Health in China: Traditional Chinese medicine: one country, two systems
BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7100.115 (Published 12 July 1997) Cite this as: BMJ 1997;315:115
- Correspondence to: Dr Hesketh
Summary
China is the only country in the world where Western medicine and traditional medicine are practised alongside each other at every level of the healthcare system. Traditional Chinese medicine has a unique theoretical and practical approach to the treatment of disease, which has developed over thousands of years. Traditional treatments include herbal remedies, acupuncture, acupressure and massage, and moxibustion. They account for around 40% of all health care delivered in China. The current government policy of expansion of traditional facilities and manpower is being questioned because many hospitals using traditional Chinese medicine are already underutilised and depend on government subsidies for survival. Research priorities include randomised controlled trials of common treatments and analysis of the active agents in herbal remedies. As more studies show the clinical effectiveness of traditional Chinese medicine, an integrated approach to disease using a combination of Western medicine and traditional approaches becomes a possibility for the future.
An ancient textbook
Over thousands of years traditional Chinese medicine has developed a theoretical and practical approach to the treatment and prevention of disease. The first documented source of Chinese medical theory, the Huangdi Nei Jing (“Inner Classic of the Yellow Emperor”) was written between 300 BC and 100 BC. It describes the diagnosis and treatment of a huge range of disorders and gives advice about healthy lifestyles, exercise, and diet which conforms remarkably well with current recommendations for the prevention of chronic disease. There is also accurate dietary advice about how to avoid micronutrient deficiency diseases such as beri-beri, xerophthalmia, and goitre.1
As with most forms of traditional medicine, the theoretical and diagnostic basis of traditional Chinese medicine cannot be explained in terms of Western anatomy and physiology. It is rooted in the philosophy, logic, and beliefs of a different civilisation and leads to a perception of health and disease that is alien to Western scientific thinking. But it is an entirely coherent system, with internal logic and consistency of thought and practice.
In the early 1950s it was feared that traditional Chinese medicine would be superseded by the “more modern” Western medicine. To counter this, a systematic assessment of the effectiveness of the traditional treatments was thought necessary. So thousands of experiments and clinical studies were carried out during the 1950s. Most were case series of patients with a specific Western disease who were then treated with traditional techniques—for example, a series of 112 cases treated for angina pectoris and another of 121 cases of bronchial asthma treated with subcutaneous acupuncture. The result of all this research activity was that in 1958 it was declared that traditional Chinese medicine and Western medicine should be given equal respect and place in the healthcare system. 1 Since then there has been a consistent policy of support for the traditional system.
Doctor trained in traditional Chinese medicine weighing out herbs in the traditional Chinese medicine hospital in Hangzhou
The treatments
The main traditional treatments are herbal remedies, acupuncture, acupressure and massage, and moxibustion. Acupuncture and herbal medicine are most widely used. The basic idea of acupuncture is that the insertion of fine needles into certain points can restore internal balance; it is the internal imbalance which leads to illness. Each acupuncture point has a defined therapeutic action, and a range of points is usually used. Acupressure simply means applying pressure to the acupuncture points, and moxibustion means applying heat to them. In the West acupuncture has become associated with analgesia, its appeal being increased by plausible biological mechanisms for its action (such as the gate theory and endorphin release). It also gained fame for its use in operative anaesthesia, but it is rarely used for this now.
Herbs are used much more commonly than acupuncture. The first pharmacopoeia was written at the time of the Nei Jing. The substances used range from herbs and minerals to rather strange animal products such as cows' gallstones or parotid gland secretions. The traditional doctor usually chooses from around 500 common classical prescriptions. Typically these are combinations of some five to 15 herbs that are boiled up together to make a drink.1 Nowadays many formulations are available in the more convenient form of tablets, capsules, and ampoules. The pharmaceutical industry is booming: sales of Chinese medicine increased by 52% between 1988 and 1992 (and sales of Western medicine increased by 51%).2 The licensing of drugs and official regulation of their sale is equally stringent for Western and Chinese medicines. But in these days of the market economy, unregulated medicines are widely sold and many products are available over the counter. It is estimated that only 20% of China's hospitals buy medicines from licensed state wholesalers, because the black market products are much cheaper.3
Two systems of medicine
China is the only country in the world where Western medicine and the traditional medicine work alongside each other at every level of the healthcare system. Traditional Chinese medicine has its own department at the Ministry of Public Health and at provincial and county Bureaus of Public Health. It has its own medical schools, hospitals, and research institutes.
Overall, it is estimated that 40% of health care in China is based on traditional Chinese medicine, with a higher proportion in rural areas.2 This figure does not include the massive amount of self medication with traditional drugs, which are used not only to treat illness but also as health promoting drugs, ranging from nutritional supplements and tonics to aphrodisiacs.
Every city has a hospital practising traditional Chinese medicine, and there is a plan for every county to have one. In 95% of the hospitals practising Western medicine there are departments of traditional Chinese medicine, most with inpatient beds; when patients arrive at the outpatient department they can opt for Chinese or Western treatment. In Jiangsu province, one of the richer, more sophisticated eastern provinces, one quarter of all outpatients in one year (10 million) had opted for traditional treatment.4
Signs at the reception desk in Nahe County Hospital, Heilongjiang, show the choice of Western and Chinese medicine. Consultations cost 1 yuan (7.5p); emergency consultations cost 1.5 yuan and a specialist consultation costs 3 yuan
The collaboration between the two systems is well illustrated by the fact that in Western medicine hospitals around 40% of the medicines prescribed are traditional. Similarly, in the traditional hospitals 40% of all prescribed drugs are Western medicine.3 At township and village levels, doctors often prescribe both types of treatment simultaneously, without apparent contradiction. A survey carried out in two village health clinics in Zhejiang province showed that children with upper respiratory tract infections were being prescribed an average of four separate drugs, always a combination of Western and Chinese.5
Training in traditional Chinese medicine varies from family apprenticeships to three to five year university training at a college of traditional Chinese medicine, though the educational standard of these undergraduates is generally lower than their counterparts at the Western medical schools. All Western medical schools devote around 10-15% of curriculum time to traditional Chinese medicine, so all doctors have some traditional training. Nurses too are trained in both and many perform acupuncture and acupressure independently.
Expansion of traditional Chinese medicine
Central government continues to have a policy for expansion of traditional Chinese medicine. An increase in the number of traditional doctors is one of the priorities for manpower development; their number continues to increase and is now over 300 000. In addition, 20% of the planned increase in hospital beds is to be for traditional Chinese medicine6; since 1985 there has been an annual increase of 8% in inpatient beds.3
But the wisdom of this planned expansion is being questioned, especially with the pressures of the healthcare market. Many traditional hospitals operate at a deficit. The better equipped Western hospitals, with their better qualified staff, attract more patients. In addition, traditional Chinese medicine is largely an outpatient, low technology specialty, so most of the income of traditional hospitals comes from the sale of drugs. Even with the 25% markup allowed, it is hard to cover operational costs. Government subsidies currently ensure survival, but there is no surplus for improving services.
A study of six traditional hospitals at county level in Jiangxi province found them all to be to be underutilised and overstaffed.3 The authors questioned the wisdom of continuing the support and expansion of traditional hospitals, which it seems is being done to protect the specialty rather than to meet need. Resources would be more efficiently used by strengthening the traditional Chinese medicine departments in Western medicine hospitals, where support services are better. This would reduce dependence on government subsidies and improve efficiency.3
Research priorities
Traditional Chinese medicine has become a source of great interest to the international research community. It is acknowledged that many of the treatments have enormous potential and could be utilised more widely. With this in view, research is essential in a number of areas. Firstly, randomised controlled trials are needed to establish the effectiveness and safety of treatments. There is still a real shortage of controlled trials of the effectiveness of traditional Chinese medicine and there are almost no double blind, placebo controlled trials. In China such trials are considered unethical because it is wrong to withhold potentially beneficial treatment.1 But the need for such trials is being increasingly recognised, and several are underway in China and other countries. The herb trichosanthin is undergoing trials by the Food and Drug Authority for use in treating AIDS.2
Secondly, from a Western standpoint, there is a need to identify the biochemical composition of the active agents in many of the herbal preparations. This approach has been successful in research into the antimalarial drug qing hao su. This herb has been used in China for treating fever for over 2000 years. In 1971 it was found to have specific antimalarial activity and the active compound artemesin was isolated. In clinical trials, parasite clearance times were shorter than with chloroquine, symptoms responded more rapidly, and there was no serious toxicity.7 Qing hao su has now become a first line drug for malaria in many parts of Asia.
Thirdly, research is needed to determine which illnesses are best treated through one approach rather than the other. In China, Western medicine is often regarded as more effective in acute situations or where the aetiology is known, while traditional Chinese medicine is more effective for immune conditions, chronic illness, or where the aetiology is unknown.1 But in practice simultaneous use of both types of treatment is so commonplace that the individual contributions are hard to assess. If the two systems are to be truly complementary more research in this area is essential to facilitate a more rational approach.
As China has opened up more to the West there have been concerns that traditional Chinese medicine would be superseded by Western medicine. This has happened for many types of acute illness, but the opposite has also happened: medicine in the West has become greatly influenced by traditional Chinese medicine. As more studies show the clinical effectiveness of traditional Chinese medicine, an integrated approach to disease using a combination of both forms of treatment becomes a possibility. This may transform the practice of medicine in the new millennium.2