This chapter examines the migration of the Chinese ‘cultural product’ of acupuncture to countries of the Imperium Hispanicum that have not, in general, experienced a marked influx of Chinese migrants and, in some cases such as Guatemala, experienced no Chinese migration at all to support such a cultural migration. Political economy; similarities of praxis; and revolutionary representations of universal health coverage are all factors that may help to explain the migration of acupuncture to Cuba, Guatemala, and the Philippines; all former colonies of the Spanish Empire. Forms of economic deprivation and structural violence directed towards a group – or as in the case of Cuba, towards an entire country – that thwarts access to healthcare, are also a common theme across these three case examples. However, by virtue of unique factors particular to a given time, place, and set of political, economic, and other social circumstances, each context may have been uniquely prepared to adopt and incorporate elements of Chinese medical practice into their local healthcare.
It might be assumed that migration of ‘culture’, or, more accurately, of a given group’s order and meaning, is primarily, or even solely, a consequence of the migration of people. However, the transmission of health practices and the understandings of health from one group to another may also be linked to factors other than migration. Political economy, similarities of praxis, and revolutionary representations of universal health coverage, are all factors that may help to explain the migration of acupuncture to Cuba, Guatemala, and the Philippines respectively; all former colonies of the Spanish Empire.
The factors of political economy, trade, foreign aid, and other forms of international soft power may lay a foundation for such migrations of order and meaning from one place to another. Sino-Latin American trade and economic relations have developed at a ‘spectacular pace’ in the late twentieth century (Dominguez 2006: 1). From 1990 to 2004, China’s imports from Latin American countries increased from US$1 to $20 billion; with Chinese exports to Latin America increasing from US$432 million to $15 billion (Ibid.). Chinese companies have invested ‘at least $25 billion in Latin America since 2005’ (Gallagher 2010: 10). At the first ministerial meeting of the ‘Forum of China and the Community of Latin American and Caribbean States’, held in Beijing in January 2015, President Xi Jinping’s goal for the next five years included US$500 billion in trade with the Latin American and Caribbean region and US$250 billion of direct investment (Dollar 2017).
Factors of political economy can also be identified in the antipathy that many Latin American countries share with China for American hegemony and imperialism (Dominguez 2006). Some Latin American governments have even viewed the People’s Republic of China (PRC) as a means towards ‘independence from the political influence of the United States and the economic dominance of Western institutions’ (Ellis 2009: 1). At present, China continues to be an important economic and diplomatic force in Latin America.
In order to identify the factors that may have facilitated the migration of acupuncture to the countries of the former Imperium Hispanicum, this chapter will examine the three case studies of Cuba, Guatemala, and the Philippines.
In December 2010, the Cuban postal service issued four stamps to commemorate the fifty years of diplomatic relations between the PRC and Cuba. The PRC has provided a vital source of funding for Cuba, and has been Cuba’s second largest trading partner and exporter of goods after Venezuela, with annual bilateral trade reaching approximately US$2.4 billion in 2015 (Kuo 2016).
Since 2002, the majority of physicians in Cuban medical schools received training in acupuncture, and all Cuban hospitals offered acupuncture anaesthesia for surgical procedures (Lo 2011). The use of acupuncture anaesthesia in surgery occurred in nearly 10% ‘of the 336,622 major surgeries performed in 2008’ (Stafford 2010: 45). However, the migration of acupuncture to Cuba pre-dated these recent economic ties and was locally supported, irrespective of Sino-Cuban relations; which in actuality were quite sporadic throughout the Cold War. Furthermore, the formal migration of acupuncture to Cuba had seemingly little to do with the presence of Chinese in Cuba since the nineteenth century.
Mass emigrations from China that occurred between the nineteenth and mid-twentieth centuries are known collectively as the Chinese diaspora. Many of these migrations to Spanish colonies were due to economic deprivation in China and the promise of a better life in new lands. From 1847 to 1873 more than 200,000 Chinese (primarily farmers from Canton) arrived in Cuba with promises of employment that would lead to fortunes; though in reality they faced indentured servitude (Delgado Garcia 1995). This particular chapter of the Chinese diaspora was a result of numerous international changes, including the Treaty of Nanking that ended the Opium Wars and resulted in the ‘creation of Hong Kong as an outpost of British imperialism’; facilitating access to labourers from South China (McKeown 1999: 313). The resulting increase in Chinese labour migration was often made via Hong Kong (Ibid.). Early nineteenth-century abolitionist campaigns in the United States and England that resulted in the restructuring of slave labour prepared the way for a new wave of Chinese migration and facilitated the Spanish colonists’ procurement of Chinese workers (Dabney 2006).
The Spanish colonists in Cuba already had experience with the Chinese, having worked alongside Chinese traders over several centuries in the Philippines (Dolan 1991). The Chinese who ultimately made their way to Cuba were predominantly poor peasants from Southeast China, who believed that labour on sugar or tobacco plantations would eventually bring them wealth (Dabney 2006). Although the Chinese contracts stated that they were wage labourers, their contracts were usually sold to plantation owners for the equivalent of US$60.36 (Ibid.). Subsequently, the Chinese workers were paid a minimal amount and, for the most part, treated as indentured servants (Ibid.).
The Chinese maintained their community in Cuba in an area called Sagua la Grande. This area eventually housed a Chinese theatre, and numerous service businesses including tailors, barbers, candy stores, gambling houses, opium shops, and Chinese physicians (Dabney 2006). The Spanish colonists were reported to have held the Chinese physicians in higher esteem than their own physicians, ‘whom nobody trusted’ (Ibid.: 178).
Along with Chinese medical practices, an abundance of plural ethnomedicines were practised throughout nineteenth century Cuba. However, just as Chinese medical practices were practised almost entirely within Chinese communities, the practices of the indigenous Guanahatabey and Ciboney, the Taino Indians, African slaves, and immigrants from other Caribbean islands were also not integrated into Cuban State healthcare of the nineteenth to mid-twentieth centuries (Volpato et al. 2009).
Similar to the trajectory of local and indigenous practices in China – which were initially dismissed by Mao Zedong and the Chinese Communist Party as ‘old medicine’ before being embraced by Mao as a ‘national treasure’, that could be used to redress rural health disparities – (Taylor 2005), Fidel Castro originally rejected all indigenous, non-biomedical practices as archaic (Rosenthal 1981; Cochetti 2008). Both Cuban and Chinese Communism embraced modernity and scientism while rejecting the past (Kadetz Chapter 42 in this volume). Modernisation was the discourse that fuelled the early Cuban communist State (Cochetti 2008).
Following the Cuban revolution (1953–1959), local healthcare practices, including religious practices, were actively discouraged. For example, beginning in 1961, Chinese pharmacies in Cuba were systematically closed until only one remained open (Stafford 2010). If biomedical practitioners used or referred patients for non-biomedical practices, they would receive sanctions from the Ministry of Public Health (Brotherton 2005). Hence, the State’s initial rejection of local non-biomedical healthcare was further supported by Fidel Castro’s renewed emphasis on the biomedical modernisation of Cuba, and the centrality of modern biomedicine to the communist State.
In Castro’s 1953 speech, La Historia me Absolverà (‘History will Absolve me’), the health of the population is proclaimed to be an important indicator of the success of governance. And in the 1975 Cuban constitution, health was incorporated as a right of Cuban citizens and the responsibility of the State (Official Gazette of the Republic of Cuba 2003: 3). As a result of this constitutional change, Castro’s government instituted the Ministry of Public Health along with ‘a national health system, the nationalization of private clinics and pharmaceutical companies and social and rural health care services at little or no cost’ (Stafford 2010: 42). The goal of these changes was to provide universal access to biomedicine.
Interestingly, though, it was during this early post-revolutionary period that acupuncture started being utilised in place of specific biomedical procedures, such as acupuncture analgesia during the mid-1970s. However, the teaching lineages of acupuncture in Cuba cannot be traced to the Chinese migrants living in Cuba, nor indeed to China specifically (Padron Caceres and Perez Vinas 2005). In 1962, after a seminar in Havana was hosted by a physician who founded the Medical Institute of Acupuncture in Argentina, Floreal Carballo, acupuncture was formally, albeit minimally, introduced into the Cuban healthcare system (Acosta Martínez 2000). Further acupuncture courses during the 1980s and 1990s employed American acupuncturists (Padron Caceres and Perez Vinas 2005). Despite its acceptance in certain circles, acupuncture would not be fully accepted by the Cuban government and medical community until 1988, when three consultants from military academies in North Korea, North Vietnam, and the PRC were invited by the Minister of Military Affairs of Cuba to organise a speciality of traditional military medicine (Ibid.). Acupuncture would then go on to become part of a medical speciality that was incorporated into the national healthcare system under the rubric of Medicina Tradicional y Natural (MTN).
MTN was formally integrated into the Cuban healthcare system in 1992 through a national mandate (Applebaum et al. 2006). By 1995, a State commission was formed by the Ministry of Health for the development of MTN throughout Cuba (Ibid.). In 1999, the National Program for MTN approved the use of acupuncture, homeopathy, chiropractic, and native medicinal plants into the national health system (Stafford 2010). But what can explain this marked departure from the State’s initial embrace of biomedical modernity and rejection of non-biomedical practices?
The Cuban government’s reversal in its acceptance of acupuncture was largely an outcome of the constitutional commitment to universal healthcare that was severely challenged by the US embargo to Cuba. The United States has held an ongoing trade embargo against Cuba since 1961; the longest such embargo in modern history (Garfield and Santana 1997). However, the first three decades of the embargo had negligible effects on Cuba and Cuban healthcare, which were protected by maintaining 70% to 90% of international trade (which included pharmaceuticals and medical supplies) with Soviet bloc countries (Ibid.).
According to Garcìa (2002), the Cuban government was well aware that the blockade against Cuba could become global and, therefore, planned for self-sufficiency, particularly in terms of healthcare. In the late 1980s, Cuban military policy acted on the need for self-sufficiency and opened the Central Laboratory of Herbal Medicine at the Higher Institute of Military Medicine, thereby taking the first steps towards the formal integration of traditional medicine (MTN) into the Cuban healthcare system (Ibid.; Stafford 2010). The military’s preparatory steps towards the widespread use of MTN were unerringly prescient, for within a matter of years, Cuba’s protection from the ongoing US embargo vanished with the dissolution of the Soviet bloc.
Cuba had produced sugar for the Soviet Union, which paid higher than world market prices for Cuban exports, and exported Soviet goods in return (Garfield and Santana 1997). After the collapse of the Soviet bloc in 1989, Cuba lost 85% of its foreign trade; with an 80% reduction in Cuban exports and a 70% reduction in Soviet bloc exports to Cuba from 1989 to 1993 (Ibid.). Cuba’s Gross National Product ‘declined by 35%; and the value of imports from all sources declined from US$8 billion to $1.7 billion’ (Ibid.: 15). Even though the PRC became Cuba’s second largest trading partner (with an increase in Cuban imports from 4.3% in 1996 to 10.9% in 1991), with the dissolution of the Soviet Union, Cuba had not only lost its most important trading partner, but also its primary source for the raw materials for pharmaceutical production (Dominguez 2006: 10; Stafford 2010).
To add to Cuba’s plight, the United States, at this juncture, strategically exacerbated trade restrictions in its embargo against Cuba (Garfield and Santana 1997: 15). In 1992, the U.S. embargo was made even more punitive with the passage of the (ironically titled) ‘Cuban Democracy Act’, whereby all US subsidiary trade to Cuba, including trade in food and medicines, was prohibited (Stafford 2010). Furthermore, any ships docking in Cuba were prohibited from docking at U.S. ports for six months thereafter, even if their Cuban cargoes were solely humanitarian goods (Garfield and Santana 1997: 15). It could be argued that the perverted logic of the Cuban Democracy Act (ie., that democracy in Cuba would be promoted by completely isolating the island economically) was, in fact, a direct reversal of the logic of neoliberalism; namely, that democracy is only fully promoted through free markets (Friedman 2002), and moreover a complete rejection of the democratic principles of sovereignty and autonomy upon which the United States was founded.
Thereafter, the United States’ application of substantial pressure on other countries to cease both trading with, and providing humanitarian goods to Cuba, resulted in a near-global trade blockade against Cuba. In terms of biomedicine, the Cuba Diplomacy Act strictly prohibited trade of ‘medicines or medical devices with 10% or more of their components made by a US company or foreign subsidiary of a US corporation […] medical supplies for humanitarian aid can be sent to Cuba only after the Cuban government holds free and fair elections’ (Stafford 2010: 43).
Such restrictions created severe issues in accessing pharmaceuticals and the materials for the domestic production of pharmaceuticals in Cuba, particularly considering that the global pharmaceutical industry was predominantly controlled by U.S. transnational corporations. The dollar value of imports for health to Cuba fell from US$227 million in 1989 to US$67 million in 1993 (Garfield and Santana 1997: 18). Many of the hard-won benefits of the Cuban healthcare system were quickly reversed, despite the State’s organised targeting of limited resources to vulnerable populations, including the elderly, children, and women (Applebaum et al. 2006). Overall, the resulting shortage of pharmaceuticals was associated with a 67% increase in deaths due to infectious and parasitic diseases; a 77% increase in deaths due to influenza and pneumonia from 1989 to 1993; and a 48% increase in tuberculosis deaths from 1992 to 1993 (Garfield and Santana 1997: 17).
Hence, it was in this context that in 1992 the Cuban government completely reversed its position on the use of non-biomedical practices; reminiscent of Mao’s need to reverse his position disparaging the use of Chinese medical practices in order to redress access to rural healthcare more than twenty years earlier (Applebaum et al. 2006). Following specific orders from Fidel Castro, certain standardised non-biomedical healthcare practices 1 were promoted as an important element of Cuban healthcare (Cooper, Kennelly, Ordunez-Garcia 2006). Suddenly, several non-biomedical practices, including acupuncture, that had hitherto been slowly and, at best, selectively and reservedly promoted or researched by the Cuban State could now scarcely be integrated into the national healthcare system quickly enough. 2
The migration of acupuncture to Cuba was, therefore, an outcome of a very specific political economic context, while the migration of acupuncture to Guatemala involved a quite different set of conditions.
Unlike Cuba, which historically housed a Chinese population that could have potentially paved the way for the migration of Chinese medicine, no Chinese population was ever present in Guatemala. In fact, just as the formal migration of acupuncture to Cuba was initiated by an Argentinian, the migration of acupuncture to Guatemala was initiated by a group of American acupuncturists. In the Northeast region of Guatemala known as Peten, American licenced acupuncture volunteers from the non-governmental organisation, The Guatemala Acupuncture and Medical Aid Project (GUAMAP), trained community health workers to treat their communities with basic acupuncture since 1994 (interview with GUAMAP CFO 2007). The ongoing success of this programme is a source of curiosity. Why would acupuncture be successfully introduced to the rural indigenous Maya of Guatemala? To attempt to answer this we need first to examine Mayan medicine.
Contextualisation of pre-colonial Mayan health practices provides a basis for understanding current Mayan medical pluralism and the reception of acupuncture by indigenous Guatemalans. A marked disruption in Mesoamerican local order occurred with the Spanish conquests of the sixteenth century. After the conquests, indigenous practices, including local health practices, were markedly influenced by the Spanish colonists.
The lack of literature on indigenous health practices pre-dating the conquests presents challenges in disentangling Spanish influences from indigenous practices. Two works that may provide the most accurate depiction of pre-Columbian life are the Popul Vuh and the Chilam Balam. The Popul Vuh, written in the mid-sixteenth century, describes the early history of the Quiche’ people and is one of the earliest surviving documents regarding Mayan illness classification and therapies. The Chilam Balam, a grouping of disparate writings named for the particular town in which they were found, and containing historical, medical, and divinatory knowledge (Roys 1933; Kunow 2003: 33), was believed to have been written by indigenous authors immediately after the conquest (Garcia, Sierra, Balam 1999). The Chilam Balam contains such information as the proper days for bleeding and purging, practices that were also affiliated with contemporary European and Chinese medical practices; which raises the question of whether Mayan practices were merely examples of ‘travelling medicine’ or forms of transcreation and hybridisation (Lo and Yoeli-Tlalim 2018) or, rather, continuities resulting from simultaneous, yet discrete, creation (Roys 1933; Gubler and Bolles 2000: 5).
Similar to the logic of myriad local, non-biomedical healthcare practices across the globe, ancient Mayans framed health as an outcome ‘of living in harmony with social and natural laws; [whereas] disease is the result of transgressing these laws’ (Garcia, Sierra, Balam 1999: xxxv). Medical practices are both a part of, and a product of, a given group and their specific system of order. According to anthropologist Mary Douglas (1966) all ‘cultural’ groups order the world and phenomena in a way that is meaningful to that particular group and that facilitates a common group understanding. Similar to Chinese medical understandings of order, categorical affiliations existed in Mayan medical order between chronology, the winds, animals, the cardinal directions, and illness (Chapters 5 and 6 in this volume; Roys 1933). Illness was diagnosed in pre-colonial Mayan society using palpation, divination, and consultation with the patient, and was primarily treated with medicinal plants, prayer, and bleeding in an attempt to restore harmony between ‘the physical, social, and cosmological order and internal bodily processes’ (Huber and Sandstrom 2001: 109). In describing the pre-Columbian classification system of illness, Orellana (1987: 28) differentiates between two categories of aetiology; illness caused by non-human beings – or by human beings who possessed supernatural powers – and natural causes, such as accidents, deficiencies, or excesses. In summary, religion, medicine, and morality were closely interwoven in pre-colonial Mayan medical practices (Ibid.: 257).
Colonisation resulted in myriad changes in Mayan health practices by virtue of colonial religion, colonial health practices, and colonial policy aimed at replacing indigenous understandings and practices with those of the Spanish colonial order. In the mid-sixteenth century, Dominican missionaries in Guatemala opened the Hospital de San Alexo, treating local Maya with European medicine (Huber and Sandstrom 2001). Catholicism was inextricably linked to colonial medicine in Guatemala. Priests, friars, and missionaries operated the Spanish hospitals and the clergy promulgated the concepts of Spanish medicine to Mayans hoping to replace Mayan medical beliefs with European beliefs, which included Catholicism (Ibid.). Colonial policy, that was enforced by a Protomedicato responsible for licensure of medical personnel, resulted in the standardisation and complete legal control of Mayan medical practices by the State (Ibid.).
A fundamental outcome of colonisation and the ensuing epidemics the Spanish brought, was the hybridisation of European humoral medicine into constructions of Mayan medical order (Huber and Sandstrom 2001). There is strong support in the literature, concerning the history of humoral medicines in Latin America, that the humoral system is not an indigenous system (Currier 1966; Orellana 1987; Foster 1994; Huber and Sandstrom 2001). For example, Trevino identifies that the Relacio’n de Tiripiti’o (written in 1579) mentions Mayan physicians discussing illnesses in terms of ‘the Galeno-Hippocratic humoral medicine that Spanish doctors practiced’ (Huber and Sandstrom 2001: 51). Concurrently, indigenous medicine was attacked by the Spanish protomedicos for not following ‘the doctrines of Hippocrates and Galen’ (Ibid.: 55). According to Baer, Singer and Susser (1997: 307), ‘humans universally have developed health care systems that reflect their living conditions and resources’. Hence, humoral medicine may not only have been a European system of order that was forced on the Mayans, but may also have been embraced by Mayans in order to survive the new infectious diseases the colonists introduced, against which the Maya were defenceless with their own interventions. Thereby, the Greco-Persian-Arabic humoral medicine of Hippocrates, Galen, and Avicenna may have been absorbed into Mayan medicine.
The centrality of the conception of equilibrium to Mayan cosmology may have provided a fertile ground for humoral theory (Orellana 1987: 260). In humoral theory, illness is believed to be caused by a disturbance resulting in an imbalance of hot and cold in the body, and remedied by hot and cold therapies that restore the imbalance (Wilson 1995; Adams and Hawkins 2007). However, in the Mayan adaptation of humoral medicine, hot and cold are not equivalent endpoints. Heat is considered more advantageous and positively associated with emotional support and affection (Wilson 1995). This meaning is illustrated in the hot classifications of fertility, pregnancy and menstruation, a powerful pulse, elders and ancestors, officials, and military officers (Ibid.). In contrast, cold is associated with factors that threaten one’s survival, including sterility, weakness, rejection, and withdrawal (Ibid.).
Given that the humoral model is structured by life stages, gender, interpersonal relationships, and social hierarchies, this model can be understood to serve as a symbolic system onto which social anxieties can be projected and from which social desires can be fulfilled (Currier 1966). However, it should be understood that the meanings of hot and cold systems throughout Mesoamerica ‘vary according to indigenous group and linguistic area’ (Wilson 1995: 131). Hence, it is unlikely that a single interpretation of humoral medicine was adopted. For example, there is relatively little agreement as to which foods are hot and which are cold, not only between geographical areas of Mesoamerica, but even among the members of a single community (Currier 1966).
In order to understand why only certain elements of medical theories and practices are translatable and adopted between one group and another, it is essential to know who mediated and controlled these translations.
The goal of the dynamic dualisms of humoral medicine, embedded in the order of Mayan medicine, is harmony; a central tenet of both Mayan medicine and traditional Chinese medicine (TCM); though this concept is relative to each system and we should not imagine that they are simply interchangeable. For example, in TCM, harmony of both the nutritive elements of the body (or simplistically stated, the more feminine or yin elements) and the functional (or more masculine or yang elements) is sought for ideal health (Ni 1995). In Mayan understandings, women and children are considered weak, whereas men are strong. Men are believed to be hotter, women colder. Men are believed to have stronger blood than women. Hot blood is considered healthier and stronger than cold blood. Hence, the concept of harmony that provides ideal health in Mayan medicine actually places stronger emphasis on masculine associations.
Furthermore, the general hot/cold duality of the adopted Mayan humoral concept can be perceived as similar to the concepts of hot/cold; yin/yang and myriad other dynamic binaries in Chinese medical systems. For example, in Chinese medical theory if there is a deficiency of yin, yang predominates and deficient heat ensues. The same is true of lack of cold resulting from yang deficiency. As death follows from the separation of hot and cold in Mayan medicine, so too is it a consequence of the separation of Yin and Yang (Orellana 1987: 29; Ni 1995). Despite the healthier and stronger nature of masculine attributes in Mayan medicine, according to Adams and Hawkins, one elderly male Mayan informant identified: ‘If there was no cold we would die’ (Adams and Hawkins 2007: 77). Similarly, Tonalli, or life force in Mayan medicine, appears to resemble the Chinese concept of life force or qi; as both can result in illness or death if deficient or absent from the body (Orellana 1987: 29; Ni 1995).
Both medical systems echo tensions with Western pharmaceuticals. Modern biomedicines are usually considered dangerously hot by Mayas, and as consuming yin in TCM (Wilson 1995). According to Mayan logic ‘Vaccinations and strong medicines burn humans by creating excess amounts of heat damaging the body’ (Adams and Hawkins 2007: 77).
Parallels can be further identified between Mayan and Chinese cosmology, mythology, understandings of chronicity and health, aetiological explanations for illness, diagnostic methods, therapeutics, and management. Garcia, Sierra, and Balam (1999: xxxii) report ‘from the moment we began to introduce Asian techniques like acupuncture into our community health work, we were received quite differently than when we had presented ourselves as Western doctors’. They maintain that one reason for this reception may be that Mayan medicine had the most developed ‘autochthonous system of acupuncture in Mesoamerica’ (Ibid.: 109). Although, we can challenge whether what Mayans practised could actually be deemed an ‘autochthonous system of acupuncture’, Garcia et al. identify two indigenous variations of medical treatment utilising body piercings, that clearly resemble the manual techniques and body topology of Chinese acupuncture and the superficial surgical practices of waike (外科). Known as jup and tok, these practices have been located in Maya communities of the Yucatan peninsula.
Purportedly the first documentation of these therapies appear in a book of the late sixteenth century; The Ritual of the Bacabes, in which illness is treated by ‘ix hun pudjub kik (the needle which bleeds) and ix hun pudjub olom (the needle which frees the blood)’. The skin is punctured ‘with the spines and thorns of several varieties of plants and several animals’ (Garcia et al. 1999: 109). Jup is a technique in which discrete points on the body are pricked several times in rapid succession, but blood is not drawn (Ibid.). Jup is performed in two ways; the same point can be punctured three times at approximately 1 centimetre depth, or the same point on the body can be punctured repeatedly until a response of inflammation to the area is achieved (Ibid.). In Tok, a point on the body is punctured in order to draw blood (often facilitated with cupping over the point-another shared practice between the two medical systems) (Ibid.: 110).
Similar in practice to Jup, is the 1000-year-old Chinese practice of Plum Blossom Needle, named for the five needles bound together to resemble a plum blossom, in which the instrument is repeatedly struck over an acupuncture point or an area resulting in inflammation or micro-bleeding (Zhong 2007). Although in acupuncture, a needle is usually inserted in a specific point on the body and is typically retained for fifteen to twenty minutes, in the technique known as ci xue liao fa 刺穴疗法, bloodletting will occur (often with cupping) as practised in tok (Cheng 1996: 110).
In TCM, more than 350 acupuncture points are identified that can be utilised in treatment; a reflection of the original astromedical conception of the continuities between the number of days of the year of the macro world and the number of points on the body of the micro world (Cheng 1996). Garcia et al. (1999: 112) have identified fifty body points used in tok and jup, all of which they have correlated with the location of acupuncture points. For example, a common and important point on the body in both TCM (yintang 印堂) and Tok/jup (tok lu ni) is located midway between the eyebrows. The skin is lifted and pierced in both medical systems. In tok/jup it is both a point punctured in children to prevent future illness and in adults to stop ‘evil wind attacks’ that may cause headaches (Ibid.). Acupuncture at this same point location can be used for headaches, as well as for ‘clearing external wind-heat’ pathogens, pathology in the brain and nose, calming the spirit of the patient, and hypertension (Cheng 1996).
There are numerous instances of other correlations in both anatomical location and function between the two medical systems, even though these practices developed quite independently from one another. Yet, despite the differences in cosmology, understanding, meaning, and order, embedded in Chinese and Mayan medical systems, the similarities in the practice of these two distinct medical therapies may offer one explanation for the reception of acupuncture in some Mayan communities. But, there may also be other factors to help explain these ‘cultural migrations’ to both Mayan Guatemala and Cuba that can be best understood via a popular representation of acupuncture as a kind of revolutionary or ‘rebel medicine’; for acupuncture represents the medicine of a people who have never had any colonial history, but who have been associated with socialist revolutions in Latin America.
Beyond political economic circumstances and beyond the similarities of foreign medical practices and local practices, there may be yet another reason that acupuncture migrated to both Guatemala and Cuba, as well as to many other similar contexts throughout the Hispanic world. A discussion between Mao Zedong and the Cuban party secretary, Blas Roca Calderio, in September 1960, marked the first instance of Sino-Latin American diplomatic relations. This bond was purportedly built upon the Cuban revolution itself. According to Lee (1964: 1132) ‘When Che Guevara was interviewed in 1959 by a group of Chinese correspondents, he made clear his admiration for Mao’. Guevara purportedly said, ‘When we were engaged in guerrilla war, we studied his [Mao’s] theory on guerrilla warfare. Mimeographed copies of his work circulated widely among our commanders at the front. It was called ‘the food from China’ (Ibid.)’. Although this bond reportedly cooled during the Cold War period – when the Cuban government backed the Soviet Union in Sino-Soviet disputes – the significance of Maoist doctrine as a blueprint for revolution and rebellion, may have secured its symbolic value (Dominguez 2006). Similarly, though there have not been significant diplomatic relations between the PRC and Guatemala, Mayan Guatemalans, who survived a thirty-six-year civil war and continue to face structural violence on a daily basis, may find meaning in a doctrine of rebellion that can be symbolically represented through acupuncture; a means to achieve equitable healthcare access.
Thus, although Guatemala and Cuba represent two completely different contexts for the migration of acupuncture, it has been identified in both contexts as an equitable solution for healthcare access, and a resolution for the potential inequities embedded in market-driven biomedicine. After all, it was the Chinese barefoot doctor, who practised both TCM and biomedicine, and whom the World Health Organization globalised as the symbol for equitable ‘health for all’ in the Declaration of Alma Ata in 1978 (Chapter 44 in this volume). Thus, embedded in these global and local representations, is a symbol of traditional Chinese medicine as a socialised form of medicine that can redress social inequities. This depiction may not only be identified in the Cuban military’s involvement in the development of MTN, and the self-organisation of vulnerable and underserved Mayan communities after the 36-year civil war, but also in another former Spanish colony halfway around the world: in the rural Philippines.
The groupings of grassroots healthcare programmes in the Philippines, known as Community-based Health Programs (CBHP), were born out of the poverty and political repression of the late 1960s. These programmes began in reaction to poor healthcare access: ‘At its inception, the health program was a reaction to existing approaches to healthcare, which did not reach the people most needing them – the poor, especially in rural areas’ (Council for Health and Development 1998: 11). In research I conducted in the Philippines, in both 2010 and 2020, informants discussed both ‘community building’ and ‘nation building’ as a primary desired outcome of CBHP groups. These groups trace their origin to the Rural Missionaries of the Philippines (ca. 1969) organised by the Association of the Major Religious Superiors of Women in the Philippines (Ibid.: 12). Informants from the various Community Health Worker (CHW) programmes of the CBHP groups identified the barefoot doctors programme of China as the template for CBHP. A CHD manual identifies CHWs as volunteer members of communities that ‘are chosen by the community’ and ‘trained in basic health skills, such as prevention and treatment of common diseases, first aid, use of herbal medicine acupuncture and acupressure and dental hygiene and tooth extraction’ (Ibid.: 8–9, 31). This CBHP curriculum was standardised in 1984 (Ibid.: 44).
Acupuncture was an early addition to the CBHP programmes. According to informants, China and the Philippines engaged in a cultural exchange during the Marcos administration (c. 1965–1986). As part of these exchanges, China offered both formal and informal short training courses in acupuncture in the Philippines, primarily for physicians. Acupuncture was quickly identified as an important cost-effective intervention for CBHPs. However, the development of CBHP organisation was soon viewed by the Marcos administration as ‘conscientizing activities considered crimes by the government’ and linked to revolutionary communist groups (Council for Health and Development 1998: 15). CHWs ‘were targeted as subversives, arrested, and killed’ (Ibid.: 30). However, the work of the CBHP’s spread to other political groups.
The Partido Komunista ng Pilipinas (PKP), founded in 1930, is the ‘oldest leftist party in the Philippines’ (Quimpo 2008: 56). In 1968, a group of ‘young communists’ broke away from the PKP and started the Communist Party of the Philippines (CPP) (Ibid.: 58). The CPP actively denounced ‘U.S. imperialism, feudalism, and bureaucratic capitalism’ calling for ‘the revolutionary overthrow of the reactionary Philippine State’ (Ibid.). Several months later, in 1969, the CPP acquired a ‘guerilla army’ known as the New People’s Army or NPA (Ibid.). This group became aligned with a larger ‘revolutionary united front’ in which several – but according to informants, not all – CBHP groups were aligned (Ibid.: 56).
It was during the period of martial law at the end of the Marcos administration, beginning in 1972, that any members of groups believed to have any affiliation with the CPP or NPA were routinely ‘arrested, tortured, detained, and/or killed’ (Quimpo 2008: 56). Several informants, including university professors and physicians, described years of torture and imprisonment for any suspected, though unproven, link with the NPA. ‘Thousands disappeared without any trace, while many others were summarily executed’ (Council for Health and Development 1998: 42). Several informants stated that neither one’s political affiliation, nor the fact that equitable healthcare was the group’s sought goal, was relevant to the government. The fact that community level organising was involved, in and of itself, constituted a threat to the government.
The NPA became a significant national movement, especially through forging bonds with the rural poor (Jones 1989). A sixty-two-year-old female physician informant in Manila reported: ‘It seemed that communism was the way that Filipinos could be free of colonialism, and the NPA was fighting for a revolution to change the system’. Healthcare was a primary concern of the NPA and many young medical students became affiliated with both the NPA and/or CBHP groups in this capacity. According to informants, it was specifically the Philippine armed forces who began to affiliate acupuncture with both the NPA and CBHP groups. Jones (1989: 233) notes the NPA had their own medics who were ‘trained to perform acupuncture and acupressure treatments and were skilled in the use of herbal medicines’. One male NPA informant reported: ‘We learned [acupuncture] from books, from Chinese books, and [from] some trainings from community doctors. Basic training was three days’. However, other informants identified that the CPP was able to send some members to China to study acupuncture. Another NPA informant stated: ‘We use acupuncture because it is cheap and does not require much [sic] materials’.
Interviews with current and former NPA-identified informants revealed that the NPA have utilised acupuncture as a means to recruit NPA members in rural communities. Informants explained that recruitment was initiated through free acupuncture treatments and later through acupuncture trainings. Thereby, the CBHPs, and especially the practice of acupuncture, became intensely politicised in the Philippines from the early 1970s. In fact, the mere presence of an acupuncture needle was considered sufficient evidence to identify one as having NPA affiliation. One female family medicine physician informant in Manila reported: ‘When we were travelling in Mindanao, we would travel with [acupuncture] needles inside of pens, because we were afraid that the army was there, at a checkpoint, and you would be checked for needles. If they found them, you would be tortured – at best – or more likely killed’.
Healthcare providers were not the only group harassed. Patients were also harassed for seeking treatment from CBHP groups. One nurse informant who worked with several CBHP groups identified: ‘The military were always watching us, and our patients were afraid to come in and be treated because of them, so they often would have no treatment’. Harassment of CBHPs did not cease after Marcos, but actually intensified with [‘Auntie’] Corazon Aquino’s administration (1986–1992), resulting in the cessation of CBHP groups in 267 communities and disruption in an additional 305 communities (Council for Health and Development 1978: 53).
In 2010, during the final days of the Macapagal-Arroyo administration, a group of forty-three healthcare workers undergoing training in disaster management and acupuncture, known as the ‘Morong 43’, were arrested by the military and detained for ten months on charges of illegal possession of firearms, explosives, and acupuncture needles (Department of Health 2015). According to an informant working with the Morong 43: ‘They were illegally detained and tortured, while the military attempted to force them to admit they were part of the NPA’. The group filed a civil case for damages against former president Arroyo and high ranking military officials. This informant’s allegations were corroborated by the 2015 report of the Philippines Commission on Human Rights that confirmed the illegal arrest and torture of the Morong 43 (Mateo 2015).
Hence, the case of acupuncture in the Philippines illustrates how the migration of acupuncture can be politicised for its provision of cost-effective accessible healthcare for all, and how it can be represented as a rejection of profit-driven healthcare. Thereby, acupuncture has served as a mechanism for political grassroots organisation.
In this chapter, we have discussed the migration of the Chinese ‘cultural product’ of acupuncture to countries of the Imperium Hispanicum that has not, in general, been accompanied by a marked influx of Chinese migrants, and in some cases, such as Guatemala, there has been no Chinese migration at all to support such ‘cultural migrations’. In other words, we have examples of the migration of a people’s systems of order and meaning without the migration of its people. One could argue that the globalisation of the outputs of the West, particularly biomedicine, has been achieved in numerous contexts without an accompanied influx of Western colonists or migrants, however Western ‘cultural products’ are clearly part of a dominant political economy and authoritative knowledge 3 of the West.
These three cases illustrate how the migration of acupuncture may have more likely been influenced by factors such as political economic circumstances and similarities to existing local systems order, than by any migration of Chinese. Forms of economic deprivation and structural violence 4 directed towards a group – or as in the case of Cuba, towards an entire country – that thwarts access to healthcare, are a common theme across these three case examples. 5
Furthermore, the cases reviewed illustrate how the reception of Chinese medicine in a given local context can be influenced by the existing plurality of healthcare practices at any local level, which in itself is a function of social, cultural, and environmental impacts. However, the migration of Chinese medical practices cannot be reduced to a simple grand analysis. Migrations of a given group’s order are specific to geographies, chronologies, political economies, and ways of knowing. Hence, by virtue of unique factors particular to a given time, place, and set of political, economic, and other social circumstances, each context may be uniquely prepared to adopt and incorporate some elements of Chinese medical practice into their local healthcare.
Particular globally standardised practices that fall under the rubric of Complementary and Alternative Medicine (CAM), such as acupuncture, chiropractic, and homeopathy were integrated under the National Program for MTN in 1999 (Stafford 2010). However, although the sale of some medicinal plants used in local practices, such as Santería (stemming from the Yoruba religion of West-African slaves to Cuba), was no longer prohibited, local non-biomedical practices were not commonly integrated into MTN. As of May 2015, ten non-biomedical practices (including: acupuncture, ozonotherapy, homeopathy, medical hydrotherapy, helio-thalassotherapy, Bach Flower Remedies, phytotherapy, apitherapy – utilising the products of bees, yoga, and ‘naturist nutritional orientation’) were formally recognised as a medical specialty requiring that ‘treatments be provided only by duly trained and certified health professionals’ (San Diego Union Tribune 2015). Yet, it is interesting to note that none of these practices were indigenous to Cuba.
Again, it is important to note that few of these ‘traditional’ practices, beyond the use of local herbs, were actually local or traditional to Cuba.
Anthropologist, Brigitte Jordan, notes how though ‘equally legitimate parallel knowledge systems exist’ that people may ‘move easily between[often] one kind of knowledge gains ascendency and legitimacy’ (1997: 56). She identifies this phenomenon as the domination of ‘authoritative knowledge’, whose consequence ‘is the devaluation, often dismissal, of all other kinds of knowing as backward, ignorant, naive’ (Ibid.).
According to anthropologist, Paul Farmer (2004), with structural violence ‘social inequality fuelled by bias can become embedded in social institutions (or structures) to effectively marginalise groups and exclude them from social benefits’ (Kadetz 2018: 293).
It is interesting to note, and possibly not coincidental, that many of the political economic circumstances influencing the reception of acupuncture in these countries -from the Marcos regime in the Philippines, to the thirty-six-year civil war in Guatemala, to the nearly sixty-year embargo of Cuba– were all very much supported by the United States.