Classic POEM: The germ theory is too Western

(originally posted at POEM on Sat, 04/28/2012 – 12:04. Posted in: Accountability / Biopsychosocial model / Client empowerment / Client-centered care / Clinical massage practice patterns / Community outreach / Comparative history of ideas (CHID) / Courageous engagement / Critical-thinking skills / Cross-cultural competencies / Disease / Education (pedagogy and andragogy) / Ethics / Everyday realities of resource-poor environments / Fiduciary duty / Foundational concepts / Healthcare practitioners’ attitudes toward massage / Human rights / Infectious diseases and conditions / Interdisciplinary knowledge / Learning without borders / Massage’s culture wars / Obstacles to integration / Professionalism / Pseudoscience / Public health / Refugees / Respect for others / Safety of massage / Safety, personal / Stakeholders of massage / The germ theory is too Western / Transparency )

Laura Allen embodies the very ideas of transparency and accountability when she says that anyone is free to quote anything she says anytime and anywhere, and I believe I’ll take her up on that.

Over on her Facebook account, which you may or may not be able to see unless you’re already friends with her, she writes:

It’s a concern to me that three times in the past couple of days, I have seen stories on here about employers who don’t want the massage therapists to change the sheets for every client. That is so unethical, not to mention a health hazard. If you are working in such a place I suggest getting out immediately and reporting the owners to the massage board AND the health board. As one person said to the owner who was mad about her changing the sheets, would you want to check into a hotel and sleep on the sheets the last person used? I don’t think so. And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.


Clear, concise, and correct. And if the guilty owner was reading the post, they didn’t choose that hill to (metaphorically) die on; Laura’s commenters were 100% supportive of the bright shining biomedical and ethical line in the sand that she drew.

It occurred to me that there could be correlation between the type of massage practiced and its underlying conceptual model, with the degree of sanitation and hygienic practices adhered to.

For example, if you truly believe that disease is caused by a bad wind entering the body, or by negative thinking, or by karma, then that’s not really much of a motivation for paying attention to getting rid of germs on surfaces.

And an interesting followup question is, if you do believe in one of those conceptual models, and you are scrupulously diligent about observing good hygiene, then why do you go to that trouble?

I mentioned that that would be a fascinating study that I would probably never get around to carrying out, but if someone else did, I would love to read about it.

Well, ask and you shall receive, I guess.

One of Laura’s commenters told a story from her own experience, that is a perfect case study of the correlation I was thinking about:

I had an MT friend who worked in a chiro’s office and he reused disposable acupuncture needles. He was quite careless with them and they’d often fall on the carpet where you wouldn’t notice them until you got off the table, barefoot, and get one in your foot. When the MTs in his office complained, he waved them off for being too “Western.” In China, they reuse needles from person to person. At least, he bragged, he only reused them on the same person. Eventually he agreed not to do acupuncture in the massage rooms so massage clients didn’t get stuck by stray needles. Sheesh.



There are so many issues here, that it’s difficult to know where to start.

Disease transmission by infected reused needles, or Hygiene 101, is only the first one.

To get back to our topic from needles, I’m sure the POEM commenters can name several conditions that can be passed from one person to another by dirty bed linen.

Sources: Left: accessed 29 April 2012, Right: accessed 29 April 2012


And although this may come as news to the chiropractor in the story, in resource-poor areas of the world, they don’t share needles because they *want* to; they do it because they have no other options.

Every time something like that reinforces the perception of MTs as elitist, classist, ethnocentric, and generally oblivious, it just makes more work for the rest of us to dismantle that perception.

So here we go, gradually chipping away at it:

First of all, the session is about what the client wants and needs, not about forcing the client–with or without full disclosure and informed consent–to settle for what people in resource-poor environments are compelled to make do with. The chiropractor in the study is not practicing in a client-centered way; his practice is centered on something else, where infection control is not a priority.

Second, in chiding others for being “too ‘Western'”, he probably sees himself as all diversity-oriented, and transcending elitism and ethnocentrism.

Nothing could be further from the truth.

He is claiming, in effect, that Chinese people don’t value their own lives and bodily integrity enough to care about basic biomedical best practices. Where he got the idea that he gets to speak for them is unclear, but his claim positively advocates poorer medical care based on nationality and ethnicity.

This violates Ethics 101 in a big way.

If Chinese people do reuse needles, what could be the explanation?

Unlike the chiropractor in the story above, who implies they are choosing to do so when they have better options, I think that looking at the availability of resources is a useful source for possible explanations.

According to the Wikipedia article “List of countries by GDP (nominal) per capita“, the US per capita annual income ranges (depending on the reporting source) from $47,153-48,387.

The per capita annual income in China ranges (depending on the reporting source) from $4,428-5,414.

The per capita annual income in Ethiopia ranges (depending on the reporting source) from $300-360.

I’ll leave as an exercise for the readers to evaluate whether Chinese people and Ethiopian people reuse acupuncture and injection needles because:

  • they don’t care about their own lives and health, or about each other, and consider infection control “too ‘Western'”, or whether
  • unused needles are much harder to come by in environments where the average person earns 11% (China) or 0.007% (Ethiopia) of what the average American earns.


Screen shot 2015-09-29 at 5.39.10 PM


And if you consider it a do-or-die cost issue–if your business, in the US context, is so iffy that you need to operate it in the American context with Chinese or Ethiopian standards of practice and margins on clean linens, unused acupuncture needles, or any other compromise on infection-control best practice, then your business is not dying.

It is already dead, and you just haven’t acknowledged the fact. If you cannot afford to practice infection control, it’s over. Deader than the parrot in the Monty Python sketch.


I’ll heartily second Laura’s recommendation:

And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.


and I’ll add some of my own.

Recommendations for educators:

  • The history of massage is an important thing for students to know about, but infection-control trumps it every time.
  • If you don’t have time in the curriculum to teach both about how people used to believe humors or bad winds caused disease, AND what we know now about how to prevent infection in a massage therapy practice, so that the students not only rotely deliver the correct answer on tests, but really show that they understand and can apply it in context, then the curriculum resources have to be devoted to infection control at the expense of pre-modern concepts of illness and disease.


Recommendations for students and practicing MTs:

  • Check to see if your school is teaching (or did teach, if you’ve graduated) proper infection-control practices.
  • Make sure that you know how to protect clients by reporting unethical and unsafe practices to the correct regulatory authorities in your area.
  • If not, make sure that you get all that information somewhere else, and use it in your practice–it’s just that important.


Recommendations for clients:

  • The time in a session is time that you have paid for, and you should not feel hesitant to ask questions about the care or service you are receiving.
  • A client-centered healthcare professional will be happy to answer any questions you may have. Hospitals in the US, UK, and elsewhere are now actively promoting campaigns (as shown in the buttons below) to ask your provider whether they’ve washed their hands before examining you. MTs who want to be part of an integrated healthcare team will not balk at following the same infection-control best practices as other members of that healthcare team.
  • Don’t hesitate to ask what infection-control procedures your MT uses.
  • When you are getting on the massage table, take a moment to look at the linens you will be lying on–do they look clean and unused, or do they appear to be re-used?
  • How many layers of linens are on the table? If it’s more than one, the establishment may be cutting corners by stacking sheets to save time between clients. The problem with stacking sheets is that mere layering will not prevent transmissible conditions from crossing those layers. Don’t accept sheet-stacking from your MT; insist on a single layer of clean and unused linens every single time. This is your time and your care; it is reasonable that you expect it to be conducted in a way that looks out for your best interests.


Screen shot 2015-09-29 at 5.38.54 PM

Sources: Left: accessed 29 April 2012; Center and Right: accessed 29 April 2012


These are steps we can take, and encourage our clients to take, to show that we are serious about developing into a healthcare profession that will accept the responsibility of self-regulation and client protection that comes along with that status.

Update: In the comments to the original post at POEM, an MT wrote:

Germ theory and infection prevention

Excellent points raised about infection and germs in sheets used in MT.

I’ve shared offices with acupuncturists for years and it’s a pet peeve of mine to find used needles on the floor, in carpets and around (but not in) the trash receptacles.

In China, they have linked outbreaks of Hepatitus C to the practice of reusing needles. (

In South Africa, HIV infection has bene linked to needle reuse as well (

So whether or not needle reuse is practiced in Third World countries, it still is a huge infection risk for anyone. Period. Even tattoo artists in the U.S. observe the practice of sterilizing needles. To hear that a chiropractor is reusing needles in the U.S. is abhorrent.

At my private office, the acupunturist had been putting her clients on top of my clean sheets and then only changing the top sheet afterwards…if she got blood on it! And she wasn’t telling me she was doing this until recently. When I told her I was concerned about her putting her acupuncture clients on my clean sheets, she then added a sheet on top of mine and again only changed mine if she happened to NOTICE blood on my sheets.  When I found this out, I stopped dressing the table for my next client until I am ready to begin the massage. (We had been keeping the tables “dressed” so it looked neater to clients walking by. Now the table is bare until we use it.)  So it’s not only practices going on that you know about, but other practicioners using your room may not have the same standards of hygeine for your table, counters and the floor. Yikes!

Here’s my response to her:

That is a superb example of practicing in a client-centered way
Submitted by RST on Sun, 04/29/2012 – 11:17.

When I found this out, I stopped dressing the table for my next client until I am ready to begin the massage. (We had been keeping the tables “dressed” so it looked neater to clients walking by. Now the table is bare until we use it.)

It’s too bad you have to resort to that, but since you found yourself in that situation, you’re really doing the right thing to protect your clients.

Good work–that’s the kind of client-centered practice that will promote the development of massage into a healthcare profession.


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