Dignity-Based Care: Lessons for Today from Two Turning Points in the Histories of Acupuncture

Abstract

“She’s so young to have had a stroke,” he sighed, shaking his head. He had just finished an electroacupuncture session with a 35-year-old patient, and we sat in the office, wrapping the lead wires.

“Dr. Small,” I asked, “what motivates you to keep going when you’ve seen so much suffering?”

He stopped coiling the wires and paused for a moment. “Sometimes you just don’t feel like giving up,” he responded, “you know, we need to promote the dignity of all people, and see the humanity in everyone. We can’t give up.”

(Field notes from shadowing Tolbert Small; Eana Meng, August 11, 2024)

***

According to the philosopher Mencius, all humans have innate dignity—the state of being worthy—simply because we are all human.¹ Promoting dignity has been identified by various fields of philosophy, law, bioethics, and health as a fundamental human pursuit. In clinical care, discussions of dignity have been most robust in palliative care, geriatrics, and nursing.^2
–4 This article is a call for complementary and integrative health (CIH) professionals to uphold dignity as a core tenet, and utilizes historical analysis to advance our arguments. History reveals the sobering realities of care without dignity in the United States, from the infamous Tuskegee Syphilis Study to daily acts of medical mistreatment.^5,6 Such acts have continued to the present day, where loss of dignity in care is associated with poorer health outcomes.^7,8 History also reveals how humans have responded. This article examines two key turning points in the history of acupuncture in the United States and the United Kingdom, where lesser-known yet pioneering practitioners have endeavored for over half a century to heal communities that have been most marginalized by health care systems. Their stories, across place and time, reveal a throughline of what lies, and must always lie, at the heart of health care: the promotion of dignity. These stories elucidate how dignity-based care is especially necessary for communities that have faced health injustices, and they demonstrate how CIH and whole person health approaches, including but not limited to acupuncture, are particularly poised for promoting dignity.⁹ This article argues that the promotion of dignity advances the fundamental goal of whole person care, and provides significant guidance for the future of CIH and health care in general.¹⁰

Definitions of dignity are expansive and often elusive, but prior scholarship has elucidated its core features. Nora Jacobson clarifies the distinction between “human dignity” and “social dignity.” The former refers to the belief held by philosophers such as Mencius, and the latter is “a consequence of its recognition,” meaning social dignity is conferred when human dignity is promoted. Social dignity is thus a goal of the therapeutic encounter. Jacobson concludes that “enough is known about social dignity that this work should now strive for greater explanatory power.”¹¹ Extensive research around dignity in palliative care, such as by Harvey Max Chochinov, has contributed the Patient Dignity Question (“What do I need to know about you as a person to give you the best care possible?”), a validated instrument shown to improve patient-practitioner relationships.^12
–14 To specify what social dignity entails, nursing literature has constructively identified respect, autonomy, empowerment, and communication as defining attributes.¹⁵ We build upon this scholarship and examine these recognized core attributes in two lesser-known histories of acupuncture. We believe these stories also contribute an additional component of commitment that is people-, place-, and time-based. Namely, these CIH histories reveal that dignity-based care is especially important for historically marginalized individuals in resource-poor areas and must be sustained in the long term. We thus advance that the promotion of dignity in health care requires respect, empowerment/autonomy, communication, and commitment.a

Turning Points in the 20th Century Histories of Acupuncture in the United States and the United Kingdom

The arrival and widespread interest in acupuncture in the United States has traditionally been attributed to a July 1971 article written by New York Times reporter James Reston, who had an emergency appendectomy and post-operative acupuncture care in Beijing while covering the preparation for President Richard Nixon’s trip the following spring. Though Reston undoubtedly introduced acupuncture to a broader American public, such a narrative is incomplete, eliding the existence of widespread acupuncture use within not only Asian communities nationwide but also with health care practitioners of the civil rights movement. Within the last few years, community members, practitioners, artists, and scholars have increasingly called attention to these accounts to rectify their place in history.^16

–19 Beyond a recovery project, however, examining these acupuncture histories also reveals new insights about dignity promotion in therapeutic encounters that all practitioners, policymakers, and participants in CIH and beyond can be guided by.

Tolbert Small, MD, in the Bay Area

Tolbert Small is the first African American physician to practice acupuncture in the United States. Born on April 3, 1942, and growing up in Black Bottom, Detroit, MI, Small’s journey to medicine was riddled with barriers. From teachers accusing him of cheating when he received the highest grade to professors doubting his ability to become a doctor, Small persevered, motivated by his desire to rectify the deep health injustices and indignities his community faced. In 1968, he graduated from the Wayne State School of Medicine and began his residency at Highland Hospital in Oakland, CA. The Bay Area bustled with political activity, and Small soon approached the Black Panther Party and offered to work pro bono.^20
–22 While he never joined the Party, from 1970 to 1974, he directed their George Jackson Free Medical Clinic and was the personal on-call physician for members and their families.

The ethos driving Small’s actions, as well as the broader Party’s health activism, was “the promotion of social justice and human dignity,” as they saw “inadequate government social services as a form of oppression.”²³ Beyond simply articulating a critique of state failure, the Party provided an answer through its numerous survival programs in health care, food, education, and more. Medical discrimination and neglect of marginalized populations led the Party to partner with sympathetic medical professionals such as Small and establish a national network of free health clinics in resource-poor areas.²¹ As Small stated, “There was a need in the community for health care, and the government was not going to provide it. We felt that until we had an appropriate government that would provide health care, that would be a service we would provide.”²⁴ With few treatment options and little attention to sickle cell anemia, which disproportionately impacts African Americans, Small also directed and helped launch the Party’s Sickle Cell Anemia Project in 1970, a comprehensive screening and education program across the country.²¹ Small’s innovative and inclusive medical “toolkit” soon incorporated acupuncture, especially as a nonpharmacological alternative for pain management.¹⁹ In all these endeavors, Small and the Party aimed to bring skilled and dignified care to their communities neglected by the larger health system.

In March 1972, the Panther Party sent a delegation to China just days after President Richard Nixon’s official trip.²⁵ Invited on the journey, Small was especially impressed by the Barefoot Doctors movement, where health care providers were educated in basic Western and Chinese medicine and brought free care to rural communities.^25,27 Small also experienced acupuncture for the first time, where treatments relieved his stiff neck. Stunned by the nonpharmacological pain relief, Small returned to Oakland committed to learning acupuncture. He taught himself by utilizing books and experimenting on his body. He soon began treating patients through house calls and at community clinics, for free. In 1980, Small and Anola Price Small opened the Harriet Tubman Medical Office, which held patient rooms designated for primary care and acupuncture. Since 1972, Small has treated thousands of patients with acupuncture and dignity.

In analyzing interviews with Small and his patient records, as well as correspondence with patients, the core components of dignity are evident: respect, empowerment, and communication. In addition, Small’s longue durée of over half a century of caring for patients contributes another key aspect of dignity: commitment. One of Small’s early patients, R.L., suffered lower back pain, which was unresponsive to other treatments but was relieved by electroacupuncture (Table 1). Small took his patients’ pain and symptoms seriously by continuously seeking options until something worked. This exemplifies respect , as defined by its etymology: re (“back”) + specere (“look at”), meaning “act of looking back at.” He saw his patients in their full humanity and not people to turn his eyes away from, as he strongly believed that “all people are deserving of care” (Interview with Tolbert Small; Eana Meng, February 9, 2019). As one of his patients noted, he went to extensive lengths to find solutions, “including care beyond the traditional norms” (Personal communication from Small’s patient, BBN; Eana Meng, June 2, 2024). This included his early uptake of acupuncture. Another patient wrote:

Table 1.

“Early Patients,” from Small’s Records, 1998

Label	Patient	Initial visit	Patient history
Early Patients	R.L.	April 16, 1974	An R.N. at Highland Hospital had sacroiliac lower back pain, which did not respond to steroid injection or manipulation. The sharp pain was relieved by 15 min of electrical stimulation using the following points: G.B.−29, B1-31, 32, and 60.
	E.E.	May 4, 1974	This patient had left temporal headaches, ear aches, and menstrual cramps. All the pain was relieved by L.I.−4, 7, S-2. On 5/5/74, and 5/14/74, the patient successfully treated herself for tension headaches.

I have been seeing Dr. Small since I was in a severe automobile accident on New Year’s Day in 1979 that nearly took my life. After spending 2 months in Alta Bates Hospital, I began seeing Dr. Small for acupuncture treatments for pain for the 11 broken bones that I sustained and because I do not do well on pain medication… I desperately needed the kind of doctor that is not only one who prescribes pills but one who treats the entire patient with kindness, understanding, and excellent medical knowledge. Dr. Small was that kind of doctor (Letter from Small’s patient, SDP; Eana Meng, December 9, 2019).

Another patient in Small’s records, E.E., demonstrated his commitment to empowerment (Table 1). After treating E.E. for temporal headaches, ear aches, and menstrual cramps, he taught her how to treat herself, such as by applying pressure on the Large Intestine 4 point (also known as “hegu”), which is indicated for headache relief. He was especially inspired by the barefoot doctors ethos, which led him “to realize that you can teach anything to anybody. That I could teach my patients to do acupuncture, I could teach my physician assistants on acupuncture.”²⁸ He taught his patients how to apply pressure to basic acupuncture points to find relief without relying on treatments. Small’s desire to teach acupuncture was part and parcel of his larger initiative of equipping his community with more medical knowledge and skills. During his time at the Party’s free clinic, he taught community health workers (many of whom started as volunteers without any health background) how to do pap smears, draw blood, screen for sickle cell anemia, and more. Norma Mtume, a volunteer who later helped direct the clinic and became a nurse, was trained by Small to do pap smears, even self-administering the procedure. Years later, she diagnosed her own cervical cancer.²⁹ As such, Small has inspired many individuals to become professional health care providers, from acupuncturists to nurses and doctors.³⁰

In February 1997, Small saw T.G., whose prior doctors had accused her of malingering (Table 2). Over the month, he worked with her for seven sessions, constantly communicating with her during and between treatment sessions. As one of Small’s former assistants noted, he believed in the “power of honest information,” and always sought to provide information that was clear to the patient (Personal communication; EL, February 7, 2025). Small was also committed to his patient’s healing, even when they could not afford it.b T.G. could not pay for treatments beyond the two sessions per month covered by her insurance; Small treated her pro bono until her symptoms were alleviated. T.G. later became a full-time patient, and Small treated her with acupuncture, primary care, and dignity for the remainder of her life—as he has done for thousands of patients for over half a century.

Table 2.

“T.G. 64 y/o Black Female,” a Patient from Small’s Records, 1998

Subjective	Chronic back pain after a fall on a stone floor at work in 1970. The pain radiates down the back of both legs and increases with coughing. The patient has failed various courses of physical therapy and steroid injections.
Objective	The MRI scan shows moderately severe focal spinal stenosis at L3-4 and L4-5 secondary to broad based degenerative disc bulges associated with very mild degenerative spondylolisthesis at the L3-4 level and the L4-5 level. There is also degeneration of the L5-S1 level, facet arthropathy, and bilateral foraminal stenosis.
Results	After seven treatments, she was 80% improved on the right side and 90% improved on the left side. She no longer has severe pain and is able to do activities of daily living independently. Five months later she retired for eight additional treatments, stating that 90% of her pain was relieved and 100% of her severe pain was relieved. (Machine WQ10B, frequency of 100, from 35 to 45 min. The last points treated were R. and L. B1.−26, B1.36. Right B1-31, B1-57, B1-37, and K-3.) Treated 2/7, 2/12, 2/14, 2/18, 2/20, 2/25, and 2/28/97.

MRI, magnetic resonance imaging.

Susan Cox, OBE in the United Kingdom

Respect, empowerment, communication, and commitment as core values of promoting dignity can be observed in a different geography with Susan Cox, an acupuncturist from the United Kingdom. Born on May 30, 1947, Cox’s childhood and teenage years were difficult.³¹ She climbed out of the depths of substance addiction through sheer love for her children and with the support of Alcoholics Anonymous and acupuncture. Cox then opened a vegetarian restaurant to do something “healing and healthy” with her children and partner. The restaurant attracted local acupuncture school students in Leamington Spa, who asked Cox to be a class patient. In addition to feeling relaxed, Cox recalled, “I was fascinated by the poetry of Chinese medicine.”³²

Cox attended the acupuncture college and resonated with the whole person view of healing and well-being. Chinese medicine helped her realize that her brain and body were not broken, and simply needed balance. Interested in learning about acupuncture for addiction, Cox traveled to the Lincoln Detox Center in the South Bronx in the 1990s, where revolutionaries of the civil rights era, such as Mutulu Shakur, had pioneered the creation of an auricular acupuncture protocol for substance use.^16

–19 Inspired by this history and hoping to infuse more scientific research into auricular acupuncture, Cox returned to the United Kingdom to establish SMART UK with her friend and neuroscientist, Kim Wager, where she has since trained over 28,000 individuals and she focuses especially on working with individuals with professional or personal backgrounds in substance use. Dedicated to bringing healing to the most marginalized communities, Cox has introduced acupuncture to over 128 of the 150 His Majesty’s Prisons.³¹

Cox often drives over seven hours a day to visit various prisons around the country, where she teaches essential Chinese medical philosophy and auricular acupressure alongside scientific theories of neurotransmitters to incarcerated individuals.³³ She respects these men and women, seeing their full humanity and capacity to learn. She takes their health seriously and teaches them that their bodies are not broken, but can heal themselves. Such a message is profoundly empowering for those who are consistently told otherwise. As one incarcerated individual relayed, “She sees us, and doesn’t treat us like children. I love the neuroscience stuff and the yin and yang theories she teaches us… I reckon I can still balance my body” (Personal communication with LW; Eana Meng, June 25, 2024).

Furthermore, Cox emphasizes that incarcerated individuals can become healers; in the past 5 years, she has introduced a “Wellness Coach” program, where she hands them toolkits including ear seeds, tea, and meditation guidance, empowering them to become wellness coaches and help others. Rather than broken people who harm, they can become transformed people who heal. As another individual expressed, “I feel like I can really help people, especially some of the young ones” (Personal communication with C; Eana Meng, June 26, 2024). Cox has trained well over 50 wellness coaches, and she consistently stays in touch with them, communicating with her students and supervising them. A few of them have since been released and pursued further acupuncture training. They now work with Cox to bring whole person health back into the very four walls that used to confine them. For decades, Cox has been deeply committed to individuals, and like Small, feels that giving up is not an option. In 2023, she received the Order of the British Empire from Prince William, the highest honor bestowed to a civilian of the United Kingdom.³⁴

Lessons for Today: Dignity-Based Care in CIH

These histories of acupuncture offer potent models for the transformative capacity of CIH in promoting dignity-based care in all therapeutic encounters, and especially for the most marginalized populations who routinely face loss of dignity in care. We believe that CIH practices and the whole person health framework are especially poised to advance the core components of dignity: respect, empowerment, communication, and commitment. CIH’s whole person health framework fundamentally respects the individual’s wholeness and humanity, aiming to see each patient as a full human within their environment rather than a diseased body or morally broken person. It emphasizes an individual’s well-being over specific illness categories. CIH practitioners are also trained to carefully and repeatedly attend to symptoms. Open to the expansive repertoire of therapeutic practices, from acupuncture to meditation, nutrition to qigong/Tai Chi, CIH practitioners can explore different options to find what works for patients, with the understanding that the definition of what works is expansive, culturally sensitive, and patient-specific. These aspects lie at the foundation of respecting patients.

Many CIH practitioners empower their patients by helping them restore their sense of self and autonomy. Whole person health frameworks, such as Chinese medicine theories, emphasize the body’s ability to heal itself, and CIH practices, such as acupuncture, are utilized to help the body rebalance itself. While such a body ontology may seem foreign to biomedical frameworks, it need not be: the foundational tenet of homeostasis within biomedicine underscores the body’s ability to maintain stable internal environments.³⁵ These messages of empowerment can, and should, be emphasized in all therapeutic encounters. Practitioners can center an individual as the locus of healing ability and frame all interventions, whether acupuncture, herbs, or medications, as supportive of their journey. Indeed, even and especially biomedical interventions, such as surgery, may be reframed; where surgeons aim to remove a tumor, they also know that the patient’s likelihood of recovery and survival are greatly dependent on the patient’s whole health and body state pre- and post-operation. Small and Cox are historical exemplars in this regard: they did not view biomedicine and science as incompatible with their uptake of acupuncture, and instead embraced and encouraged their integration in pursuit of quality and dignified patient care.

In addition to a message of empowerment, CIH practitioners can place therapeutic tools directly in the patient’s hands, as Small and Cox have done. Whether it is with teaching ear seeds, acupressure, mindfulness, or qigong/Tai Chi, many CIH practitioners involve the individual’s participation for increased health benefits; patient activation, the willingness and ability to take independent action to manage their health care, is well established to improve health outcomes.^34,37 Notions of patient compliance and adherence can be recast as patient autonomy and agency. To guide safe practices and support patients’ healing journeys, practitioners thus also need to communicate with and be responsive to their patients. These are inherent components of many CIH practices, such as acupuncture, which involves the patient’s live feedback during and between treatments, and practitioners adjust accordingly.

A final core component of dignity-based care, as exemplified by Small and Cox, is commitment. Where some dignity scholarship has discussed the importance of commitment,^36,39 these histories of CIH practitioners contribute a more nuanced and specific understanding of commitment around people, place, and time. Small and Cox have been especially committed to bringing healing to individuals most neglected by health systems and working in the most historically marginalized areas, for the longue durée. For over 50 years, Small has made house calls to patients without transportation around the Bay Area; for more than 20 years, Cox has driven up to over seven hours a day to prisons in the United Kingdom. These endeavors are often done pro bono and supported by their other work, through Small’s primary care practice or Cox’s private acupuncture practice. Despite being almost entirely retired from their individual practices, they continue their commitment to this work. A whole person health framework naturally lends itself to understanding individuals in their environment and addressing specific circumstances, and these histories of acupuncture reveal what commitment precisely entails for dignity-based care, where Small and Cox have committed to their particular patients in specific spaces for the long haul.

We believe that the CIH and whole person health field is poised to make a systems commitment to promoting the dignity of all patients, and especially of the most historically marginalized, by taking these historical actors as examples. Already, CIH practitioners and programs around the world are centering dignity’s core components in respecting, empowering, communicating with, and committing to patients and communities, especially the most marginalized. This includes the numerous individual practitioners who center dignity in all their therapeutic encounters, and those who dedicate their practices, whether full-time or partly, to making CIH practices accessible for the long term. Various organizations also endeavor to bring CIH practices to historically marginalized communities, including, but certainly not limited to, People’s Organization for Community Acupuncture,⁴⁰ Acupuncture Without Borders,⁴¹ Prison Yoga Project,⁴² Freedom Community Clinic,⁴³ and Small Steps Healing Project.⁴⁴

CIH research institutes can provide the infrastructure to promote dignity-based care at the individual and systems level.^45

–48 Researchers at the University of California, San Francisco Osher Center for Integrative Health have established how CIH practices such as group acupuncture can promote patient activation, which is a core of patient empowerment.⁴⁹ Preliminary data around group-based integrative pain management for diverse primary care safety net patients also reveals the ability for CIH practices to address stigma, where patients feel seen and respected by their health care providers.⁵⁰ For example, an interview with a study participant revealed how she does not usually receive “the benefit of the doubt,” from her health care practitioners, but felt seen and well taken care of by her acupuncturist in the study.⁵¹ This has also been observed with Tai Chi patients.⁵² Furthermore, Maria Chao and Shelley Adler have established integrative health equity principles that guide research practices for creating ongoing mechanisms of feedback and accountability from community partners,⁵³ exemplifying the key tenets of respect, empowerment, communication, and commitment in dignity-based care. The team at the Harvard Osher Center for Integrative Healthc has also supported the Small Steps Healing Project, a student-led initiative co-founded by Eana Meng and Karem King within the grassroots organization We Got Us, that hosts free pop-up CIH clinics around the city.⁵⁴ Together, they will directly evaluate the role of dignity in CIH therapeutic encounters and health outcomes. Initial conversations with clinic participants prove promising; a community member revealed how it was the first time that he “felt so seen by a health care practitioner” after a Reiki session (Personal communication with JT; Eana Meng, August 22, 2022).

The promotion of dignity in CIH is not novel. Indeed, this article has precisely hoped to elucidate a long history, weaving individual threads from the past to the present and revealing a web of potentialities that demonstrate how CIH practitioners are especially poised to promote dignity-based care. In combining prior dignity scholarship with historical acupuncture examples, we provide a starting point for common ground and articulate a more concise language for the field of CIH to promote dignity. In turn, we demonstrate how the history of CIH practices contributes to broader dignity scholarship. Key identified attributes of dignity are (but not limited to) respect, empowerment, communication, and commitment; key actors are practitioners, community organizations, research institutions, and patients themselves, especially those from the most marginalized communities. We have laid out a cursory overview of significant past turning points and present examples of dignity-based care that can guide the future of CIH, and we call for further contributions from others committed to promoting dignity in CIH practices and health care in general, and for the most historically marginalized communities in specific. By declaring dignity as a goal for all therapeutic encounters and at a systems level, we believe that, in turn, we can promote the dignity of our health care system as a whole.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

a

As explored in the patient cases, we believe that empowerment refers to empowering an individual to recognize their agency and thus will collapse the two terms.

b

Another patient wrote, “I and my family were patients for years at the [Harriet Tubman] clinic and unfortunately sometimes came up short on the payments for services but always felt cared for and welcomed.” Personal communication; MF, Jun 26, 2023.

c

This team includes Peter Wayne, Gloria Yeh, Katherine Hall, Aterah Nusrat, Viviane Nguyen, Jaclyn Chai, and Daniel Litrownik.

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