Chinese medicine (CM), known as traditional Chinese medicine or TCM in the West, is not only an integral part of the Chinese national healthcare systems, but it is also one of the most popular complementary and alternative medicines in the world. The important role that CM plays in the Chinese healthcare systems, and in promoting global medical pluralism, has been attributed to its unique approach toward understanding diseases and the methods used to treat them. Since California became the first state in the US to license acupuncture as an independent healthcare profession in 1976, more than forty-five states, including the District of Columbia, have given TCM similar status. With US Congressional approval in 1998, the National Institutes of Health established the National Center for Complementary and Alternative Medicine and listed TCM as a form of complementary and alternative medicine. Today there are about fifty
TCM colleges in the US offering graduate degrees in acupuncture and herbal medicine, and TCM practice has been widely applied in various Western medicine clinical settings throughout the country.
In China, CM is a medical as well as a cultural system. Its theoretical framework is largely developed from early Chinese cultural and philosophical thought including yin and yang and the Theory of the Five Phases, both of which are addressed later in this essay. The holistic and dialectic principles prescribed by these traditions are not only the foundation for CM, but they are also the basic rationales for Chinese people to comprehend social and cultural realities and to guide their social behaviors. Throughout Chinese history, these principles have affected both the development and practice of CM and have, in turn, been influenced by Chinese social and cultural changes.
THE CHARACTERISTICS OF CM
In contrast to modern Western medicine approaches, CM views the human body as an integral part of the natural world; the rise of disease is the result of failure of the human body to adapt to the environmental conditions or the failure of the physiological system of the human body to maintain its internal balance.
In CM’s view, “qi” 气 (a form of vital energy), “essence,” “blood,” “body fluids,” and human “spirit” are the basic substances sustaining the body’s function and activity. Though the clinical conceptualization of these basic substances and the dynamic relationships among them are implicit and complex, it is believed that these substances work interdependently to maintain the normal function of the human body.1
Among these substances, qi is the most important and frequently used concept in explaining the change of human health conditions in CM. Qi is viewed as the source and the driving force for the physiological activities of all body parts and organs. There are five major types of qi, and each is responsible for providing particular functions for parts of the body.2 Qi is invisible, and it travels inside the body to various parts through specific pathways known as meridians. More than thirty meridians form a well-connected “highway” system and are responsible for transporting and regulating qi and other substances’ activities. A major CM belief is that when any of the meridians are stagnated, health problem will arise.
CM practitioners use a two-stage diagnostic method in clinical practice—data gathering and interpretation. Since CM believes that any functional abnormality inside of a human body would be manifested outwardly, the focus in clinical data gathering is to identify these manifested symptoms through the practice of the following four examination methods:
Looking for any specific changes in the color and shape of tongue, face, skin, hands, nails, and the patient’s body movement.
Asking specific questions that would reveal the patient’s experience with existing conditions, their previous medical history, and life style.
Listening to patient’s tone of voice, breathing, and coughing sounds, etc.
Feeling the pattern of pulse movement and body reaction to palpation.
After the initial observations are made, practitioners then interpret the information according to the principles of differentiating symptom-complexes prescribed by CM clinical theories. The process of interpretation begins with the assumption that the manifested symptom is the consequence of the change of function in the body system. Therefore, the focus in this process is to identify changes in the functionality of various body parts in relation to the nature of courses for these changes and to differentiate primary and secondary courses. Based on the clinical diagnosis, the practitioner then prescribes proper treatment to remedy the identified changes and to remove stagnation in the meridians. CM practitioners use an array of treatment methods including acupuncture, herbal, Tuina 推拿 (a form of body manipulative therapy), and Qi Gong 气功 (a meditative practice that combines slow body movements with controlled breathing techniques).
Each of these methods provides a unique way to disperse the stagnation, nourish the basic substances, promote a balanced circulation of qi and blood, and provides needed remedies to help heal the body. The rationales for making a specific treatment plan are also based on various considerations, including the seasons of the year, the patient’s body composition and health condition, gender, and age. Therefore, it is common that two persons who suffer from similar illness symptoms would be treated with different methods.
CM medical practitioners believe that the quality of one’s spirit can both contribute to the rise of health problems and play an essential role in the healing process. Therefore, treating one’s spirit must come first before any other treatment methods are applied.
In order to detect adequately the quality of the patient’s spirit, to discern the level of emotional disturbance, and to provide proper remedies, CM requires its practitioners to possess a highly cultivated spirit and social morality. Because of this unique view and the lack of a clear definition on the concept of spirit in the medical classics throughout its history, the practice of CM has been intertwined with aspects of spiritual and ritual healings.3
THE ORIGIN OF CHINESE MEDICINE
Although the practice of Chinese healing arts appeared long ago, it is commonly agreed that CM as a theoretically and systematically based practice began to emerge during the Warring States Period (some time in the fifth century to 221 BCE) when the very first medical writing, Inner Classic of the Yellow Emperor (Huang Di Nei Jing) appeared. The Inner Classic of the Yellow Emperor employed a wide range of perspectives including Ying and Yang, Five Phases, Confucianism, and Daoism, among others. Issues concerning the rise and nature of diseases, the principles of diagnosis, and treatment methods were also addressed. The theories of Yin-Yang and Five Phases emerged long before the writing of Inner Classic of the Yellow Emperor. These two paradigms were the key frameworks for ancient Chinese to understand the pattern of changes in both the natural and the social worlds.
According to the Theory of Yin and Yang, the constantly evolving natural world, including all matter, results from the movements of two great opposing and cosmic forces within them, called yin 阴 and yang 阳. This theory holds that everything, including the human body, is constructed and originates from these two flowing energies that are opposed to each other but exist side by side, even within each other. They regulate ceaseless emergence, variation, and change in all things. The theory suggests that variations in functional conditions of the body are the result of the interplay of these two forces. An equilibrium state— a healthy state according to this doctrine—manifests harmonious in- teraction between the two forces. When the equilibrium state is threatened, or when the normal relation between the two forces is disturbed, functional disorders will occur.
A basic function of the Theory of Five Phases (also known as Wu Xing 五行) is that all things in the natural world coexist interdependently, forming a system in which they constantly change to maintain a balanced relationship with each other in order to maintain normal functions in a dynamically evolving system. A change of one also changes the rest. Illustrated by using five basic elements in nature—water水, wood 木, metal 金,fire 火, and earth 土 —the Five Phases Theory posits that the state of being of any system is the result of dynamic interaction among these elements. The nature of their interactions is confined by both mutual flourishing and constraining relationships between and among the elements. For example, wood is nourished by water but is consumed by fire. Since all things are in constant change, to avoid being over-powered by fire, the further transformation or growth of wood also depends on the water source. As all things in nature change following this principle, a harmonized and steady development follows. However, when one or more elements evolve excessively or lack change, then the balance is broken and problems occur.
This theory defines all human body parts, including organs and tissue, as analogous to the five elements in the Theory of Five Phases. The functionality of a particular body part is influenced by the functionality of others. In CM, for example, kidney, liver, and heart are associated with the elements of water, wood, and fire respectively. The state of the fire depends upon the function of liver (wood produces the fire), and the liver (wood) also depends on the function of the kidney (water). Therefore, when the kidney is exhausted, not only the liver but the heart suffers.
. . . the constantly evolving natural world, including all matter, results from the movements of two great opposing and cosmic forces within them, called yin 阴 and yang 阳.
Since these two theories imply that human behaviors play an important role in influencing the process of changes within the body and the relationship between the human body and the physical environment, the concept of prevention has infiltrated the consciousness and daily life of the Chinese people. Proper personal behavior, balanced diet, regulated emotion, and frequent exercise have been seen not only as ways to maintain health, but also as the most effective method of healing. As stated in the Inner Classic of the Yellow Emperor, “a wise man prevents diseases rather than treating them, and prevents disorder rather than restoring order.”4
MEDICINE IN IMPERIAL CHINA
The development of CM has been systematically flourishing. During the Tang (618–907 CE) and Song (960–1279) dynasties, CM developed into a multi-disciplinary practice. Medical publications exceeded the amount of all previous dynasties combined. An imperial medical college was founded in the Tang dynasty; its main function was to meet the health needs of the Emperor and his family. In the Song dynasty, other medical colleges were established across the country, first to train only men for CM. Also, state-administrated medical examinations were used to certify doctors during this period. The examinations covered a broad range of subjects in both written and oral forms. Assigned posts and salary-levels were determined by examination results. Although the practice of medicine by women has a long history in Chinese society, it was not until well into the Song dynasty that women doctors were officially recognized.
However, the medical colleges established during the Tang, Song, and subsequent dynasties trained only a small proportion of medical practitioners. The vast majority of CM practitioners were trained as apprentices according to the specific medical traditions of their masters or family members, if CM was the major source of livelihood. Prospective CM practitioners were not required to pass formal examinations. As the result of the lack of centralized effort in standardizing medical training and practice, various schools of thought emerged, and CM became a pluralistic and personal experience-based practice.5
IMPACT OF FOREIGN INFLUENCE
From the arrival of the first Arab doctor in 738 until the outbreak of the Opium War in 1839, Chinese health culture was influenced by Arabic, Persian, Indian, Tibetan, and Mongolian traditions. Chinese traditions continued to dominate, but after the Jennerian smallpox vaccination was introduced to China by a British East India Company surgeon in 1805, a steady stream of medical missionaries and other emissaries of Western medicine began to gain a foothold within China.6
After the Opium War, the Qing dynasty (1644–1911) was too weak to either maintain power or to stop the invasion of foreign powers, and a series of Western interests divided and dominated different parts of China. As Westerners established power in their territorial enclaves, they also brought medical personnel and built clinics and hospitals. Because of the corruption and decline of the Qing dynasty, Chinese people started to question their own traditions, and to call for “self-strengthening.” Under both external and internal pressures, the Qing Court had no choice but to respond to demands for reform. Western books and technological materials were translated into Chinese. Students were selected to go to Western countries and study medicine. In 1880, the first Western medical school was established in Tianjin, a major city in northern China.7 Subsequently, the Chinese medical system underwent massive change.
THE DEVELOPMENT OF CHINESE MEDICINE
The Republican Period
Shortly after the 1911 fall of the Qing dynasty, the new republican government increased modernization under the leadership of the Guomindang Party. Party leaders believed that to modernize they must modify Chinese traditions and adopt a general Western model of social development that included medical reforms. Thanks in part to Western economic resources, private Western medical schools and medical facilities, including a large number of missionary-supported hospitals, were established and expanded primarily in the cities. Despite the enormous popularity that CM practice enjoyed at all levels, especially in rural areas where modern medicine was almost non-existent, the government had practically no interest in supporting the less “scientific” CM practice. In order to clear any obstacles for developing a modern health care system, in 1929 the government attempted to ban the practice of CM. Though this was unsuccessful because CM had been and was the only available medical care source for the vast majority of the population, CM was not allowed at any government supported medical institutions.8
Despite official disdain, CM continually prevailed over the next twenty years, especially in the vast rural areas. Several major factors contributed to its survival during that period. First, Chinese medical culture had long been an integral part of Chinese culture and many of its beliefs and practices were inseparable from the way of life of many Chinese. Also, for many Chinese, CM was not only a familiar healing method, but it was inexpensive and effective in addressing common health problems. Despite governmental determination to modernize, the ongoing wars, including the war against Japanese occupation (1937–1945), exhausted resources allocated for revamping medical practice. The chaos of continued wars also destroyed Chinese social structure and created long lasting social instability and suffering. Consequently, the few existing modern and Western style medical facilities were only able to serve the urban elite class, while CM practitioners were viewed as the only available resource for the majority of the Chinese population.
CM AND THE PEOPLE’S REPUBLIC
When the People’s Republic of China was established in 1949, the new government faced a society with enormous health problems aggravated by wars and political unrest. Almost every type of nutritional deficiency and infectious disease was prevalent throughout China, especially in the rural areas. The cumulative effect of these problems impacted all parts of Chinese society. In 1949, infant mortality in the first year of life reached up to 200 deaths per 1,000 live births; it is estimated that thirty percent of children died before the age of five.
The high rates of disease were, in part, a reflection of the almost total absence of modern medical resources and trained manpower. Hospital facilities were scarce, with many provinces having .05 and .06 hospital beds per 1,000 people. Lack of medical doctors trained in Western medicine resulted in a doctor to population ratio between one to 25,000 and one to 50,000.9
To effectively mobilize resources to deal with these health threats faced by the new government, at the first and second National Health Conferences in 1950 and 1951 the Chinese Communist Party (CCP) and the Ministry of Health (MOH) issued “walking on two legs,” or the mobilization of both Chinese and Western medical resources to battle the imposing public health challenges.
The call for the “walking on two legs” approach, which in part was a political decision, not only recognized the value and role that CM played in Chinese public health, but also officially integrated CM into the Chinese health care system. The “walking on two legs” policy soon proved effective and ignited a new enthusiasm within the Chinese medical community to further strengthen the role that CM plays in the national health care system.
A series of steps to standardize and regulate CM began to take place. In 1952, the CM practice licensure system was implemented that required all practitioners to take state-controlled examinations. To standardize Chinese medical knowledge and practice, Chinese medical schools were established throughout the country. Intended to modernize CM, these schools included subjects related to Western medicine in their curricula.
Despite this progress, trying to unify various schools of thought in CM and to modernize a traditional and pluralistic medical system proved to be a difficult task. Even among CCP leaders, there were different views on the effort of integrating CM practice with Western medicine. Many CCP officials believed that CM should only play a small role in developing a modern China, since they felt CM to be a backward way of thinking often mixed with supernatural elements. Considering both Chinese political and health realities, however, Mao Zedong and the CCP formalized a public health policy that promoted CM and continued the effort of integrating CM with Western medicine practices.
To implement this policy, the Bureau of Traditional Medicine was founded within the MOH. In 1955, the Academy of Chinese Medicine was created within the administration of the MOH. Many young but established practitioners of CM and Western medicine were selected for cross-training. CM hospitals were also established across the country. In addition, almost every Western medicine hospital began to host a CM department. CM hospitals and doctors enjoyed an equal standing with Western medicine facilities and personnel in terms of status and state funding. CM became a part of the free government medical care system.
The efforts made during the 1950s and the first half of 1960s to institutionalize CM and to create a new form of medicine that integrated Chinese and Western medical practices ignited a sense of excitement within the Chinese medical community and impressive progress in battling China’s health problems and delivery methods was achieved. During the early 1960s, Chinese and Western medical physicians successfully explored and widely applied acupuncture anesthesia in surgical operations. Patients under acupuncture anesthesia suffered less post-operative pain, recovered faster, remained conscious, and were able to communicate with doctors during the operations. However, since the effort of modernizing CM was also fraught with politics, eventually disagreements increased among the medical experts from both medical systems on how and which parts of CM should be modernized. Many Western medicine experts insisted that CM was fundamentally incompatible with “modern” medicine and opposed the integrated approach; while within CM, top experts of various CM schools disagreed with the procedures for standardizing CM training and practice developed by the MOH. As these debates intensified, in 1965 Mao became critical of the MOH because they were ineffectual in promoting the CCP effort to integrate Western medicine and CM, and he questioned the motives of all those who opposed the integrated approach. As a result, not only did those who questioned the integrated approach became political casualties, but the development of China’s medical system took a dramatic downturn when the Cultural Revolution started in 1966.
During the Cultural Revolution (1966–1976), the Academy of Chinese Medicine that was established in 1955 (along with most CM colleges) closed. Medical professionals from both CM and Western medicine camps, who previously opposed the integrated approach, were condemned and discharged from their posts; many were sent to the rural areas to receive “re-education.”
After having cleared out the opposition, the CCP continued its effort to develop the “new medicine”—the integration of CM with Western medicine. Practitioners were required to learn the theories and methods of both medical systems and to treat patients using the combined method. Trained with only simple skills in both Chinese and Western medicine, thousands of high school graduates, as well as young medical college students, were sent to the countryside as “Barefoot Doctors” working alongside peasants in the fields.
Although integrated medical practice—including the “Barefoot Doctors” movement during this period—made impressive progress in providing basic and affordable medical services to urban populations and in facilitating the expansion of a practical health care infrastructure in the rural areas, CM as a professional field experienced a significant setback during the Cultural Revolution, especially in education and research.
With Mao’s death and the end of the Cultural Revolution in 1976, CM began to undergo another transformation. Led by Deng Xiaoping, China embarked on the mandate of “Four Modernizations”—agriculture, industry, science and technology, and national defense. The focus of Chinese health care also shifted from providing primary and community health care to improving the training of medical professionals and modernizing hospital technology.10 In the early 1980s, the State Administration of Chinese Medicine and Pharmacology Science was created to direct the Academy of Chinese Medicine and activities related to the standardization of CM practice, research, publications and internationalization.
Considering the importance of CM in the Chinese health care system, its popularity in Chinese society, and the complexities of CM in both theory and practice, the new health policies developed by CCP and the MOH began to advocate the “three paths” approach—promoting Chinese, Western and integrated medicine as individual fields that would coexist in the Chinese national health care system.
Spirited by political and social transformation, research on applying CM and integrated medicine treatment modalities to deal with epidemic health problems has also intensified. This research has yielded some impressive results, especially in fields such as the application of acupuncture and herbal medicine to treat cancer, coronary heart disease, diabetes, stroke rehabilitation, and other diseases. During the 1980s, the use of integrated medicine to treat certain types of cancer showed promising results. For example, by providing patients with a Chinese herbal medication known as “bu xue yao” (drugs for stimulating and nourishing the blood) while they received the standard radiation therapy, clinical research showed that patient survival rates were twice that of a control group receiving radiation only.11 Since then, the use of radiation therapy along with herbal medications has become the standard treatment plan for cancer patients.
Since the 1980s, the number of CM colleges and universities has increased considerably. According to the 2008 China Statistical Yearbook of Chinese Medicine, there are forty-seven Chinese medical schools; among all Western medical schools, eighty-nine offer CM degrees; and among all other types of universities and colleges, 138 offer CM degrees. After passing the licensure exam, graduates from these schools are classified as either “Western medicine,” “Chinese medicine,” or “integrated medicine” practitioners. At the same time, the effort toward standardizing the classification of labeling disease has also accelerated. In 1996, the National Standards for Clinical Diagnosis and Treatment Terminologies was published and implemented.
As China’s economic development began to accelerate in the 1990s, the development of Chinese medicine facilities also flourished. Toward the end of the Cultural Revolution in 1975, there were only 160 specialist hospitals for CM in China; in 2008, the number increased to 3,115. The total beds in these facilities also expanded from 13,675 in 1975 to 386,941 in 2008.12
Today, CM and integrated medicine enjoy equal status with Western medicine and play an important role in China’s pluralistic health care system. Their services account for approximately forty percent of all health care delivered in China.
1. P.U. Unschuld, Huang Di Nei Jing Su Wen, Nature, Knowledge, Imagery in an Ancient Chinese Medical Text (Berkely: University of California Press, 2003).
2. Ted J. Kaptchuk, The Web That Has No Weaver: Understanding Chinese Medicine (New York: McGraw-Hill, 2000).
3. Linda L. Barnes, Needles, Herbs, Gods and Ghosts. China, Healing, and the West to 1848 (Cambridge, MA: Harvard University Press, 2005).
4. Ilza Veith, The Yellow Emperor’s Classic of Internal Medicine (Berkeley: University of California Press, 1970, 2002).
5. Elizabeth Hsu, The Transmission of Chinese Medicine (Cambridge, UK: Cambridge University Press, 1999).
6. S.M. Hillier and J.A. Jewell, Health Care and Traditional Medicine in China, 1800–1982 (Routledge & Kegab Paul, 1983).
7. Anelissa Lucas, Chinese Medicine Modernization: Comparative Policy Continuities, 1930s–1980s (Praeger Publishers, 1982).
8. P. Wang, “Traditional Chinese Medicine,” in Traditional Medicine and Health Care Coverage (Geneva: World Health Organization, 1983).
9. D. Lampton, “Health, Conflict, and the Chinese Political System,” Michigan Papers in Chinese Studies, 18 (Ann Arbor: The University of Michigan Center for Chinese Studies, 1974).
10. Volker Scheid, Chinese Medicine in Contemporary China—Plurality and Synthesis (Durham & London: Duke University Press, 2002).
11. A. Emmett, “Where East Does Not Meet West,“ Technology Review (Nov/Dec 1992): 48–56.
12. China Statistical Yearbook of Chinese Medicine (2008).