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Traditional Chinese Medicine in Chinese-American Communities
Fall 1996
Conrad Wang, Cornell University
Traditional Medicine in Chinese Societies:
Traditional medicine, as practice in China and other East Asian countries, is a coherent and sophisticated system of techniques and methods. Among them include acupuncture, herbal medicine, acupressure, qigong, and oriental massage. Traditional medicine, as a system of healing and treatment, has a long history in Chinese society. It developed primarily through observations of the sick and the effects of physical forces and natural products on human health. To the Chinese, traditional medicine is not just a separate and distinct system of treatments, but rather is an integral part of the Chinese culture. In order to understand why people still turn to traditional medicine in this age of a highly developed modern medical system, one must not only look at the effectiveness of traditional medicine in treating illnesses, but also at the interconnections between traditional Chinese medicine and the Chinese culture and beliefs.
Over the centuries, the Chinese have developed ways of conceptualizing what the causes of bodily sickness are and ways of acting to prevent or to stop its course once it has begun. The concept of ying-yang is the most important and distinctive theory of Chinese Medicine. It also permeates all aspects of Chinese culture and philosophy. It has been said that all Chinese medical physiology, pathology, and treatment can eventually be reduced to this fundamental and basic concept of ying-yang(Gold, pg. 60).
The therapeutic techniques of Chinese medicine are unified in the principles of ying and yang. Along with ying-yang, another important concept in traditional medicine is qi. Essentially, in Chinese medicine, the body and mind are not seen as a mechanism but as a unified vortex of energy and vital substances that are in constant interaction and dynamic change and fluctuation, the result of which is the creation of an organism, a human being(Kleinman, pg. 91). At the basis of all this activity is qi.. The essence of diagnosis is to attempt to understand how an individual's ying-yang balance has been disrupted and where the flow of qi has become disturbed. Once known, the essential goal of treatment is to balance the ying and yang of the patient and establish a harmonious flow of qi.. The various techniques of Chinese medicine always work to manipulate, augment, and balance qi.. In herbal and nutritional medicine, it is the qi of the herbs and foods that is considered when therapeutic effect is sought. Acupuncture therapy is directed to balance the qi of the body, which flows along specific pathways or meridians. Therapeutic exercises are designed to affect the qi of the bodily organs and emotions and to harmonize the general qi of the patient.
Similar to the ying-yang dichotomy, the concept of hot and cold elements in the body, plays a major role in Chinese people's understanding of bodily health and sickness. References to hot or cold substances and their effect on the body are made very frequently by the common people in Chinese and Chinese-American communities. The terms "hot" and "cold" are used to described the intrinsic properties of the foods, which often has nothing to do with their actual temperature. Chinese parents often make soups that are considered "cold," such as green bean soup and winter melon soup, during the summer time.
To the Chinese, nutrition is of vital importance in medicine and there is a close relationship between diet and health. The importance of diet has never been ignored in China. In contrast, the importance of this relationship is just now being emphasized in modern medicine. If there is one thing universal in Chinese medicine, classical or folk, professional or self-managed, that one thing is diet therapy (Kleinman, pg. 143). Modification of food patterns is considered to be part of treatments. A balanced diet creates, restores or preserves a balanced physical being. Good health involves real strength, energy and power, not merely the absence of disease. Some foods that are considered "hot," such as protein foods and especially meat broths, are supposed to make or strengthen qi. Those foods are known as tonics or literally, "patching medicines."
In Chinese culture, the boundary of what is considered food and what is medicine is not very well defined. Food could be graded into medicine and medicine graded into food, thus showing very clearly the extent to which food and health were connected in folk thought (Kleinman, pg. 154). This lack of real dividing line between food and medicine is also demonstrated in one of the interviews I conducted. I interviewed a person who is a second generation Chinese-American. When I first asked her if she or her family takes any herbal medicines, she said no. Upon further questioning, I found out that the ingredients in one of the soups her mother makes sound like herbal medicine. When I told her this, she said it was a tonic soup which she does not consider to be medicine. I think her response showed the unclear boundary between food and medicine, as well as the interconnections between medicine and culture in Chinese and Chinese-American communities. Often, traditional medicine and Chinese cultural practices are so intermeshed that even Chinese people themselves cannot distinguished the two apart.
The importance of traditional medicine in Chinese culture and beliefs is one reason why Chinese-Americans still utilize it, but another perhaps more practical reason is its effectiveness in treating some illnesses. Chinese-Americans often utilize both Western and traditional Chinese medical in seeking medical treatments. From the interviews I conducted, I often heard the argument that since the body of knowledge and skills in Chinese medicine has been developed from, and has been tested by, empirical experiences of countless people over several thousand years, there must be some reasonable degree of medical validity to it. In the views of Chinese-Americans, Chinese and Western medical approaches represent alternative responses to illness, and he/she uses each of them to the extent that they may appear to produce positive results.
To get a better understanding of Chinese and Western medicine and their differences, I interviewed Shing Wu, who is a licensed acupuncturist. I asked him what he felt was the major strengths and weaknesses of Western medicine. According to him, the major strength is emergency medicine and when the patient is ill with an identifiable illness. Modern medicine is life-saving in a crisis, but modern medicine fails to cure chronic diseases, whereas traditional medicine seems to excel. Modern medicine is also helpful in suppressing the symptoms, but suppression of symptoms is not equivalent to a cure. Another strength of traditional medicine is that it treats the person as a whole as opposed to Western medicine, which sees the human being as consisting of isolable systems. Chinese medicine is oriented toward helping people feel well before they become ill, such as through tonics, and helping people feel better when they have an imbalance that cannot be identified as an illness by Western medicine.
From the interviews, it seems as if most of the Chinese-Americans I talked to use a combination of Western and traditional medicine. Which approach the person chooses depends on the illness and what he/she perceives as the better cure. For example, the majority of people I interviewed would go to an acupuncturist for problems with chronic muscle pain. This is a condition which Western medicine usually cannot cure. On the other hand, acupuncture seems to get good results on treating that type of illnesses. There are some specific instances where Chinese medicine is preferred, such as for tonic care, medicines that produce fewer side-effects, and curing disease rather than symptoms. Also, for some illnesses, people often first seeks medical help with either Western or traditional medicine and if it does not seem to be successful, they try the other. I think majority of people in Chinese-Americans communities realize that traditional Chinese medicine and modern Western medicine each have strengths and weaknesses. The best approach would be to supplement and overcome each system’s weakness with the other’s strengths.
Another interesting observation I made is that there seems to be a positive correlation between retention of Chinese cultural heritage and prevalence of Chinese medicine utilization. A possible explanation for this phenomenon is the integrated nature of Chinese medicine and culture. From the interviews I conducted, it seems first generation Chinese-Americans utilize Chinese medicine the most. They often turn to Chinese medicine for illnesses which it has been proven effective, whether clinically or anecdotally. They usually are the most knowledgeable about Chinese medicine. For second generation Chinese-Americans, the prevalence of use depends on exposure to Chinese medicine through family and retention of Chinese culture in the family. Many of the second generation Chinese-Americans I spoke to mentioned of parents giving them Chinese medicines to take. Those that had greater exposure to Chinese medicine usually had greater knowledge of its benefits and are more enthusiastic about its use. For example, Doris Li, who is a second generation Chinese-American said " I think it does some wondrous things. In some respects it's better than Western medicine. It's also more natural and contains less toxic chemicals so it has less side effects. It's also good when you are feeling weak and lethargic." On the other hand, for those Chinese-American families that have become more "Americanized," knowledge of Chinese medicine and its usage decreases. This could be due to increasing unfamiliarity with Chinese medicine and adoption of Western medical views of traditional medicine as "quackery."
Demographics:
In recent years, the numbers of people who seek care from non-traditional health care providers are growing. Despite the prevalent use of alternative medicine among people in the U.S., there has been very little research conducted to study this phenomenon and obtain accurate demographic data. The few statistical data and research papers that do exist are scattered and limited in scope. Currently, there are no national database kept on statistics such as the number of people who utilize alternative medicine, their demographics, the type of treatment they receive, the number of alternative medicine practitioner, and success rates. In January 1993, one authoritative study on alternative medicine appeared in the New England Journal of Medicine (Eisenburg et al, 1993). The study showed that the use of unconventional therapy was not confined to any narrow segment of U.S. society. It was also found that one in three respondents (34 percent) reported using at least one unconventional therapy in the past year. Extrapolation of the study data to the U.S. population suggests that in 1990 Americans made more visits to providers of unconventional therapy (425 million) than U.S. primary care physicians (388 million). Americans also spent approximately $13.7 billion on unconventional therapy, three quarters of which ($10.3 billion) was paid out of pocket. In comparison, the annual out-of-pocket expenditure for hospitalization was $12.8 billion. The study concluded that the frequency of use of alternative medical therapies in the U.S. is far higher than previously reported.
Although there is considerable number of people who seek out traditional Chinese medicine, especially among the Asian American communities, there have not been similar studies conducted. There is virtually no available data on the number of practitioners of traditional Chinese medicine in the U.S. or the number of patients and their demographics. Thus, we do not know the true extent of use among people in the U.S. or specifically in Asian American communities. Part of the problem lies in the difficulties of collecting statistical data on traditional Chinese medicine. What little available data there are mainly comes from the areas of acupuncture and oriental massage. This is due to the fact that in the U.S., the professional practitioner base for traditional Chinese medicine is organized around acupuncture and oriental massage. But even in the area of acupuncture, which enjoys recognition and accreditation in most states, there is a lack of data on the national level. Currently in the U.S., there are no national professional organizations which oversee the licensing and governing of all acupuncturists in the country. There are regional associations of acupuncturists, but their memberships are not mandatory and their geographic boundaries often overlap. If records are kept, they usually exist on the level of the individual practitioner and institute. Since there is very little exchange of data and records among traditional Chinese medicine practitioners, it would be very hard to construct a national or even a regional database. Besides the problem with data collection, the lack of research on traditional Chinese medicine might also be due to the reluctance of the medical establishment to investigate what many of them still consider "quack medicine." Another problem is that in many states, some forms of traditional Chinese medicine such as herbs are not considered to be legitimate medical treatments and their uses to treat illnesses are considered illegal.
Although acupuncture is better known and enjoys greater legal privileges in the U.S., in reality, more people in Asian American communities seek out herbal medicine for illnesses and preventive care than acupuncture. Some Chinese herbal medicines, such as ginseng, have become the hottest items on the health food market today. Although there is a long history of herbal medicine in Asian countries, herbal medicine is not recognized by the U.S. government as a legitimate form of health care. Currently, practitioners of herbal medicine do not enjoy the same legal status as acupuncturists and are not allowed to make claims of curing diseases. However, use of herbal medicine in the U.S. is increasing due to greater awareness among the public and the growing Asian American population. Unfortunately, there are no existing data on the number of herbal medicine practitioners or users in the U.S. Most of them advertise in ethnic newspapers to avoid the legal scrutiny of the authorities. The underground nature of some of the herbal medicine practitioners makes it hard to collect data on them. Herbal medicine is practiced legally by acupuncturists and some other people in the health profession. The outlook for herbal medicine in the U.S. looks good but there needs to be more research done on the subject for it to gain respectability among the medical community.
Policy Development and Action Plan
Although traditional Chinese medicine is enjoying growing popularity in the United States, there are a number of legal and professional issues that need to be resolved. The main one being the need to license and regulate those who practice traditional Chinese medicine. Currently, only acupuncture is licensed and regulated by the states. However, even with acupuncture, which enjoys the most professional recognition and legal protection of the Chinese medicines, there are differences in licensing and regulatory policies among the states. There is a need for a standardized national policy on licensing and regulation of acupuncturists. This would not only insure that an acupuncturist from one state could practice in another state, but also create standards of practice and uniform levels of professionalism. This would increase the acceptance of acupuncture among the public and the medical profession. Another factor that has hampered its potential growth is the lack of a unified national professional organization similar to the American medical Association or the Congress of Chiropractic State Associations. Currently, there are over a dozen professional acupuncture organizations. They are mainly organized according to geographic region and sometimes a particular tradition of acupuncture. This lack of a unified professional organization has limited the ability of acupuncturists to lobby for legislation, advance its causes, and establish its credibility among the medical establishment.
The advent of regulation -- from a national board examination to state licensing -- often means greater legitimacy for a given profession. This is what is sorely needed in the area of herbal medicine, which is gaining popularity in the U.S Even though herbal medicine plays a greater role in traditional Chinese medicine than acupuncture and is utilized more often by patients, there is no licensing or regulation of herbalists in the United States. In most states, herbal medicine is not recognized as a legitimate medical procedure. Currently, some states allow herbal treatments to be administered by a certified acupuncturist. The U.S. Food and Drugs Administration does not regulate most herbal medicines as long as they do not claim to cure illnesses.
The absence of licensing and regulation has led to much chaos and confusion among those who practice Chinese medicines such as herbalists and patients who seek it. It has also created potentially dangerous situations where unqualified individuals are practicing herbal medicine and making false claims. One only needs to look in any Chinese newspaper to find a great deal of advertisement for herbalists and other types of traditional Chinese medicines. Over the summer of 1996, an investigation by the "New York Daily News" into unlicensed and fraudulent medical practices in New York's Chinatown led to the arrests of 10 people (Gordy, 8-17-96). One of them, known as the "Liver Lady," peddled pills that claim to cure liver cancer or hepatitis. The Daily News reporter, Molly Gordy, sent the pills to a lab and found that they were nothing but aspirins. The reporter also found Chinese herbalists who have been dispensing remedies that are banned by the Food and Drug Administration. The fake doctors and their dangerous medications were advertised openly in Chinese-language newspapers.
It is interesting to note that the authorities only took action on the issue of fraudulent medical practices after there was a great deal of publicity generated. Even though herbalists are not supposed to claim to cure diseases, this is what happens all the time. Many people from the Chinese-American community go to herbalists when they are sick and ask to be cured. The herbalist gives those patients specific herbal remedies to cure their illnesses. All this is supposed to be illegal under the FDA's classification of herbal products as food supplements. Yet, the government does not seem to have any problem with all the activities as long as only Asian -Americans are involved. This might change as herbal medicine becomes more popular among the general U.S. population and its use increases.
For herbalists to properly practice their profession, there also need to be governmental policy changes made concerning treatment of herbs. In the U.S. today, herbal products can only be marketed as food supplements and the FDA remains skeptical of herbal remedies. The increase use of plant medicines has potential for improving public health and lowering health care costs. Phytomedicines, when combined with the preventive model of medical practice, could be a cost-effective and practical way to shift from disease treatment, the focus of modern health care, to prevention. Unfortunately, the regulatory lockout of natural remedies has crippled natural products research in the U.S. universities and hospitals ("Alternative Medicine," pg. 197). There is no dedicated level of support by the Federal government for herbal medicine research. Currently, herbal remedies are not viable candidates for the existing drug approval process. The total cost of bringing a new pharmaceutical drug to market in the U.S. is an estimated $140 million to $500 million dollars ("Alternative Medicine," pg. 197). Federal guidelines require each chemical compound in a given plant extract be investigated before the plant extract can be tested for clinical usefulness. Since botanicals are not patentable, it is unlikely for herbal medicine manufacturers to recover this exorbitant expenditure. Another major barrier is that the academic infrastructure necessary for proper study of ethnomedical systems has seriously declined in recent decades ("Alternative Medicine," pg. 201). A possible solution for the problem of drug approval for herbal medicines in the U.S. is by incorporating some aspects of the European model. Two features of European drug regulation make it more hospitable to natural remedies:
1. In Europe it costs less and takes less time to approve medicines as safe and effective. This is especially true of substances that have a long history of use and can be approved under the "doctrine of reasonable certainty." According to this principle, once a remedy is shown to be safe, regulatory officials use a standard of evidence to decide with reasonable certainty that the drug will be effective. This procedure dramatically reduces the costs of approving drugs without compromising safety.
2. Europeans have no inherent prejudice against molecularly complex plant substances; rather, they regard them as single substances. Thus whole herbal products would be considered as a single active ingredient. This makes it simpler to define and approve the product ("Alternative Medicine," pg. 186).
Relaxing regulatory requirements for efficacy for herbal products might make it economically feasible to bring herbal remedies to market. The FDA needs to serious consider herbal remedies as legitimate treatments for some illnesses and allow herbal treatments to be sold as such. There also needs to be more scientific research conducted to confirm the herbal remedies' validity. Many European and Asian countries have already conducted much research in that area and their results could contribute to our understanding herbal medicine.
Recently, there has been an increase in the number of people practicing traditional Chinese medicines in Chinese-American communities. This increase in traditional Chinese medical practices, whether legitimate or fraudulent, is caused by several factors. An important factor is the large influx of Chinese immigrants into the U.S. Many of those new immigrants are low-wage workers without health insurance and cannot. afford the high cost of medical services in the medical establishments. Besides the fear of deportation, many of the new immigrants also face the language barrier and the unfamiliar bureaucracy when dealing with the Western medical establishments. These factors cause many of them to seek out traditional Chinese medical practices instead of Western medicine.
The influx of Chinese immigrants has also brought in many health professionals who had trained in either Western or Chinese medicine. Some of those who were licensed in their native countries come here and begin to practice before passing their license exams. Others who were trained in Western medicine switch over to practicing Chinese medicine since there is no licensing involved. There are also those who have neither medical knowledge nor the qualification to treat patients. Many of them are lured by the financial incentives and often falsify their educational and clinical backgrounds to open medical practices. Since many of their patients live in isolated immigrant communities and do not have the knowledge, language, nor experience to report those fraudulent medical practices, they continue to practice.
In order for traditional Chinese medicine to gain acceptance and prosper in the United States, there must be certain policy steps taken. There are short term and long term goals that needs to be achieved. If the currently condition continues to exist, consumers will lose confidence in traditional Chinese medicine and might even abandon it all together. The government will crack down on those practicing, whether qualified or not. Perhaps the most damaging would be the loss in credibility of traditional medicine as a valid system of health care due to fraudulent medical practices. People might revert to the old beliefs that traditional medicine is nothing but quackery. There is a need for some sort of professional standard and qualification. The short term goal, as suggested by members of the New York Association of Traditional Chinese Medicine is to figure out which traditional doctors are qualified to practice. This could be accomplished through a validation service where the reported credentials of applicants are checked out. Although practicing traditional doctors are not required to go through the validation process, this process might help the consumer to pick qualified traditional doctor. The validation process is a good start to separate those who are qualified from those who are not and restore consumer confidence. This would be mainly aimed at those currently practicing. In the future, there could also be standardized written and practical examinations for those interested in becoming a traditional doctor.
The long term goal would be to gain government licensing of traditional doctors and the creation of a national professional organization to regulate its members and advance its causes. Traditional Chinese medicine is at the point today where acupuncture was back in the early 70's. At that time, acupuncture also had to struggle with the issues of gaining acceptance and obtaining government licensing. The steps taken by acupuncturists to gain some of those legal and professional privileges could serve as a guide for those practicing herbal medicine.
Although the course of action is clear, there certainly will be many obstacles and resistance that will be encountered along the way. The main one being the reluctance of the medical establishment to consider alternative therapies as effective treatments. In the United States, conventional biomedicine has had much more power to define what health care is than anyplace in the world. Part of it has been the teachings by the medical establishment that alternative medicines are all folk beliefs, a less-evolved form of medicine, and that we have more useful tools. Another part of it is the fact that there has been a centralization of power in the hands of physicians that has not been the case in most other countries. The professional organization of medical doctors in the U.S., the American Medical Association, has a great deal of political clout and financial resources. The AMA is very protective of its professional privileges and often flexes its political muscles to stop infringements upon it from alternative medicines. It took chiropractors many years, through intense lobbying and lawsuits against the AMA for it to achieve a certain level of recognition and acceptance among the medical community. Acupuncture, the more established and more researched of the traditional Chinese medicines in the U.S., is still viewed by many in the AMA as unproven therapy or worse yet, quackery. Currently, neither the Chinese herbalists nor the Chinese-American community for that matter has the necessary political power to fight the powerful AMA and lobby for legislative actions. Certainly, it will be an uphill struggle for Chinese herbalists to gain acceptance among the medical community and gain professional privileges.
Although resistance from the biomedical community is high, traditional Chinese medicine, along with other types of alternative medicine, is gaining ground as its popularity among consumers soars. Increasing consumer demand has caused some health care providers to offer more liberal coverage policies that include alternative medicines. In October 1996, Oxford Health Plans announced its alternative medicine program that includes a network of acupuncturists, massage therapists, chiropractors, dietitians, clinical nutritionists, and yoga instructors (Village Voice, 12-10-96). HIP, another health care provider, is examining the holistic approach for pain management. Kevin Davitt, the spokesman for HIP, said that they are now covering acupuncture and massage therapy because many of HIP's 850,000 clients in New York ask for its coverage and that HIP has "a growing number of Asian members, and they want this. You have to respond to market demand to be competitive (Village Voice, 12-10-96)." As HMOs and health care providers gain more power in defining what health care is in the U.S., their acceptance of alternative medicines such as acupuncture and herbal medicine perhaps will force the medical community to acknowledge those treatments and seriously examine them for their effectiveness in treating diseases. This might ultimately prove the most practical route for traditional Chinese medicine to achieve recognition and incorporation into the U.S. health care system.
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