their authority over and defend the dominant paradigm of western medicine against the threat of traditional Chinese medicine. Barnes argues that the medical profession’s adversarial reaction to the public’s sudden interest in acupuncture was twofold: first they asserted control over acupuncture through the demand for research and clinical trials; secondly, they regulated practitioners in what amounted to another form of social control. Of the emphasis on pain management in acupuncture research and the neglect to study other areas in which acupuncture might prove an effective form of treatment, Wolpe additionally argues:
…the entire theoretical framework of traditional Chinese acupuncture had to be replaced … Biomedicine had no means of assessing the validity of these cultural models. Traditional acupuncture theory and treatment philosophy was therefore all but discarded, and acupuncture analgesia/anesthesia—a very small part of traditional acupuncture’s therapeutic claims (acupuncture anesthesia was not used in China until the 1960s)—was presented as acupuncture’s only true potential contribution to Western medicine.
Barnes echoes Wolpe’s suspicion of biomedical “authorities” in her article “The Acupuncture Wars: The Professionalizing of Acupuncture in the United States”:
To control the actual practice of acupuncture, U.S. physicians argued that it should be categorized as an experimental procedure and that it should only be performed in a research setting either by a doctor or under a doctor’s supervision … by appearing to support research, and by creating structured channels through which to engage with this foreign modality, biomedical authorities could claim that the playing field was not only level but also open to new approaches.
Her assessment of the medical profession is unflattering. As we have seen and as Barnes also concedes, between acupuncture and Western medicine, the latter modality was the one that was at a disadvantage, as it was met with challenges posed by the former’s having taken on a special meaning to early lay practitioners, patients, and the American public “as part of a broader cultural stance of resistance in the pursuit of alternative ideals.” As recently as 1999, Wolpe continued to argue that “Modern American biomedicine has been singularly successful in excluding competitors from challenging its legitimacy.”
The case that the medical profession has sought to undermine the profession of acupuncture does not survive scrutiny. As has been described, medical professionals such as Dr. Thomas Elmendorf and the UCLA acupuncture research team demonstrated a sincere willingness to explore the potential of acupuncture and to even see it integrated into mainstream medicine. By 1997, this integration was realized so completely that the National Institute of Health held a two and a half day seminar on acupuncture for the continuing education of physicians.
Not only is this evidenced by historical documents, but by the timeline of acupuncture legislation, which illustrates a trend towards autonomy. The passage of Senate Bill 86 (Moscone-Song), passed in 1975, legally moved acupuncture from an experimental procedure performed behind the walls of California’s universities back to the private offices of community doctors. SB 86 was a major victory for acupuncturists on several counts. By creating an advisory committee answerable to the Board of Medical Examiners and a state certification program, it paved the way for recognizing acupuncture as a legitimate therapeutic profession.
The victory for acupuncturists was bittersweet. To the chagrin of many acupuncturists, the required diagnosis and referral by a Western doctor was difficult for patients to obtain, as few medical doctors were willing to refer patients to acupuncturists for fear of compromising their credibility among their peers, many of whom believed that further experimentation was necessary to determine acupuncture’s effectiveness. The requirement of a Western diagnosis was also seen as counterproductive to acupuncturists, whose methods of diagnosis were radically different.
Legislation that followed between 1978 and 1998, however, reversed many of the initial restrictions placed on acupuncturist, including the requirement of a Western diagnosis and doctor’s referral. The legislation’s trajectory reveals a progression from initial easing up of restrictions, to professionalization via certification, to self-regulation; a path towards recognition and autonomy.
S.B. 1106, passed in 1978, had several effects. It added four public members to the acupuncture board, each of whom would serve a three-year term, authorized the board of Medical Quality Assurance to approve apprenticeship programs for acupuncturists as specified, established standards for continuing education for acupuncturists, required anyone who failed to renew a certificate within five years of its expiration date to demonstrate skills in acupuncture in addition to any required examinations, and called for the retaining of ten percent of the application fee for an acupuncturist’s certificate if the application were to be denied or withdrawn. It deleted the “grandfather” provision, which allowed a certificate to be issued to anyone who had performed acupuncture for five years. Finally, it required acupuncturists to post their certificates in each location of practice and specified the fee for a duplicate certificate.
A.B. 1391, which passed 74-25 in the legislature in 1979, repealed that part of SB86 that required a prior diagnosis or referral from a physician, surgeon, chiropractor, dentist, or podiatrist and the requirement that acupuncturists report back to the referring doctor.
In 1980, A.B. 3040 replaced the Acupuncture Advisory Committee with an Acupuncture Examining Committee, and expanded the scope of practice to include electroacupuncture, herbal remedies and dietary supplements, Oriental massage, and other traditional Chinese therapies. It also articulated a necessity that individuals practicing acupuncture be subject to regulation and control as primary care physicians.
Finally, in 1998, S.B. 1980 and S.B. 1981 removed the Acupuncture Committee from Medical Board jurisdiction, renaming it the California Acupuncture Board.
8. Conclusion
The published analyses of the American medical profession’s negotiation of the sudden introduction and popularity of acupuncture in the early 1970s do not do justice to what was actually a very and progressive response on its part. Authors like Wolpe and Barnes tend to downplay the open-mindedness with which Western physicians met acupuncture in the 1970s, by reifying the medical community and portraying it as an ignorant, hostile, and monolithic entity bereft of any diversity of opinion. Paul Starr has argued, on the contrary, that the uniformity and cohesiveness of the medical profession broke down in the 1970s, as the influx of foreign doctors transformed it into the most ethnically diverse of the upper-income occupations.
It should not be assumed that this critical evaluation of these authors’ perception of Western medicine’s reaction to acupuncture in the 1970s is only maintained by those partial to the former or suspicious of the latter. In his acupuncture textbook, Understanding Acupuncture, Dr. Stephen Birch echoed similar sentiments:
[Wolpe] proposes that by placing acupuncture in the ‘holding cell’ of experimental status, that threat [to western medicine] was eliminated. For those who participated in acupuncture licensure efforts, it is clear that both physician opposition and internal conflict among acupuncture’s philosophical and ethnic divisions retarded those efforts. However, the extent of any physician-funded opposition is unclear. And, regarding what future in-depth research will reveal regarding the political role of physicians, the contribution if individual physicians should not go unmentioned.
The medical profession did indeed encourage legislative restriction on the promising, exciting, and exotic therapy that the public found to be acupuncture in the early 1970s. As we have seen, their reasons for doing so were chiefly out of concern for public welfare. After a period of investigation by open-minded Western doctors and legislators, however, acupuncture was put on a track which led to it becoming fully integrated into mainstream medical practice.
Bibliography
Primary Sources:
“Acupuncture Arrest in Palo Alto.” The San Francisco Chronicle, April 18, 1974
“Acupuncture Bill OKd.” Los Angeles Times, Aug 15, 1972; Pp. C3
“Acupuncture: Canadian anesthetists report on visit to China.” Canadian Medical Association Journal, November 16, 1974, Vol. 3.
“Acupuncture Craze Gets A Sharp Poke In Medical Report.” Wall Street Journal. June 18, 1974.
Adler, Bernard C., MD. “Letter: Acupuncture.” Journal of the American Medical Association. Nov. 13, 1972. Vol. 222, No. 7.
American Acupuncture Anesthesia Study Group. Acupuncture Anesthesia in the People’s Republic of China: A Trip Report of the American Acupuncture Anesthesia Study Group. Washington: National Academy of Sciences, 1976.
“Behind the Bamboo Curtain.” Time Magazine, Nov. 7, 1949.
Bonica, John J., MD. “Therapeutic Acupuncture in the People’s Republic of China: Implications for American Medicine.” Journal of the American Medical Association. Vol. 228, No. 12, June 17, 1974.
California State Senate Committee on Health and Welfare. Staff Analysis of S.B. 86 (1975). Microfilm at the California State Archives, drawer 1, reel 4, item 26.
California State Legislature. Acupuncture: A Hearing before the Assembly Select Committee on Health Manpower. Sacramento: October 19, 1972.
California State Legislature. Senate Bill 86 (1975), Governor’s Chaptered Bill File, California State Archives. Microfilm, drawer 3, reel 3, item 30.
California State Legislature. Senate Bill 1106 (1978). Governor’s Chaptered Bill File, California State Archives. Microfilm drawer 3, reel 3, item 53.
California State Legislature. Assembly Bill 1391 (1979). Governor’s Chaptered Bill File, California State Archives. Microfilm drawer 3, reel 3, item 57.
Carron, H., B.S. Epstein, and B. Grand. “Complications of Acupuncture.” Journal of the American Medical Association, Vol. 228, Issue 12, 1552-1554, June 17, 1974
Ching, Frank. “China: It’s the Latest American Thing!” New York Times, Feb 16, 1972.
Dallos, Robert E. “New U.S. Craze: Acupuncture Kits to Bamboo Pipes.” Los Angeles Times. February 26, 1972.
Department of Alcohol and Drug Programs, State of California. Comparison of Acupuncture to Methadone Treatment of Narcotic Addiction: Interim Report to the Legislature. January, 1989.
Duffy, Gordon. Letter to Governor Ronald Reagan. August 4th, 1972. Governor’s Chaptered Bill File, California State Archives. Microfilm drawer 3, reel 3, item 13.
Elmendorf, Thomas N., M.D. “A Letter on Acupuncture.” California Medicine: The Western Journal of Medicine, August 1972, Pp. 75-76.
“First Arrest under New Acupuncture Law.” The San Francisco Chronicle, Dec. 16, 1972.
“Herbs, Leaves and Eels’ Blood Fill Medicine Gap in Red China.” New York Times, March 20, 1966.
Johnson, Susan, L.Ac. Interview with author. March 2, 2009.
Kuiper, John J., M.D. “Pneumothorax as Complication of Acupuncture.” Journal of the American Medical Association, September 9, 1971. Vol. 229, No. 11.
Lerner, Max. “And Now Americans Embrace the China Craze.” Los Angeles Times, Feb. 21, 1972.
Mark, Lester C. “Letter to the Editor.” Journal of the American Medical Association. (223:922) 1973.
Mark, Lester C., MD. “Double-blind Studies of Acupuncture.” Journal of the American Medical Association. September, 1972. Vol 225, Pp. 1532b.
National Institute of Health. NIH Consensus Development Conference on Acupuncture, Bethesda, Maryland. November. 3-5, 1997.
Nelson, Harry. “Nobel Winner Explains Use of Acupuncture as Anesthesia.” Los Angeles Times, June 1, 1972.
Nelson, Harry. “Acupuncture Not a Cure-All, Chinese Says.” Los Angeles Times, Nov. 1, 1972.
Oganesoff, Igor. “Drug, MD Shortage Forces China to Turn to Ancient Remedies.” Wall Street Journal. July 10, 1963.
Perlman, David. “500 S.F. Doctors See Acupuncture.” San Francisco Chronicle. May 10, 1972.
Perlman, David. “Acupuncture Tried at UC.” San Francisco Chronicle, October 28, 1972.
Reston, James. “Now, About My Operation in Peking.” New York Times. Jul 26, 1971.
Rosen, Samuel. “I Have Seen the Past and It Works,” New York Times, Nov. 1, 1971.
Rosen, Samuel MD. “On Quackupuncture,” New York Times, May 28, 1974.
Shapiro, Arthur K., MD. and Edmund Y.M. Chein BS. “Evaluation of Acupuncture.” Journal of the American Medical Association. June 11, 1973. Vol. 224, No. 11.
Shapiro, Arthur K., MD., and Edmund Y.M. Chein, BS. “Letter: A Mini Symposium on Acupuncture.” March, 1974. Vol. 227, Pp. 1122-1123.
The Practice of Acupuncture: A Legislative Position Paper. California State Archives. Microfilm drawer 1, reel 4, item 26. Reproduced below. (see Appendix).
Weisser, Peter. “Acupuncture at the Capitol.” San Francisco Chronicle, June 30, 1972.
Secondary Sources:
Barnes, Linda L. “The Acupuncture wars: The Professionalizing of Acupuncture in the United States – A View from Massachusetts.” Medical Anthropology, Volume 22, Number 3, July-September 2003.
Birch, Stephen J., and Robert L. Felt. Understanding Acupuncture. New York: Churchill Livingstone, 1999.
Commission on California State Government Organization and Economy. Acupuncture: A Complementary Therapy Framework. Sacramento: Little Hoover Commission, 2004.
Duke, Marc. Acupuncture. New York: Pyramid House Books, 1972.
El-Hai, Jack. The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness. Hoboken: Wiley, 2005.
Elmar T. Peuker, MD; Adrian White, MD; Edzard Ernst, MD, PhD; Franz Pera, MD. “Traumatic Complications of Acupuncture: Therapists Need to Know Human Anatomy.” Archives of Family Medicine, Vol. 8, No. 6, November, 1999.
Fairbank, John K. and Kwang-Ching Liu, eds. The Cambridge History of China, Vol. 11: Late Ch'ing, 1800-1911, Part 2. Cambridge: Cambridge University Press, 1980.
Kent, George P. “A Large Outbreak of Acupuncture-Associated Hepatitis B.” American Journal of Epidemiology, Vol. 127, No. 3
MacMillian, Margaret. Nixon and Mao: The Week That Changed the World. New York: Random House, 2007.
Melzack, Ronald. “How Acupuncture Works: A Sophisticated Western Theory Takes the Mystery Out.” Psychology Today, 7 1 June 1973.
Musto, David F. Quest for Drug Control : Politics and Federal Policy in a Period of Increasing Substance Abuse, 1963-1981. New Haven: Yale University Press, 2002.
Ortner, Sherry B. “Theory in Anthropology since the Sixties.” Comparative Studies in Society and History, Vol. 26, No. 1, (Jan 1984).
Risse B. Guenter, M.D., Ph.D. Modern China and Traditional Chinese Medicine: A Symposium Held at the University of Wisconsin, Madison. Springfield: Charles C. Thomas, 1973.
Said, Edward. Orientalism, New York: Vintage Books, 1979.
Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.
Wall, Patrick D., and Ronald Melzack. "On the Nature of Cutaneous Sensory Mechanisms." Brain, 85:331, 1962.
Wang, Zhenguo, Chen Ping, and Xie Peiping. History And Development of Traditional Chinese Medicine. Beijing: Beijing Science Press, 1999.
Wolpe, Paul Root. “The Maintenance of Professional Authority: Acupuncture and the American Physician.” Social Problems, Vol. 32, No. 5, June 1985.
Wolpe, Paul Root. “Alternative Medicine and the AMA.” in Robert Baker et al. (eds.), Ethics in American Medicine. The American Medical Ethics Revolution. Johns Hopkins University Press, 1999.
Zhiyong, Chen. “Of Pins, Needles, and Pain Relief”. China Daily, Feb. 15, 2006.
Appendix
The Practice of Acupuncture: A Legislative Position Paper
Available on microfilm at the California State Archives, file 1, reel 4, item 26
A. The Problem
Although acupuncture is probably the world’s oldest known system of medicine, its introduction into the American healthcare delivery system has been highly controversial. Legislation enacted by different state legislatures has varied from total legalization (Nevada) to specific restrictions even upon licensed physicians (New York). Basically, two opposing (but not necessarily conflicting) points of view have emerged: “medical authorities” argue that some kind of regulatory controls must be exercised over non-physician practitioners to prevent exploitation and/or danger to the public, and they cite published reports of infection, nerve damage, cardiac arrest, pnrumothorax, etc. following acupuncture treatment. On the other hand, non-physician acupuncturists (and their supporters) argue that they should not be regulated by physicians who know almost nothing about it and who have a vested financial interest in maintaining a status quo which allows them to practice legally.
B. The Solution
We believe that these two positions can be reconciled by the enactment of legislation that provides for the following:
(1) Licensure of all practitioners.
(2) Qualifications for licensure.
(3) Standards of practice.
(4) Establishment of an Acupuncture Advisory Board.
(5) Funds for research.
C. Licensure of all Practitioners
Although in some states, non-physician acupuncturists are permitted to practice by referral or under the supervision of licensed physicians, the great majority of physicians are untrained in acupuncture and therefore are unable to evaluate the training, experience, and competence of acupuncturists, nor the appropriateness of any technique which they wish to deploy. Therefore, we feel strongly that all practitioners of acupuncture (including physicians and dentists) should be specifically licensed and regulated by the Board of Medical Examiners, if they are able to meet the minimal qualifications listed above. Acupuncture licenses should be subject to periodic review so that appropriate sanctions can be taken against incompetent or unethical practitioners. Licensure will insure at least minimal training and competence, and will permit acquisition of appropriate malpractice insurance and professional certification of non-physician acupuncturists. Like osteopaths, chiropractors, nurse practitioners, registered physical therapists, and other medical paraprofessionals, licensed acupuncturists should operate their own offices, carry their own malpractice insurance, etc., thus allowing them a certain degree of autonomy from other medical practitioners. The penalty for practicing acupuncture without a valid license should be a misdemeanor offense.
D. Qualification for Licensure
In order to qualify for licensure, all applicants should be required to pass written and practical examinations demonstrating knowledge in the following areas:
(1) Fluent knowledge of the English language. In order to communicate effectively with western patients and referring physicians, fluency in English is essential. It is highly unethical to place patients in a situation in which they cannot communicate easily with the therapist, not obtain clear answers to their questions. In addition, Oriental non-physician acupuncturists may attempt to treat inappropriate symptoms unless they readily understand the specific basis for referral. Just as it is the responsibility of foreign trained physicians, nurses, psychologists, physical therapists, etc. to pass licensing board in English, so should acupuncture applicants be required to pass written and oral examinations in English. Although one may argue that a translator may obviate the need for this requirement, in practice it is not a satisfactory substitute, and in addition, such an arrangement is impossible to enforce.
(2) Basic knowledge of anatomy and physiology. Applicants should demonstrate reasonable knowledge of the locations and functions of the major organs, blood vessels, and the peripheral nerve pathways. For example, the location of the lungs should be well known in order to generate respect for the possibility of pneumothorax following needle insertion in the chest or upper back areas.
(3) Basic knowledge of western medicine. This would include familiarity with western diagnostic terms and disease entities. For example, acupuncturists should know the ramifications for treating a hemophiliac or a patient taking anticoagulants, and that electro-acupuncture across the chest is contraindicated in patients with cardiac pacemakers. In addition, knowledge of basic first aid techniques (e.g. Cardiopulmonary resuscitation, etc.) should be required.
(4) Basic knowledge of aseptic procedures. Although many Oriental practitioners do not believe in the “germ theory” of disease, we feel that this notion should be respected (pending evidence to the contrary), in order to prevent the spread of infectious diseases (e.g. hepatitis). Therefore, familiarity with the techniques and principles underlying the use of needle sterilization equipment and aseptic procedures must be demonstrated.
(5) Basic knowledge of acupuncture. An appropriate examination can be prepared to determine expertise in the principles and practice of acupuncture. Although there are many different systems of acupuncture (e.g. Chinese, Korean, Japanese Kyodoraku, Do-In, Shiatsu, etc.), all are based on fundamental meridian theory, and the point combinations used to treat most illnesses are quite similar. This portion of the licensure should be very fundamental with an emphasis on clinical technique. It is with respect to this item that the Advisory Board can pass judgment on a case by case basis.
E. “Grandfathering” of Applicants
We are strongly opposed to “grandfathering” applicants simply because they have a variety of certificates, licenses, or other documentation certifying prior training and experience. First of all, such “evidence” is obtainable in Hong Kong and elsewhere for a small fee, and it is almost impossible to determine the true validity of such claims. Secondly, many “experience” acupuncturists who insist that certain problems can be treated only by causing third degree burns and nerve damage should not be permitted to practice simply because they have been doing so illegally for an arbitrary period of time. Thirdly, most competent and experienced acupuncturists can easily meet the requirements for licensure listed above. The Board of Medical Examiners should be permitted to waive certain requirements in exceptional cases.
F. Standards of Practice
Licensed non-physician acupuncturists should be permitted to treat patients only on the basis of the diagnosis and written referral of a licensed physician or dentist (who should be prohibited from fee-splitting). This will insure that primary diagnostic responsibility remains in the hands of appropriately trained medical practitioners. Specific standards of practice should be established to delineate clearly the techniques which are permissible (e.g. needle insertion, moxibustion, auriculotherapy, etc.). Finally, appropriate consent forms should be signed by patients, and detailed records of all procedures used should be kept for at least three years.
G. Establishment of an Acupuncture Advisory Board
Given the complexities of determining qualification for licensure and standards of practice, an Acupuncture Advisory Board to the Board of Medical Examiners should be appointed by the Governor. Although it has been said that a camel is a horse that was designed by a committee, a judiciously selected board comprised of well known and highly respected professionals active in the area of acupuncture can be created. For the sake of all practicing acupuncture as a respected medical profession, it is important that the Board be composed of prestigious advocates of acupuncture who will win the support and cooperation of the medical community. Antagonism between the Advisory Board and the Board of Medical Examiners will serve no one’s interest. We recommend that the Advisory Board be composed as follows:
(1) A representative of the Board of Medical Examiners, to serve as a liaison for the Advisory Board.
(2) A representative of the California Medical Association, to serve as a liaison with the CMA.
(3) Two physicians who are trained and experienced in the field of acupuncture.
(4) One dentist who is trained and experienced in the field of acupuncture.
(5) Five non-physician acupuncturists (with at least one Chinese, one Japanese, and one Korean member), all of whom meet the qualifications listed.
(6) A non-physician research scientist who is trained and experienced in acupuncture, and who is readily knowledgeable of the clinical data concerning the proven effectiveness of acupuncture, as well as the potential complications of acupuncture.
(7) A non-physician academician who is trained and experienced in acupuncture, and who is trained and experienced in educational testing and test design.
H. Funds for Research
In light of the fact that much remains to be discovered about the effectiveness, complications, and contraindications of acupuncture, a portion of the fees received from licenses should be distributed to approved, ongoing medical school research projects investigating acupuncture. All licensed acupuncturists should be required to report their results to the Advisory Board on a semiannual basis, which will provide important clinical research information.
I. Urgency
Although some may argue that legislation is urgently needed which will permit non-physician acupuncturists to practice immediately, we feel that the safety and best interests of the people of California are served only if all of the safeguards we have outlined above are enacted, no matter how long it takes to implement them. Acupuncture is now widely available throughout California, and although certain non-physician acupuncturists may achieve better therapeutic results than physicians now practicing, we believe that this is outweighed by the potential dangers which may result to the public if these safeguards are not provided
