The spread of acupuncture to Italy: a brief history
The first descriptions of acupuncture reached Italy after Matteo Ricci’s travels in China. Ricci (1552–1610) was a Roman Catholic missionary of the Jesuit Order and a sinologist who built a bridge between Western and Eastern cultures. However, it was only in the 1960s and’ 70 s that acupuncture spread systematically across Italy, with a relatively short delay compared with other Western countries. The first learning experiences started in the’ 70 s and occurred in Italian schools of acupuncture, where they were often supported by French teachers. However, at that time, patients were still few, and acupuncture practitioners received insufficient and superficial training due to the lack of teaching materials in Italy.
In 1968, the first medical and scientific acupuncture society was founded: Its name was SIA (Italian Acupuncture Society), and in 1973, it was followed by the SIRAA (Italian Society of Reflexotherapy, Acupuncture, and Auriculotherapy). The former followed a traditional approach adopting the principles of the Chinese medical philosophy, whereas the latter refuted those principles and reduced acupuncture to its neurophysiological mechanisms.
We must wait until the’ 80 s to witness a real rise in interest deriving mainly from the scientific relationships established first with foreign acupuncture schools, above all from the Anglo-Saxon countries, and then, later during the’ 90 s, with the universities of traditional Chinese medicine in China. A deeper knowledge of the subject was being acquired. Consequently, both teaching activities and clinical practice improved.
In 1987, the founding of the FISA (Italian Federation of Acupuncture Societies) was a genuine milestone for the growth of acupuncture in Italy: The past—represented by the two previous scientific societies, that is, SIA and SIRAA—was superseded by both a political and scientific perspective.
With Ruling No. 7176 in the year 1982, the Italian Supreme Court of Cassation asserted that medical doctors could exclusively practice acupuncture. Since then, only people with a degree in medicine and surgery who passed the state exam and were properly certified as a medical doctor could practice acupuncture.1
Acupuncture and the law
From a legal perspective, acupuncture has always been considered a form of complementary and alternative medicine (CAM)/non-conventional medicine (NCM) following the line established by international institutions, such as the WHO and the European Parliament.
In particular, in the WHO’s document Traditional Medicine Strategy 2014–2023,2 the WHO set two main goals:
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To support member states in promoting the safe and effective use of non-conventional medicine to harness its potential contribution to health, wellness, and people-centered health care, and to increase the availability of and access to NCM, above all, for underprivileged people.
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To promote the safe and effective use of NCM through the regulation, research, and integration of products, practices, and practitioners into the health system, as appropriate.
At the beginning of the’ 90 s, the increased recourse to NCM and the great differences between legislation in force in EU member states gave rise to a motion for resolution by the European Parliament in 1992: “Non-conventional forms of medicine and therapies” had to be exactly defined and classified.
Consequently, on May 29, 1997, the European Parliament approved Resolution No. 75 on the status of non-conventional medicine, later known as the Statute of Non-Conventional Medicine.3 On November 4, 1999, the Council of Europe intervened and approved resolution No. 1206, A European Approach to Non-Conventional Medicines.4 In 2002, for the first time, the European Parliament provided a special, simplified registration and labeling procedure for homeopathic medicinal products to apply particular rules for their evaluation.
On October 23, 2007, the European Parliament and the European Council jointly approved the Seventh Framework Program of the European Community for research and technological development, including demonstration activities 2008–2013 (FP7). For the first time, non-conventional forms of medicine were listed and officially recognized by EU institutions in line with the resolutions of 1997 and 1999.5
Still within the initiatives promoted by the European Union, in 2014, the European Commission financed the China–Europe Taking Care of Healthcare Solutions (CHETCH) project, a research activity and international mobility program conducted over the four years of the Marie Curie International Research Staff Exchange Scheme (IRSES) within the Seventh Framework Program of the European Community.6
The research project resulted from extensive cooperation between Europe and China and lasted four years. (The results were presented in Brussels, at the EU Headquarters, on December 1, 2017.) The research team was comprised of 10 institutions, including European and Chinese universities and the AMAB (Association of Medical Acupuncturists of Bologna). The multidisciplinary project gathered researchers in the following areas: social sciences and humanities, economics, law, and medicine. The team conducted studies and reviewed documents on the European and Chinese healthcare systems with a comparative approach.
Europe was found to have developed good practices of universal healthcare systems, but the significant and dramatic changes that occurred over the past two decades led to a decline in public assistance. Practices of traditional Chinese medicine were growing and represented a valuable therapeutic option for an increasing number of disorders. Conversely, during the’ 80 s, China embraced extensive reforms in the healthcare system to upgrade the quality and coverage of assistance. Since then, China has invested widely in research.
Many experts were involved in CHETCH, including researchers in the social sciences, economics, international law, bioethics, modern biomedicine, and traditional Chinese medicine. The team of medical experts aimed at identifying which practices and approaches of TCM could be cost saving and effective in the treatment of specific disorders and, therefore, exported to Europe to face the European welfare crisis. Moreover, they developed a process of recognition and scientific validation of TCM versus complementary alternative medicine, as recommended by the WHO’s Traditional Medicine Strategy 2003–2005. Throughout the project, acupuncture played a central role. Its integration into European healthcare systems was considered an opportunity in a society with growth in the elderly population and in chronic diseases.
The association of acupuncture with homeopathy, osteopathy, phytotherapy, and ayurvedic medicine was a logical way of proceeding when the different forms of NCM had to be regulated, but it slowed down the procedure to have acupuncture legally recognized. The main reason for this delay was the divergent attitude of medical doctors towards these forms of NCM. That is, they were more prone to accept acupuncture since evidence-based medicine (EBM) had demonstrated its effectiveness for the treatment of some disorders, but strongly thwarted homeopathy, since they accused it of lacking scientific evidence.
Finally, in February 2013, after about 30 years from the first law proposals on NCM by the Italian Parliament, the State–Regions Agreement in Italy clearly defined the professional profile of the medical acupuncturist.
Training for medical doctors to become ‘Experts in acupuncture’
In 2011, FISA President Carlo Maria Giovanardi was appointed Expert of the Superior Health Council for Non-Conventional Medicine. This appointment proved the growing interest of prestigious institutions, such as the Superior Health Council, in acupuncture. Consequently, FISA played a key role in establishing requirements and coordinating teaching activities for education in acupuncture at the State–Regions Conference held on February 7, 2013. The purpose of the conference was to establish criteria and procedures to provide quality teaching, education, and best practices in acupuncture and other forms of NCM, such as herbal therapy and homeopathy, by medical doctors, dentists, veterinarians, and pharmacists.7, 8 The ratified agreement reads “the need for certified quality education and training in acupuncture is highlighted. […] Criteria are identified and minimum requirements set to provide uniform training courses across the entire national territory. […] Professionals engaged in these disciplines acquire qualifications on completion of courses. […] Practice on patients is exclusively reserved to medical doctors and dentists, as happens in the preventive, diagnostic, therapeutic, and rehabilitative field.”
It continues as follows: “The legislation pursues the primary goal of protecting the citizens’ health with the aim of ensuring people’s right to freedom of choice of medical doctors and dentists providing care […] respecting professional ethics” and “[The legislation] enables citizens to have access to health professionals with adequate training in the disciplines of acupuncture. […] [Acupuncture is] considered a method of diagnosis, treatment, and prevention that supports the medical establishment, their common target being health promotion and protection, as well as rehabilitation.”
Education and training were, and still are, regulated as shown in Table 1; the main goals of this training are listed in Table 2.
Table 1.
Training for medical doctors to become ‘Experts in Acupuncture’.
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Table 2.
The main goals of training in acupuncture.
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Cost of acupuncture treatment
In Italy, the costs of acupuncture treatment are partially reimbursed to patients as follows:
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Directly, by private health insurance plans. The cost of acupuncture treatment is partially reimbursed to the patient who has a policy. The policy holder only pays the deductible out of pocket. The amount of the deductible changes according to the type of company and contract signed.
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Indirectly, by means of fiscal subtractions on the patient’s income tax declaration. In Italy, the income tax declaration is a fiscal accounting document used by taxpayers (whether fiscal residents or not) to declare their annual incomes to the Revenue Agency. The agency then calculates the amount of taxes to be paid. From the gross taxes, taxpayers may subtract 19% of the costs of acupuncture sessions.
The role of the Italian federation of acupuncture societies (FISA)
FISA was founded on March 9, 1987. Today, it is the leading self-regulatory body for the practice of acupuncture in Italy and represents most Italian MD acupuncturists. It is the only Italian scientific society of acupuncture to be accredited by the Ministry of Health. Its members include 19 medical associations and 13 schools of acupuncture. Since its foundation, 4,187 MDs have been trained and certified by FISA, thanks to its 108 teachers and 74 teachers in training (last updated December 31, 2018). In addition, FISA coordinates national resources, offers assistance, and disseminates information related to acupuncture and TCM to create opportunities for youth to achieve successful futures.
FISA standards are recognized by regional, national, and international associations, institutions, and organizations. FISA has fostered alliances with regional governments and assisted the Ministry of Health in many assignments.
Challenges and prospects
Over the last few years, acupuncture has increasingly spread in Italy. Nowadays, it is administered not only in private clinics, but also in public structures belonging to the National Healthcare Service. When acupuncture was first introduced in Italy, it was mainly used to treat the symptoms of pain syndromes. Therefore, it is most used in public pain relief centers. Over time, its range of application has remarkably increased; it now covers a wide variety of fields, including the treatment of chemotherapy-induced side effects in cancer patients, among others.
Despite its indisputable growth, there are still some groups of medical doctors who display a hostile attitude towards its administration. In their opinion, acupuncture lacks scientific evidence and can only have a placebo effect. Such an attitude relates to a lack of knowledge: No adequate information is provided by medical schools. Even postgraduate programs and doctoral training give no guidance on this discipline.
What can we do?
High-quality research implementation is mandatory and urgent. International societies of acupuncture should be encouraged to cooperate closely with international scientific societies: The aim is to have acupuncture included in international guidelines, that is, to have it recommended in the treatment of disorders for which it has already been proved—and with substantial scientific evidence—to be highly effective.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
No financial support was received for the preparation of this article.
Ethical statement
The authors agree upon the standards of expected ethical behavior set by Elsevier. Nonetheless, this manuscript did not involve any human or animal experimentation.
Data availability
Public access to the research data supporting this editorial is provided through the references listed at the end of the article.
Authors’ contribution
CMG drafted the paper; CMG, UM, AP critically revised the paper and contributed to the paper; its publication is approved by all authors.
Sitography
www.senato.it
www.statoregioni.it
www.portale.fnomceo.it
www.salute.gov.it
www.camdoc.eu
www.chetch.eu
www.agenziaentrate.gov.it
www.fisa.it
References
- 1.Supreme Court of Cassation, criminal section VI, Judgment no. 7176, dated July 19, 1982, Pres. CLEMENTE DI SAN LUCA “Abusive practice of a profession – Acupuncture – Practice by a person without a degree in Medicine and Surgery - Existence of crime”.
- 2.World Health Organization . 2013. The WHO traditional medicine strategy; pp. 2014–2023. [Google Scholar]
- 3.The European Parliament . The European Union; Brussels: 1997. Resolution on the status of non-conventional medicine; p. 0067. OJ C 182, 16/06/1997. [Google Scholar]
- 4.Council of Europe. Resolution 1206 (1999). A European approach to non-conventional medicines. (Extract from the Official Gazette of the Council of Europe — November 1999). Parliamentary Assembly. 4 November 1999.
- 5.FP7 - Seventh framework program of the European Community for research and technological development including demonstration activities (FP7). EU, Official Gazette, L 301/5, November 20, 2007.
- 6.Marie Curie International Research Staff Exchange Scheme (IRSES), FP7-People-2013-IRSES, published on July 10, 2012, within the 7th Framework Program of the European Community.
- 7.“Agreement according to the article no. 4 of the Decree Law no. 281 of August 28, 1997, between central government, regions, and autonomous provinces of Trento and Bolzano, concerning rules and procedures for training in and practice of Acupuncture, Phytotherapy, and Homeopathy by medical doctors and dentists” (February 7, 2013 – The Presidency of the Council of Ministers - Unified Conference State - Regions - Proceedings ref. no. 54.
- 8.Note of clarification from the Ministry of Health, (0040978-P); July 24, 2014.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Public access to the research data supporting this editorial is provided through the references listed at the end of the article.