Community Medicine

Most often we refer to community medicine as a form of delivering medicine within specific communities which we name as under-served, minorities, special needs, etc. and we seek to use existing definitions of community and its structures in order to deliver some form of medicine. But one can look into the issue of community medicine and ask the question of whether one can use medicine as a form of creating and building a community? And, if one were to start with that assumption, would it make sense to target “special” audiences.

Most health care providers agree that the most prevalent disease of out time is isolation. Regardless of the nature of any mental or physical disease, huge numbers of people suffer from isolation and lack of support which contribute to whatever other health issues they might have. In fact, depending on how we define health and healing, we might reach the conclusion that isolation and lack of community is a root cause of ill-health.

First we need to define what is healing, or what is health. We can, of course, list a whole array of laboratory parameters that define the “norm” in human physiology, and the list will be virtually inexhaustible. Even if we were to come up with a bio-mathematical model of health, we still need to remember three simple truths: that we are all of the nature to become ill, that we are of the nature to grow old, and that we are of the nature to die. The only way to avoid all ill health all together is to not live in the first place. What we can change about ill health is how we view it and the amount of suffering we will engage in. The deterioration of the physical body cannot be a good measure of health, since we would then condemn all those over a certain age as “sick” and “damaged” beyond repair or hope.

Another definition might be to define health and healing in a more flexible and open-ended manner. We could define health and healing as those processes that involve space, light, and the existence of new possibilities. This definition states that lack in these elements are states of disease, regardless of what the bio-medical parameters state, and that a state where these three elements do exist is a state of health in spite of possible named-disease entities that might co-exist in the person at that time.

Space and light provide the ground upon which healing can occur. Any congestion, physical or mental obscures healing and creates disease. And without all possibilities

being available to one, a state of “disease” cannot change into a state of “health.” It is common to see people who suffer from chronic degenerative diseases (clearly defined biomedically, and often expected to die within weeks or months) display a radiance that one does not easily detect in many so-called healthy individuals. The individual with “terminal cancer” who radiates healing around them cannot be defined as healthy by any biomedical notion, yet, they have opened themselves to space, light and all possibilities (or love, compassion, joy, and equanimity in Buddhist terms) to the degree that this over-rides the importance of the physical disease. Many people with “terminal illnesses” who have reached that state will claim that in some ways they are healthier than they were when they thought of themselves as biomedically “healthy.”

Yes, this is a definition that involves the mind, and gives the impression that it excludes the body, but that is inevitable since pain and suffering, the issues we try to avoid in disease and why we define diseases in the first place, are perceptions of the mind: they are not physical entities divorced from a state of mind.

These concepts are expressed classically also. The Hua Yen Jing (Avatamsaka Sutra) describes the Buddha realm, the realm of all healing, as that of infinite space and infinite possibilities. Here, every lotus petal has within it a lotus flower whose petals too contain lotus flowers, and ad infinitum. The one contains all, and all contains the one is the principle of the Hua Yen Jing, that is the principle of the existence of all possibilities: in any one thing, any one cell of the body, all possibilities exist: the possibility of health and recovery is always there, even in the mutated cancer cell. Space is not limited to our conventional perceptions, there is always more space. According to the Hua Yen Jing the Buddha’s mother is visited by all Buddhas of all ages during her pregnancy, coming to greet the new Buddha. Yet in spite of the multitude of beings in her womb she feels very happy and that there is room for more. Space literally expands when healing is there. When Vimalakirti gives his treatise (Wei Mo Jie Jing) his tiny room suddenly is able to accommodate countless Bodhisattvas each perched on infinitely large chairs: space expands, “reality” unrigidifies, and all possibilities can occur when healing occurs. (These concepts are expressed in the Judeo-Christian tradition also. The Holy of Holies is described as containing a certain amount of space, and yet after the arc and worship implements are placed in it, it still containing the same amount of free space: the worship implements appear to not occupy any of the space. On the Day of Atonement, the people are described as being extremely crowded so there is no space left between people, yet, when it is time to prostrate, space has expanded so that all can lie down flat without touching each other.)

What prevents us from embodying space light and the existence of all possibilities? Isolation, lack of community, feeling unsupported, feeling unconnected, feeling separate, must surely be at least part of the answer. How can I feel spaciousness if I believe in myself as separate? If I feel myself as separate than all that is around me, the only space I can truly trust is the space that I myself occupy. In order to feel infinite space, I must be able to connect with something besides what I consider to be my “self.” One cannot accept the existence of all possibilities as long one insists that one is a separate, independent, entity from the world: one can only accept the possibilities one has touched oneself. Only by fully connecting with the world around me and seeing myself as part of it, can I touch all possibilities.

Su Wen Chapter 1 tells us that to create health we need to observe the Way, model ourselves after Yin and Yang, and attain harmony. This means we cannot live as separate selves, looking only to satiate the ego and its desires, but rather to connect with the Tao and Heaven/Nature. Disease is stated to be the result of over-indulgence in emotions, food, alcohol, and over-activity. Over-indulgence in an emotional state comes when we are unable to connect with any thing outside of that emotion, constricting ourselves to only that possibility for a period of time. Usually we over-eat, drink, and engage in other addictive behaviours because we feel lonely, unsatisfied, disconnected. To this day the causes of disease are emotions which invade/overpower the Heart, overindulgence (in food, drink, sex), and the 6 climatic influences which are in fact ways by which we respond to change (see In Search of A Philosophical Medicine). In other words, the causes of disease are the result of isolation, lack of connection, and support, and hence lack of ability to flow with the Way.

Quan Yin (Avalokita in Sanskrit) is the Bodhisattva of Compassion and also serves as the icon of medicine. Her name means “S/he who hears the cries of the world.” We might think this is a quality to be fostered by physicians, the ability to listen to others and to develop compassion. But, in fact, this is a quality to be developed in any person who is seeking healing. When I hear the cries of the world I develop compassion, and then I am more easily able to transcend my own pain. Developing compassion, listening to others, connecting with others, allows our mind to expand beyond the states of pain and suffering, and to overcome disease.

How do we take this theoretical, “spiritual,” guidelines and apply them to community medicine? First we should look at the conventional way of practicing “privatised” Chinese medicine in the West.

What happens when we see patients in our treatment rooms, each person in a separate room? We see patients individually in order to secure confidentiality and privacy. But those are two qualities that can contribute to the disease process. Confidentiality implies that there is shame in the process that the individual is going through: that is why we keep their process in confidence. Privacy also serves to isolate the person from others, giving them a sense that they are separate from and unlike others. We mostly treat patients in rather small rooms, with closed doors and windows. We want to allow the Qi to move since it is the stagnation of Qi that causes disease, and yet, where will the Qi move to in a small room behind closed doors and windows? There is a tremendous advantage in treating people in open spaces and with other people. I have noticed this through teaching and conducting grand rounds. Although I use the same techniques in my private practice as I do when I teach, patients always seem to respond better and faster when I treat them in a large room and in front of other people. I can only attribute this to the Qi being able to circulate: ideas are exchanged, inhibition is not encouraged, etc. In my experience when patients interact with each other (and other people) and share the healing process, they heal faster

Miriam Lee, one of my mentors and one of the first practicing acupuncturists in the U.S., would treat in a one-bedroom basement apartment, with 9 beds separated only by curtains. Patients could hear every word exchanged in every interaction, and could literally touch the person on the other side of the curtain. Miriam would often ask people to walk out into the common space and see how their leg, shoulder, back pain (or whatever ailment they had) were doing as the needles were in them. This way everyone got to participate in everyone’s healing. It became a communal experience. At times Miriam would offer patients lunch. I am aware of not one of her students who has been able to achieve the results Miriam did, in spite of years of training and Miriam openly sharing her “secrets.”

There are some models of treating people in a community setting, primarily in detox clinics, but these models serve “specialised” populations. What about all the other people who would benefit from a community experience, from learning about healing through a collective experience, from mutual support, from the successes and failures of fellow patients, from the wisdom of others in general?

In fact we might argue that a specialised community clinic is not really a community clinic since it includes only small portions of the community. A true community is composed of the under-served and the over-served, the rich and the poor, those who are used to privatised medicine in luxurious settings, and those who have only been to Kaiser. And most importantly, the community is composed of people with many different kinds of health issues, severe, mild, chronic, acute, as well as people who are officially not sick but still seek healing on many levels.

It is time we built a new model for medicine, a model that fosters medicine as building community. Imagine a place where all kinds of people come to heal, some from physical diseases, some from the disease of loneliness, some through the act of participation and volunteering, etc. A place where there is no distinction between doctor and patient, staff and clients. A place where all come in to breathe the fresh air of a community that practices awareness, support and nourishment. A place where people drop in to have tea or lunch in mindfulness so as to enjoy an opportunity to be in a peaceful environment and with other people who care for themselves and others. Integrating our daily life with health-care sessions is important for the creation and sustaining communities. The sharing of tasks, such as cooking, cleaning and caring for others, helps bind people in ways that mere support groups cannot.

Can we build a community centre where both the practice of day-to-day mindfulness and cultivating love is practiced along with health care? A place where people come together in meditation sessions, working in the garden, cooking, as well as acupuncture session, yoga classes, nutrition groups, etc. Isn’t it time to integrate all aspects of our lives rather than having health care as a separate entity?

Patients are not the only ones who would benefit from this model. Neither are those we normally do not see as “patients” but would still come to a community centre to practice healing on a spiritual or social level. Practitioners can also benefit from such a project, personally and professionally. It is well known that some practitioners use very simplistic acupuncture, and get excellent results. Other practitioners using the same techniques would not produce as good results. This is often because the successful practitioner exercises a certain “charm” on the patient: they have a personality that enables them to “sell” the idea of healing to the patient. Often this is their best asset: they dress, talk, and act “for success.” We might say this is a form of doing Qi Gong – altering the patient’s perspective on their healing process by giving them trust in the competency of the practitioner they chose. Many practitioners cannot produce this “Qi Gong” effect, and for those the support of a community of patients all rooting for each other can be a tremendous help in achieving greater results.

Can we build a community centre that is based on healing? If the definition of healing is wide enough, I believe that the answer is yes. We would need to redefine healing so as to include all activities, all walks, of life and mind, and implement our centre so as to support and address all aspects.