Sights and Experiences — A Glimpse of TCM in Britain
Editor's Note
Mr. Zhu Buxian is a high disciple of the famed Nantong physician Zhu Liangchun. Some years ago he went to Britain and opened a TCM clinic in Oxford. His clinical skill at lifting heavy cases spread by word of mouth; patients from across Europe came to him.
In this piece Mr. Zhu analyzes the state of TCM in Britain and diagnoses the disease of TCM's transmission. His view cuts to the pathogenesis — almost the same problem we meet in reviving TCM at home.
After reading, one will, from a new angle, grasp more deeply how vital it is to preserve and develop TCM's character.
Sights and Experiences — A Glimpse of TCM in Britain
Zhu Buxian
Records show: Chinese medicines reached Europe via Arab lands at least by the 10th century; acupuncture drew Dutch attention by the 17th. (1) Since then TCM's outward spread to Europe and the Americas has been continuous, rising over time. From the 1980s, against the background of China's reform and opening, more TCM workers went abroad; in Western countries with developed science they practiced and transmitted TCM, opening a new page of East-West cultural exchange. This is a new test of TCM and has added new elements to its development. It shows the world the wisdom-light of Eastern traditional culture and has greatly strengthened our cultural self-confidence. But the lessons it has brought back in practice deserve deep reflection. With humility, I outline below my own sights and experiences in Britain, hoping to draw readers' attention and thought.
1. The TCM Boom and Its Hidden Concerns
Britain's medical system divides into mainstream medicine and complementary-and-alternative medicine. The first is Western medicine, with legal status, part of the National Health Service. The second is in free practice without legal status; TCM workers in acupuncture and Chinese herbs belong here, alongside osteopathy, homeopathy, reflexology. The rise of the TCM boom came directly from TCM's practical value. For diseases Western medicine has no clear answer to, TCM often achieves better results; with growing fear of side effects of synthetic drugs (antibiotics, steroids), people turn to natural medicines. Eczema is common; TCM treats it well — winning reputation for TCM. The TCM boom is both historical chance and historical inevitability. Whether TCM can rise further, obtain legal status in Britain, and enter mainstream and the NHS — this is seen in TCM's present state and in Britain's ongoing TCM legislation.
TCM in Britain is mostly in scattered, individually run clinics. Their number has grown from few to many across the country — estimates around 3,000; some run as chains, often in large shopping centers for convenience of patent-drug buying, acupuncture, or herbal treatment. The TCM boom has driven the import of Chinese herbs, patents, acupuncture needles and equipment; herb sales have surged; several influential Chinese-medicine companies have appeared. Meanwhile TCM education has made strides: English-language TCM books have multiplied; private acupuncture and TCM colleges have appeared; some even train TCM (acupuncture and Chinese-medicine) graduate students. Worth noting: Middlesex University in cooperation with Beijing TCM University, from 1997 launched Europe's first TCM-degree program — a five-year course. The Sing Tao Daily of November 4, 1996 reported this in detail, praising the first European higher-education-recognized TCM bachelor's program, which would play an important role in the development of TCM in Europe. As one of Europe's fastest-growing TCM countries, Britain's influence on the rest of Europe is not small.
As TCM's influence grows, concerns about quality and safe medication arise — together with cultural difference and the varied level of practitioners. Praise for TCM is heard; so is slander. To protect patient, public, and practitioner interests, TCM legislation is needed. In January 2000, the Science and Technology Committee of the House of Lords, in its report on complementary-and-alternative medicine, recommended statutory regulation of herbal medicine and acupuncture. In January 2002 the Department of Health, the Prince of Wales' Foundation for Integrated Health, the European Herbal Practitioners Association, and trade groups jointly formed the Herbal Medicine Regulatory Working Group; in July 2002 the Department of Health and the Prince of Wales' Foundation also formed the Acupuncture Regulatory Working Group, to advise on statutory regulation. In September 2003 both groups published their reports. Building on those recommendations, in March 2004 the Department of Health issued Proposals for the Statutory Regulation of Herbal Medicine and Acupuncture, going to broad consultation. The model: a unified CAM Council, with herbal medicine and acupuncture each regulated as a whole; the council to handle professional education, registration, continuing development. The herbal practitioners in the proposal include Western herbalists, Chinese herbalists (and TCM), Tibetan herbalists, Indian and Sri Lankan Ayurvedic, Japanese Kampo, etc. Acupuncture practitioners include traditional and Western-medical acupuncturists. Under this proposal TCM would be split into herbal and acupuncture parts; its integrity lost; nor do herbs and acupuncture cover all TCM therapies — and TCM doctors working with herbs would have a status equivalent to Western folk herbalists. This cast a shadow over TCM's prospects.
TCM legislation is a complex process; legislation itself shows British society's respect for TCM. TCM can use it to fix its legal place and fight for its rights. While the consultation continues, after the Department's proposals came out, British TCM groups argued strenuously for an independent TCM Council, equal to acupuncture and herbal medicine, registered and managed independently, autonomous, preserving integrity. If TCM circles unite and reach this goal, hidden concerns can be removed; hope remains. We must clearly recognize: for TCM to have legal status equal to Western medicine, become a force in the NHS — a long, twisting road remains.
2. The Many Doubts TCM Faces
TCM's rapid growth overseas has drawn wide attention. How safe are Chinese herbs? What are acupuncture's indications and mechanism? Will Chinese and Western drugs interfere when used together? Such questions are pressed.
A so-called Aristolochic Acid kidney-damage incident caused great waves. The outline: in 1992 two young Belgian women, undergoing a slimming therapy containing Chinese herbs, developed acute interstitial renal fibrosis; another seven women at the same clinic, on the same therapy, were admitted to dialysis for late or near-late renal failure. Eight of the nine had biopsies showing wide interstitial fibrosis, no glomerular damage. Two were first seen in late renal failure and dialyzed immediately; the other seven had acute kidney-function deterioration with serum creatinine doubling in three months. The clinic specialized in slimming and had run 15 years without incident. In May 1990 the therapy changed: the capsules' original prescription had added Chinese herbs Han fangji and houpu (both powdered). In June 1992, among 25 randomly chosen women treated for over three months after 1990, three had renal damage. Chemical analysis of different brands of these herbs found no renal-toxic impurity (e.g., fungus) or plant-original substance (e.g., ochratoxin or aristolochic acid); but the capsules the patients took contained constituents different from those Chinese herbs' alkaloids. (2) What caused the renal damage in these patients? Later reports said the aristolochic acid in the Chinese herbs caused it. (3) Some held the toxicity of aristolochic acid was activated by other simultaneous substances. (4) But aristolochic acid is found only in guang fangji of the Aristolochia genus, not in Han fangji. Whether the clinic erred is unknown. From these reports, though Chinese herbs cause kidney disease is sensational, the evidence is insufficient and unconvincing.
In Britain, some long-term users of Chinese herbs for eczema were found to have transient abnormal liver function — reports of which, even without firm evidence, shook some patients' confidence in Chinese herbs. The Lancet, August 1999: a 49-year-old woman taking Chinese herbs two years for eczema developed late renal failure, started dialysis, had transplant three years later. Another, 57, taking Chinese herbs six years for chronic eczema, likewise developed renal failure, awaiting transplant. Their herbs were analyzed by HPLC and mass spectrometry; aristolochic acid was found, a substance leading to renal toxicity and carcinogenicity, sourced from mutong. Mutong has bai mutong and chuan mutong variants; guan mutong (the Aristolochia species) carries it. (5) Direct result of these events: all Aristolochia-genus Chinese herbs and patent medicines containing them were banned in Britain. The range of usable Chinese herbs further shrank.
These events deserve deep thought. We can equally question whether other factors are excluded — kidney function before taking the herbs; whether Western drugs were taken simultaneously; etc. But from the standpoint of our own improvement, the chaotic state of some Chinese-herb species must be corrected; quality control must be strict; drug-natures always have leanings — formula-making must follow rule. If the doctor neglects pattern-discernment and keeps to one formula long-term, that is not the herbs' guilt but the doctor's. From contingent events we should find some necessity — this is the rigorous attitude of scholarship.
Will herbs and Western drugs interfere? Reports note: ginkgo, garlic, danggui, or danshen with warfarin can bleed; renshen with antidepressants brings agitation; Xiao Chaihu Tang lowers serum prednisolone. (6) These deserve our attention and deeper study.
On acupuncture: March 16, 1998, Adrian White at a major pharmaceutical foundation said they had found decisive evidence that acupuncture relieves toothache, back pain, nausea; on smoking cessation and weight loss, only placebo effect. On cervical pain, headache, arthritis, rheumatism, myocardial infarction, asthma — no consensus, though much anecdotal evidence. He held now is the time to study acupuncture seriously; little is known of its neurophysiology; it should, like other therapies, be evaluated and tested. On the principle of acupuncture analgesia: stimulating a specific point — perhaps a nerve fiber or receptor — with needle, electric impulse, or laser, triggering rhythmic release of endogenous opioids and oxytocin. (7) Pity: his understanding of acupuncture is restricted to neurophysiology, having departed from TCM theory — e.g., the guidance of channel doctrine. One opinion among many.
3. The Balance Doctrine Helps Communication
Repeated negative reports have not extinguished British enthusiasm for TCM. In this tradition-respecting country, TCM grows on — a meaningful cultural phenomenon: Chinese and Western cultures conflict but can also embrace. How to promote mutual understanding and reduce misunderstanding? From different angles. I think balance (平衡) is one point of convergence.
Balance covers much; its content varies by hearer. TCM stresses yin-yang balance; the British like balance too — health-care seeks balance: healthy diet, natural food, attention to meat-vegetable, refined-rough mix. Under work tension and competition, mental stress is hard to bear; many learn to relax, practice yoga, taiji, qigong — letting body and mind reach balance. Records show the Mawangdui silk Huangdi Si Jing put forth a balance doctrine; (8) it is an important pre-Qin philosophical thought. TCM treatment in essence: carefully observe where yin and yang lie and regulate them, taking level as goal (Suwen · Zhi Zhen Yao Da Lun). The thought of balance accords with the middle — 守中 (Laozi), 養中 (Zhuangzi), 執中, 致中和, supplement the insufficient, drain the surfeit, neither excess nor deficiency. As Qing physician Zhang Xugu said: "Centrality and harmony — both yin and yang are level, neither leaning, neither resting; losing this is to part from the Way." (9) Many patients, treated unsuccessfully with antibiotics, when I explain my prescription's aim is to adjust the body's yin-yang balance — not direct antibiosis — receive it well. I have felt this often. Many British people gradually accept the yin-yang balance concept.
In TCM, the thought of balance is everywhere. In formula composition the ancients stressed 约 — the army with system. Lingshu · Jin Fu: "The constraining of a formula is like tying a sack. A full sack untied — it leaks. A formula without constraint — the spirit is not with it." Without constraint, no spirit of formula-building; nothing practical. Within formulas, cold-and-hot together, motion-and-rest joined, dry-and-damp mutual, drain-and-supplement together, or issuing within retaining, blocking within unblocking — all carry the meaning of constraint. The common use of gancao to harmonize the drugs — that harmonize takes balance. Drug-natures lean; misused, mis-combined, blindly over-dosed — harm. Only proper combination converts the lean to balance, makes a putrid thing miraculous, brings full drug effect. That Belgian slimming clinic's capsules — Chinese and Western drugs mixed — used Chinese drugs as Western drugs, no rule. To want to use Chinese drugs without consulting TCM theory — how can it not fail? Obesity has many causes; treat by pattern, not by one universal formula.
Fangji — long used in TCM. That guang fangji contains aristolochic acid has been known. I even believe that, with modern science advancing, more cases of TCM containing some toxic constituent will be found. Chinese herbs are complex; the mechanism of compound formulas yet harder to explain. If on finding such a constituent we simply ban — the result is obvious. After bitter thought: we must self-warn, self-spur, self-strengthen, return to TCM's own features, actively respond to questions on toxicity, give objective evaluation, seek reasonable explanation. The marvel of Chinese drugs lies in combination; the basic rule of formula-making is system and constraint. Chinese drugs do not produce resistance as Western drugs do — perhaps because of this. We should study aristolochic acid and related drugs for toxicity and safety, and study the use of fangji in classical formulas — from Zhongjing's onward — paired with shengdi, guizhi, huangqi; investigate Fangji Dihuang Tang, Mu Fangji Tang, Fangji Huangqi Tang; compare powder vs. decoction. This will give a fair evaluation of guang fangji's good and harm and reference for future patent and dosage-form reform. Constraining the formula is balancing the formula. From this, communication is helped; Westerners can gradually understand the essentials of Chinese-drug combination, and confidence in safety grow.
Looking now: under Western influence, Chinese drug-prescribing rules quietly change. The drugs in the prescription are Chinese, but the guiding thought has westernized — this drug raises immunity, that one antibacterial, that one antiviral, that one anticancer. Chinese drugs used as Western drugs has become fashion — perplexing, worrying. This is not to say TCM should refuse modern research findings on Chinese drugs; but when TCM theory and the basic rule of formula-making are shaken, we slide toward abolish-medicine, keep-the-herbs — TCM scholarship will shrink; the advantage of TCM gradually lost. Can one not be alarmed?
4. Holding to TCM Principle and Variation
Holding to tradition is not stubborn fixity. In clinic we meet new challenges — some diseases of the same name (asthma, tinnitus) have causes and patterns far beyond the old books; some diseases not recorded (CFS, Crohn's) need new exploration. Plus the patterns from long Western drug use (antibiotics, steroids), and restricted drug range in Britain (insect drugs banned, etc.). Under such conditions, how to play TCM's strengths — opinions differ. I value variation: Yijing · Xici: "When the Yi reaches its end, it changes; change brings circulation; circulation gives endurance." And: "Variation is timeliness." Only with change-and-flow can things fit the time, last long-renewed. TCM's li-fa-fang-yao — all can vary: traditional theory can yield new readings, fitting present need; with no rule to follow, find rule beyond rule; old formulas may not fit today's illness, but can be modified by pattern; one drug can serve many uses, with infinite combinations.
Take asthma. In Britain very common. The ancients on cause: Qing Li Yongcui's Zheng Zhi Huibu representative — "There is blocked qi within, untimely outside-feeling, glue-fixed phlegm in the diaphragm." In Britain seen mostly: allergy (pollen, dust, animal fur and feathers) and triggered by weather change, dietary error, mood discomfort. Patients have often tried antibiotics, steroids, inhalers without effect. Asthma inhalers are widely used: Ventolin (a bronchodilator), Becotide (containing beclomethasone for steroid-dependent asthma). Initially effective and able to control attack quickly, then comes tolerance and considerable side effects: Ventolin can cause digestive upset, fast heart rate, irritability, more severe bronchospasm; corticosteroid inhalers may cause spread of infection, water-sodium retention, low potassium, GI bleeding, hypertension, diabetes, osteoporosis, with long use adrenal atrophy. Western treatment of asthma focuses on bronchospasm and inflammation — in short, on the disease. If we are led by this line and blindly imitate, only screening anti-allergy, anti-inflammation formulas, that is not wise. TCM has its own values and methods: from outer manifestation of asthma judge inner cause, not external alone; observe progress and retreat from contention of right and evil, not symptom control alone; view from the whole of zàng-fu relation, not local. In short, regulate yin-yang balance and protect the right — first save the person, then treat the disease (Yi Zong Ji Ren Bian).
I once treated a man, 41, painter, asthma 15 years, worse in the last 4–5 years, often using antibiotics and steroids; to keep working, he used Becotide. On presentation: open-mouthed, lifting shoulders to breathe, breath unsettled, chest oppression, blocked nose, watery thin phlegm, scant; face red, hot; tongue plump, pale-red, coating scant; pulse thin-wiry-rapid. This was lung-qi blocked, fluid evil with internal heat. I asked him to stop Western drugs and gave Guizhi Tang combined with Qianjin Bai Qian Tang (baiqian, ziwan, banxia, daji), modified: chuan guizhi 5 g, raw baishao 8 g, guang xingren 10 g, baiqian 10 g, fried ziwan 10 g, fa banxia 10 g, sangbai 10 g, raw shigao 15 g, raw gancao 3 g. One dose daily, one week: asthma much reduced, tongue red turning to pale; another week: no asthma. Maintenance: chuan guizhi 5 g, raw baishao 8 g, huangqin 3 g, guang xingren 10 g, fried ziwan 10 g, raw shanyao 15 g, luxiancao 15 g, wuweizi 5 g, raw gancao 3 g, one daily for two months. No attack. Follow-up at two months: stable, working normally. Note: the root was insufficient wei-outside; smelling paint odor blocked lung qi; the order of governance ceased; phlegm accumulated; asthma arose. Becotide controlled the symptom but did not restore zàng-fu function. Long course, cold and heat mixed, deficient and replete intertwined — quite hard. Guizhi Tang with Qianjin Bai Qian Tang — harmonize ying and free yang, free lung qi, level counterflow, dissolve phlegm and water — gained effect. The red face is due to long steroid use — not for hasty sweet-cold drugs. The maintenance formula adjusted by pattern: removed phlegm-and-rheum drugs, added kidney-and-spinal-strengthening — intended to lift wei-outer function. This is a case of successful withdrawal from steroids — not to be generalized. How to prevent asthma relapse and successfully withdraw the steroid in steroid-dependent patients remains a clinical problem, awaiting deeper study.
5. Conclusion
TCM, by its unique dialectical thought and treatment means, has won fame abroad — using its strengths to fill Western medicine's gaps, gradually winning acceptance by its difference. This shows we must hold to tradition, develop the national essence — not abandon the root in blind westernization. Tradition and modernity do not contradict — today is the continuation of yesterday; we cannot disregard history. The point is to open the rich treasure within history, draw beneficial lessons, integrate, seek new, change — to fit today's need. Since Western medicine entered our country with the European wind blowing east, many TCM reformers proposed "hold to TCM and consult Western," "Chinese-Western combination" — opening an age. But TCM and Western medicine are wholly different scholarly systems; especially under Western strength, blind sameness will erase our character. Seeking difference will help our own development. This sounds paradoxical, but seeking sameness and seeking difference are two sides; we can choose by the angle. Seeking difference helps us analyze and compare, recognize our strengths and weaknesses, find more leverage points in clinic and research, open new ground for TCM, avoid blending and losing ourselves. Only with constant self-enriching, self-renewing, self-improving can we win more respect of the world, and Chinese and Western cultures move from mutual embrace to harmony.
References
1. Encyclopedia of Chinese Medicine — Chinese Medicine, Shanghai Scientific and Technical Publishers, 1997: 123.
2. Vanherweghem JL, Depierreux M, Tielemans C, et al. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet 1993, 341(8832): 387–391.
3. Ono T, Eri M, Honda, et al. Valvular heart disease and Chinese-herb Nephropathy. Lancet 1998, 351: 991.
4. Van C de Strihou Y. Valvular heart disease and Chinese-herb Nephropathy. Lancet 1998, 351: 991.
5. Lord GM, Tagore R, Cook T, et al. Nephropathy caused by Chinese herbs in the UK. Lancet 1999, 354: 481–482.
6. Fugh-Berman A. Herb-drug interactions. Lancet 2000, 355: 134–138.
7. Abdulla S. Jury still out on aspects of acupuncture. Lancet 1998, 351: 962.
8. Chen Guying. Laozi: Modern Notes and Modern Translation. Taiwan Commercial Press, 2000: 68.
9. Zhang Nan. Yi Men Bang He. Beijing: TCM Classics Publishing House, 1999: 108.