Chinese Medicine and Transnational Transition during the Modern Era: Commodification, Hybridity, and Segregation 9811599483, 9789811599484

Table of contents :
Preface
Contents
Notes on Contributors
Abbreviations
List of Figures
List of Tables
1 Introduction
Introduction
Rise to Decline
Revival and Hybridity
Key Features of Transition During the Modern Era and Existing Literatures
About This Book
Professionalization, Integration, and Hybridity
Commodification and Marketing
Transnational Transition
Conclusion
References
Part I Professionalization, Integration, and Hybridity
2 The Origin and Systematic Development of Chinese Medicine Education in China from Historic Time to Date
Introduction
Ancient TCM Education
The Origin of Modern Higher TCM Education
The Current Status of TCM Higher Education
Education Level
Programs/Majors
Length of Schooling
Curriculum
Education Model: Integrated Institutional and Master-Apprentice Education
Status Quo of Integrated Chinese and Western Medicine
The Origin and Development of TCM Education in Hong Kong SAR, Macao SAR, and Taiwan, China
Conclusion
References
3 The Evolution and Role of Traditional Chinese Medicine (TCM) in Healthcare System and Integrated Medicine in China
Introduction
Major Methods and Specialties in Chinese Medicine
The Integration of Western Medicine (WM) and Traditional Chinese Medicine (TCM)
The Evolution of TCM in Hospital Care in China
Overall Development of Traditional Chinese Medicine Hospitals in China
Analysis of Medical Fees at the Outpatient
Analysis of Medical Fees at the Inpatient
Analysis of Traditional Chinese Medicine and Western Medicine Drug Revenue
Medical Staff at Traditional Chinese Medicine Hospitals
Findings from the Qualitative Analysis
Relying on WM Drugs While Innovating TCM Drugs
Cultivating the TCM Medical Staff
Implications for Policy Makers and Public
Integrated TCM and WM in Hong Kong
Integrated Traditional Chinese Medicine and Western Medicine Model in the HKU-SZ Hospital
Future Development of Integrative Medicine in Hong Kong
References
Part II Commodification and Marketing
4 Tibetan Healing Traditions, Scientific Commodification, and Cultural Identity
Prevailing Scholarship: Attending to the Complex Convergences
Introduction
Tibetan Healing Traditions in China: A Brief Introduction
Commodification and the Spectacle of Minority Cultural Identity in China
Commodification and Commercialization of Tibetan Areas
Commodification and Scientisation of Tibetan Medicine
Tibetan Healing Traditions: Marking Cultural Identity and Religio-Ecological Dialogue
Balancing Commodification and Tibetan Healing Traditions
Conclusion
References
5 Medical Marketplaces, Commercialism, and Chinese Medicine in the Cholera Pandemic in Southeast Coastal China, 1961–1965
Introduction
Medical Market, Commercialism, and the Fragmented Medical System
“Bourgeois Medical Styles”: Medical Institutionalization and Political Discipline
Chinese Medicine in the Cholera Pandemic
Conclusion
References
6 Chinese Medicine in the Cosmetics Market in China: History, Contemporary Development, and Challenges
Introduction
The Definition and Classification of Chinese Medicinal Cosmetics
Chinese Medicine Theories of Producing and Using Chinese Medicinal Cosmetics
Chinese Medicine and Its Relation to the Human Body and Cosmetics: A Historical Preview
The Development of Chinese Medicinal Cosmetics in Contemporary China
The Current Situation of Chinese Medicinal Cosmetics Market
The Challenges and Insufficiencies of Applying Chinese Medicine in Cosmetics
Conclusion
References
Part III Transnational Transition
7 Chinese Medicine in Malaysia After Decolonization: Segregation and Unequal Access
Introduction and Methodology
Segregation and Inequality
Chinese Medicine as a Middle-Class Private Phenomenon in Malaysia
Ethnic Preference
Segregation and Sex Preference
Conclusion
References
8 Current Challenges and Issues for Traditional and Complementary Medicine (T&CM) in Malaysia
Introduction
T&CM Clinical Practice in Malaysia
T&CM Education in Malaysia
Development of T&CM Skill Training Continues Professional Programs in Malaysia
T&CM Research in Malaysia
Conclusion
References
9 Imperial Medicine and Ethnicity in an Urban Society: Cholera Epidemics in the Philippines
Introduction
The Historiography of State and Voluntary Welfare Provision
Cholera and Port Quarantine
Public Health in Manila
Medical Practices
Conclusion
References
10 Perceptions on Illness and Wellness in East Asia: Contemporary Views on Japanese Medical Systems and Traditions
Introduction
History and Anthropology of Medicine in Japan
Research Design and Methodology
Medical Anthropology as Framework of Analysis
Prevalent Views on the Japanese Healthcare System
Hospital Stigma: The Unwritten Subtext
Kampo Medicine (漢 方): Tradition Versus Modernity
The Futei Shuuso (不定 愁訴) Enigma
The Role of Religion
Phenomenology of Popular Health Practices
Promoting the Image of the Healthy Japanese
Conclusions
References
Index

Citation preview

Chinese Medicine and Transnational Transition during the Modern Era Commodification, Hybridity, and Segregation Edited by Md. Nazrul Islam

Chinese Medicine and Transnational Transition during the Modern Era

Md. Nazrul Islam Editor

Chinese Medicine and Transnational Transition during the Modern Era Commodification, Hybridity, and Segregation

Editor Md. Nazrul Islam BNU-HKBU United International College Zhuhai, China

ISBN 978-981-15-9948-4 ISBN 978-981-15-9949-1 (eBook) https://doi.org/10.1007/978-981-15-9949-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: MaraMaram_shutterstock.com This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Dedicated to all the Chinese medicine practitioners who selflessly devoted their time in developing Asian medical sciences over the millenniums And my Grandfather The late Shakhi Uddin Munshi who was a life-long educator

Preface

Writing on transition of Chinese medicine is not new in academia and there are literatures written by social scientists, historian, philosophers, public health scholars, and so on across the board. This volume emphasizes on the transnational transition of Chinese medicine and argues that the professionalization of Chinese medicine along the Silk Road caused similar segregation as western medicine does in accessibility and affordability. Under this process of segregation, a hybrid form of Chinese medicine has developed and that includes both drug/product and practice. A middle class readily available health consumer group has developed in recent years with the rise of globalization and/or penetration of global capitalism in the East and Southeast Asia. They are the prime target under this segregated practice of Chinese medicine and demand a hybrid form, which suits their lifestyle. Large and small Chinese medicine manufacturers are eager to respond this demand through preparing patent drugs and health products having sophisticated outlook and convenient use. At the same time, practitioners of Chinese medicine are catering to the need through adopting modern technologies and equipment during diagnosis and treatment those are largely used in Western medicine, and ignoring traditional methods. Both the groups are eager in capitalizing profit margin and claim hybrid medicine or integrated Chinese medicine as the global future of Chinese medical science. This volume is a collection of the papers presented in the Interdisciplinary workshop on Chinese Medicine along the Silk Road: Transition

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and New Discovery and held on December 3, 2018 at the BNU-HKBU United International College, Zhuhai, China. There are also few chapters which were not presented in the above workshop but included in this volume. The workshop was an interactive interdisciplinary dialogue among various academic communities involve in doing research on Chinese medicine and other Asian medical specialties. Medical historian, philosopher, economist, sociologist, Chinese medicine practitioners, public health scholars, scientists, and education administrators were invited to take part in this interdisciplinary dialogue. I would like to acknowledge the General Education Office, BNUHKBU United International College for being the organizer of the workshop and providing logistic support. I would also like to thank Prof. Lilian Kwan, the then Associate Vice President of the United International College for giving an opening speech for the workshop. I deeply appreciate the contribution and support of the remaining two session chairs of the workshop: Prof. Mildred Yang, the then Director of General Education Office, and Dr. Milen Jissov, the then Acting Director of General Education Office, BNU-HKBU United International College. Prof. Chuxiong George Wei, the then Associate Vice President, BNUHKBU United International College chaired the key note session. Prof. Wei went through the entire manuscript and gave valuable feedback. His comments and suggestions helped the authors revising the chapters and improve significantly. I truly acknowledge his contribution and appreciate generosity in spending time for this book. My colleagues from the General Education Office, BNU-HKBU United International College Ms. Sijing Pan, Ms. Carol Ruhuan Huang, and Ms. Wan Yuan have done tremendous amount of logistic work for organizing the workshop. I very enthusiastically acknowledge their sincere contributions. Last but not the least, I thank to all the participants and paper presenters of the workshop who traveled from far and near, a few to name: Dr. Ivette Vargas-O’Bryan from Austin College, USA; Dr. Farah M. Shroff from the University of British Columbia, Canada; Prof. Lixing Lao from the University of Hong Kong, Hong Kong SAR; Prof. Sookja Kim from the BNU-HKBU United International College, China; Francisco V. Navarro V from the Ateneo de Manila University, Philippines; Dr. Fang Xiaoping from the Nanyang Technological University, Singapore; Dr. Kim Yun Jin from the Xiamen University Malaysia, Malaysia; and Dr. Yoshihiro Chiba from the Institute of Human and Social Sciences, Kanazawa

PREFACE

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University in Japan. My former student Ms. Zeng Ying also spent valuable time for helping this project as student volunteer in many occasions. I truly appreciate her selfless support. Zhuhai, China September 2020

Md. Nazrul Islam

Contents

1

Introduction Md. Nazrul Islam

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Part I Professionalization, Integration, and Hybridity 2

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The Origin and Systematic Development of Chinese Medicine Education in China from Historic Time to Date Pei Xue and Jian-Ping Liu The Evolution and Role of Traditional Chinese Medicine (TCM) in Healthcare System and Integrated Medicine in China Hong Zhou

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Part II Commodification and Marketing 4

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Tibetan Healing Traditions, Scientific Commodification, and Cultural Identity Ivette Vargas-O’Bryan Medical Marketplaces, Commercialism, and Chinese Medicine in the Cholera Pandemic in Southeast Coastal China, 1961–1965 Xiaoping Fang

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Chinese Medicine in the Cosmetics Market in China: History, Contemporary Development, and Challenges Sijing Pan

Part III 7

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Transnational Transition

Chinese Medicine in Malaysia After Decolonization: Segregation and Unequal Access Md. Nazrul Islam

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Current Challenges and Issues for Traditional and Complementary Medicine (T&CM) in Malaysia Yun Jin Kim

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Imperial Medicine and Ethnicity in an Urban Society: Cholera Epidemics in the Philippines Yoshihiro Chiba

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Perceptions on Illness and Wellness in East Asia: Contemporary Views on Japanese Medical Systems and Traditions Arnel E. Joven

Index

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Notes on Contributors

Yoshihiro Chiba is Associate Professor in the Faculty of Economics and Management, Institute of Human and Social Sciences, Kanazawa University, Japan. He received Ph.D., Masters and Bachelor in Economics from Hokkaido University. Previously he worked as an Associate Professor in the School of Rehabilitation Sciences, Health Sciences University of Hokkaido, and as an Associate Researcher in the College of Economics, Hokkaido University, Japan. Md. Nazrul Islam is Associate Professor in the General Education Office and JIRS Fellow, BNU-HKBU United International College. He received a Ph.D. in Sociology from the University of Hong Kong; an M.Sc. in Community Health and Health Management from Heidelberg University; and a Bachelor’s (First Class Honors) in Anthropology from Jahangirnagar University. During his tenureship Dr. Islam has taken visiting position in the School of Population and Public Health, University of British Columbia; Center of Asian Studies, University of Hong Kong; and at the Institute of Philippines Culture, Ateneo de Manila University. He received German Academic Exchange Service (DAAD) Scholarship, The United Nations University Fellowship, and The University of Hong Kong Research Postgraduate Studentship. He is the author of Chinese and Indian Medicine Today-Branding Asia published by Springer (2017) and editor of Silk Road to Belt Road: Reinventing the Past and Shaping the Future by Springer (2019), Public Health Challenges in Contemporary China: An Interdisciplinary Perspective by Springer (2016). xiii

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Arnel E. Joven is currently the Chair of the History Department, University of Asia and the Pacific, Pasig City, Philippines. In 2012, he received his Ph.D. from the University of Philippines (UP). From 2012 to 2013, he received a research grant from Asia-Phil, Ateneo Center for Asian Studies to conduct research on “Contemporary Japanese Medical Practices.” He also conducted research on “Contemporary Korean Medical Practices” in 2014 for the Academy of Korean Studies (AKS). Dr. Joven has also conducted research and publications on the history of medicine in the Philippines during the early Spanish colonial period and Japanese occupation period. He is a member of various global academic societies dedicated to the History of Medicine. In the University of Asia and the Pacific, he teaches Philippine History, Rizal, Christian Civilization, and area studies on Japan, Korea, and Southeast Asia. Yun Jin Kim earned his Ph.D. at Nanjing University of TCM, China, under the grant of National Natural Science Foundation of China (NSFC). His research interests encompass global burden of disease, neurological disorder, and epidemiology. Currently he is an Assistant Professor and Program coordinator in School of Traditional Chinese Medicine, Xiamen University Malaysia. Dr. Kim is an international collaborator of The Institute for Health Metrics and Evaluation (IHME), University of Washington; an adviser for Korea-Technology Advisory Group (K-TAG) at The Korea Institute of Advancement of Technology (KIAT); and a member of Korean Scientists and Engineers Association in Singapore. Jian-Ping Liu is the Dean of the School of Basic Medical Science, Beijing University of Chinese Medicine and Pharmacology, Beijing, China. He is also concurrently the Director of Centre for Evidence-Based Chinese Medicine in the same Institute. Sijing Pan is assistant instructor in the General Education Office, BNUHKBU United International College. She received M.Sc. in Education from the Hong Kong Baptist University and Bachelor in Applied psychology from the BNU-HKBU United International College. She is interested in the development and application of Chinese medicine. She used to work as assistant instructor for of General Education Free Elective course Asian Medicine and Globalization for two years. She assisted in the interdisciplinary work shop on Chinese Medicine along the Silk Road: Transition and New Discovery.

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Ivette Vargas-O’Bryan is Professor of Religious Studies (Asian traditions) in the Department of Religious Studies at Austin College in Sherman, Texas. Professor Vargas-O’Bryan holds a Ph.D. in Buddhist Studies and two M.A. degrees (religious studies and Sanskrit and Indian Studies) from Harvard University, and a B.A. in political science from Columbia University. She is currently the Vice President (and subsequent President in 2020) of the Southwest Commission on Religious Studies of the American Academy of Religion (AAR) and the Co-chair of the Comparative Studies of Religion of the AAR. She has held a number of eminent positions in the USA and abroad including being a Fulbright Scholar in Hong Kong, Co-Conveyor of the Center for the Humanities and Medicine at the University of Hong Kong and Li Ka Shing Faculty of Medicine, research scholar at several institutes in South Asia, and curator of several art exhibitions at the Crow Collection of Asian Art in Dallas, Texas. Several of her publications and presentations reflect her primary research interest on the intersection of religion and medicine in South Asia and Tibetan areas of China including the 2015 Routledge publication, Disease, Religion and Healing in Asia. Her current cuttingedge book project concerns the transmissions of a tenth-century Buddhist nun’s legacy of leprosy and healing across Asia. Xiaoping Fang is Assistant Professor of Chinese History at School of Humanities, the Nanyang Technological University, Singapore. His current research interests focus on the history of medicine, health, and disease in twentieth-century China, specializing in the post-1949 period. He is the author of Barefoot Doctors and Western Medicine in China (Rochester, NY: University of Rochester Press, 2012 and 2015). Pei Xue works in the Center for Evidence-Based Medicine at the Beijing University of Chinese Medicine and Pharmacology in Beijing, China. Hong Zhou is Associate Professor of Health Service, School of Management, Hainan Medical University. She received her B.S. of Medicine and Traditional Chinese Medicine and M.Sc. in Community Health and Health Management, Heidelberg University, Germany. She is the recipient of prestigious German Academic Exchange Service (DAAD) Fellowship. Previously she was a Visiting Scholar in the School of Public Health, UCLA, USA. She worked as Volunteer and Collaborator at Essential Medicine and Health Technology, West Pacific Regional Office, World Health Organization (WHO). She has received several prestigious

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research awards and projects from the Hainan Provincial Government of the People’s Republic of China, National Natural Science Foundation of China (NSFC), and so on. Professor Zhou’s research focuses on Health Policy and Management, and Health Technology Assessment. She has published book chapters and journal articles in Hospital Management and Health Policy, Health Economics, etc.

Abbreviations

AYUSH CIA CM DCA DoSM DSD GMP HKU-SZ MQF SAR SARS SATCM T&CM TCM TIM WHO WM XUM

Ayurveda, Yoga, Unani, Siddha, and Homeopathy Central Intelligence Agency Chinese Medicine Drug Control Authority Department of Statistics Malaysia Department of Skills Development Good Manufacturing Practice The University of Hong Kong-Shenzhen Hospital Malaysian Qualification Framework Special Administrative Region Severe Acute Respiratory Syndrome State Administration of Traditional Chinese Medicine Traditional and Complementary Medicine Traditional Chinese Medicine Traditional Indian Medicine World Health Organization Western Medicine Xiamen University Malaysia

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List of Figures

Fig. 8.1 Fig. 8.2

Skills and higher education pathways for T&CM in Malaysia List of programmed standards for T&CM education in Malaysia

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List of Tables

Table 6.1 Table 8.1 Table 9.1 Table 9.2 Table 9.3 Table 10.1

Classification of Chinese medicine List of private institutions of higher education offering T&CM courses in Malaysia Cholera fatalities and mortality in the Philippines (1888–1889) House inspections in Manila (1901–1904) Achievements of public physicians in Manila (monthly average) (1901–1904) Brief data of interviewed respondents, 2012

97 153 170 176 181 193

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CHAPTER 1

Introduction Md. Nazrul Islam

Introduction Like other medical traditions, Chinese medicine underwent a process of transition from its inception and was never static for a long period of time. Various stages of transition can be found from the earliest classic Huang Di Nei Jing (The Yellow Emperor’s Classic of Medicine or Canon of Medicine) to date. The classic is a combination of two epics: Su Wen (The Basic Question) and Lingshu (The Spiritual Pivots), which systematically documented etiology, physiology, diagnosis, treatment, and disease prevention (Islam, 2017; Dong and Zhang, 2002). Arguably, the current outlook of Huang Di Nei Jing was given by medical practitioners from the Han (206 B.C.–220 A.D.) dynasty, although the text contains materials from the Wei and Jin dynasties (Islam, 2017; Zhang, 2012). The earliest form of practicing Chinese medicine most probably followed and/or was dominated by the shamanistic tradition, while there were overlapping approaches to healing between shamans and practitioners and shamans played a vital role

Md. Nazrul Islam (B) BNU-HKBU United International College, Zhuhai, China e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_1

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in responding to the health needs of the rural masses (Lin, 2013). Elite clients from rural and urban settings also relied on medical services from both shamans and physicians. The shamanistic practices of healing coexisted with physicians throughout the Han dynasty.

Rise to Decline The first major transition probably occurred towards the end of the Han dynasty when social and political chaos caused the expansion of religious movements and gave Buddhists monks an opportunity to spread their teaching (Fan, 2013). The healing tradition played a significant role in the spread of Buddhism in China and Buddhist monks imported South and Central Asian healing modalities to China which were adopted in the philosophy and practice of Chinese medicine (ibid.). Huang Di Nei Jing also contains elements that echoed Buddhist and Daoist religious philosophy. As the text suggested, secrets of preserving health and preventing disease such as “minimizing desire” and “maximizing the pleasure of health,” “following the rules of nature or naturalness,” “tempering or moderating diet,” could be found in Buddhist and Daoist moral and religious teaching (Huang Di Nei Jing, 2009). Towards the end of Han dynasty, Buddhist monks and Daoist priests were active in converting grassroots peoples from indigenous religious beliefs to Buddhism and Daoism and often leveled “indigenous religious officiants/healers” as shamans. This was the major strategy by the physicians of that period to distinguish themselves from shamans and marginalize the latter through getting support from Buddhist and Daoist religious missionaries (Fan, 2013). Thus, the transition from shamanistic tradition to organized religious connotation was the earliest transition within the practice of Chinese medicine. This transition was initiated more by external religious and political factors than theoretical and methodological crises within the healing tradition. The Tang (618–907 A.D.) dynasty witnessed another transition in Chinese medicine when medical practice largely became part of the state bureaucracy and government healthcare system. This was the first time that the official health department was established by the imperial court and medical schools were established by the state for the formal training of physicians to serve court members and royal families (Islam, 2017). The rise of organized Buddhism and Daoism as religions, aristocratic clans, and systematic medical governance which promoted various social and institutional changes all took place during the Tang dynasty (Lin,

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2013). New forms of the transmission of medical knowledge, new recognition and status for medical practitioners, and new types of healing methods were developed. The Taiyishu (Imperial medical office) was established by the government to offer healthcare services to the imperial family (Hinrichs, 2013). These new institutional arrangements produced a new group of medical elites who became part of the state bureaucracy and/or in the top tier of social hierarchy. They claimed authority over the monopolistic practice of Chinese medicine. The Taiyishu was favoured by the Song (960–1279 A.D.) dynasty to run the state health service including the training of medical professionals and health service delivery and survived until the Ming (1368–1644 A.D.) dynasty with slight modification (Huard, 1970). There were several significances related to the transition under the Taiyishu model: It was the first attempt by the imperial court to monitor and regulate medical professionals and health service delivery, although the target recipients were the royal family and elite members of the court; secondly, although religious missionaries, Buddhist and Daoist in particular, were still active, the state intervened in the health service and took control over the practice of medicine. Religious missionaries and the state bureaucracy competed for control of the practice of medicine. However, the state was able to consolidate its authority over the practice of medicine, and finally, the transmission of medical knowledge as a family secret or through apprenticeship was also subsequently developed. This trend gave the monopoly to a few elite families in taking charge as medical service providers. They became part of the state bureaucracy and kept hindering medical knowledge and practice for subsequent generations, and developed family dynasties in the medical field. Some of the methods and modalities practiced under Chinese medicine began to spread beyond Chinese territory, along the line of the Silk Road during the Tang to the post-Tang period through the hands of religious pilgrimages, travellers, and merchants. With the further expansion of trade along the Silk Road during the Tang and until the Song period, new medical knowledge, methods, and herbs from outside were also incorporated into Chinese medicine. Medical theories, methods, and products from Arabia and Persia (Islamic tradition), India, and other parts of Central and South Asia were adapted in Chinese medicine and vice-versa (Bradley, 2018). The enormous similarities among the Chinese, Islamic, and Indian medical traditions were the result of the sharing and adopting of medical knowledge and skills from each other in medieval China. There is evidence behind this claim, such as Haiyao bencao

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(Overseas Pharmacopoeia) written by Li Xun, an ethnic Persian born in China who tried to combine medicine from the Persian tradition with Chinese medicine (Chen, 2007). Chinese physician Sun Simiao during the Tang dynasty wrote Qianjin yifang (Supplementary Prescriptions Worth a Thousand Gold Pieces) which cited the work of Javika (a famous Indian physician) from Buddhist legends and worked for the court of King Kaniska (ibid). Chinese medicine thus learned, shared, and adopted medical knowledge, skill and properties from other civilizations and vice-versa during the ancient and medieval periods. The introduction of Western medicine to China towards the end of the nineteenth century by Christian and Jewish missionaries had a severe impact on Chinese medicine (Dutta, 2009). Although the primary goal of the religious missionaries was to promote religious belief, they used Western medicine as a tool to get access to the majority of the Chinese population who used to seek help from practitioners of Chinese medicine. The Qing (1644–1912 A.D.) dynasty was socially and politically weak for various reasons and a perception emerged of modernizing China according to the Western line and this became popular in social and political thinking. The first wave of mass ethnic Chinese migration from Southern and Eastern China to Southeast Asia also started during that time. These Chinese migrants permanently landed in the region and became a part of Southeast Asian nationalities. Because of their ethnic identification and cultural fascination some of them carried Chinese medical heritage overseas either as practitioners or for conducting business related to Chinese herbs, plants, and health products. Most of these Chinese medicinal practices were concentrated among the Chinese diasporic communities and often did not become a part of the mainstream healthcare system. They continued to transmit the knowledge and practice of Chinese medicine as a family secret or family apprenticeship which started in China during the medieval period. The first half of the twentieth century witnessed a rapid decline of Chinese medicine for political and economic reasons. Firstly, the practice of Chinese medicine was developed in medieval times as “experiential”1

1 A term used by the famous sinologist Joseph Needham.

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science or “knowledge-based science”2 as opposed to Western “experimental” science. China did not try to introduce an “experiment-based innovation process” into Chinese medicine, instead it heavily relied on “experience-based technological invention” until the twentieth century (Lin, 1995). Experience-based science and technology could not cope with the soring population over the nineteenth to twentieth centuries because of the nature of the practice. In principle, an experience-based medical science supports individualistic diagnosis, treatment, and prescription. Developing a standardized mode of diagnosis, treatment, and prescription is not a prerequisite for an experiential science. However, because of the rapid growth of the population and the rise of numerous new diseases the demand for medical practitioners was boosted and practitioners of Chinese medicine failed to respond to the increasing demand. On the other hand, Western medicine was already introduced to China which adopted new technologies through trial and error and was much more successful in responding to the increasing demand caused by the soaring population. World Bank statistics show the severity of the rising population from the nineteenth to twentieth century which revealed that China’s population grew from 381 million people in the year 1820 to 437 million in 1913 and 1,275 million in the year 2001 (Maddison, 2005). The population growth over the twentieth century was approximately sixteen times higher than that of the previous century. Since Western medicine was able to develop an objective and standardized medical practice it responded positively to the health needs of the rapidly rising population. Secondly, with the rise of the nationalist movement and the foundation of the Republic of China in the early twentieth century, health work became one of the key tropes for the new Chinese leadership in nationbuilding. The nationalist leaders fought against the imperial ruler and were inspired by Western modernity and treated the imperial regime as a barrier to the progress of Western enlightenment in China. Attaining Western science, technology, and medicine was viewed to be crucial for the development of the modern Chinese state, and science became an integral part of state formation and nation-building throughout the republican era (Chen, 2005). The republican leaders treated Chinese 2 A term I cited from a famous Professor of Ayurveda in India, Prof. P K Devnath, whose family tradition of practicing Indian medicine has lasted for more than ten generations.

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medical science as superstitious which heavily relied on the Confucian ethos. They rejected Chinese medicine in order to clear the way for the development of the monopoly of Western medical science in China.

Revival and Hybridity A significant transition in Chinese medicine occurred after the formation of the People’s Republic of China in the year 1949 and was fuelled by nationalist inspiration. The newly formed political elites who called themselves “socialist” and were led by Chairman Mao linked Chinese medicine with nationalism and claimed it as national pride or a “great treasure” which was neglected by the earlier regime. They proposed the revival of Chinese medicine and developed a healthcare system that combined Chinese medicine with Western medical science under the framework of socialist modernization. The socialist modernization relied heavily upon the discourses of Western science and civilization and evidence-based science was used to articulate national agendas and define the boundaries of Chinese medicine (Chen, 2005). One of the key strategies of the nationalistic revival in the socialist era was to modernize Chinese medicine according to the Western line and found institutions that followed the Western model of education and practice. Colleges and teaching institutions specialising in Chinese medicine were founded in large cities across China for training new groups of students. Most of these newly founded Chinese medicine institutions adopted an educational model and curriculum that was already in place for teaching and learning Western medicine. Chinese medicine was systematically taken out of the family and the apprenticeship tradition was dismantled and placed under an institutional framework. An integrated education curriculum was adopted which combined Chinese medicine with Western medicine courses. Students of Chinese medicine had to learn a certain number of subjects taught in Western medicine under this education curriculum. However, the formalization and professionalization of Chinese medicine according to the Western line set Western medicine as a benchmark for Chinese medicine. A large number of graduates from Chinese medicine institutions practice Western medicine. My previous study in China shows that about ninety percent of the graduates from colleges of Chinese medicine practice Western medicine and about eighty five percent intend to do so (Islam, 2017). Nationalist claims over Chinese medicine have several significances: Firstly, this has created a new form of institution and educational arrangement which

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is popularly known as zhong xiyi (integrated Chinese medicine). Since establishing Western science was a priority in nation-building during the Mao to Post-Mao era this trend became dominant until recent years. Several Southeast Asian countries such as Malaysia, Philippines, Singapore have also adopted this model in their Chinese medicine educational setting. Secondly, this trend symbolizes a transition which could arguably be a set-back for authentic Chinese medicine and prioritizes Western medicine. Theoretically, although the intention was to enlighten Chinese medicine practitioners on Western medicine and vice-versa, there was no systematic effort to broaden the horizons for Western medicine practitioners on Chinese medicine. In other words, it was a monolithic trend to educate Chinese medicine practitioners about Western medicine and create a venue for them to practice Western medicine through the back door. A hybrid medical practice has been developed in contemporary China under the umbrella of integrated Chinese medicine. Thus, the nationalist claim over Chinese medicine during the Mao era was a paradoxical venture and problematically reproduced Western hegemony. This is an apolitical claim which intentionally or unintentionally ignores the essence of Chinese medicine: its origin, history, development, etc.; and only prioritizes the needs of the market. After adopting the Open Door Policy during the post-Mao era, China continued to promote the practice of integrated Chinese medicine and exported it overseas. There is another development which has been brought by “globalization” and the drug manufacturers who are marketing thousands of health products, cosmetics, toiletries, beauty products, food additives, dietary supplements, quick fix pills, etc. under the name of “Chinese medicine.” Their major selling point is natural or herbal content and having “no side effects.” Chinese medicine has been turned into consumer goods and a twenty-first-century market niche. A large share of the profit margin of Chinese medicine manufacturers come from selling quick fix pills for particular chronic conditions such as diabetes, obesity, impotence, constipation, back pain, and so on.

Key Features of Transition During the Modern Era and Existing Literatures Transition in medicine in modern China can be seen as a process, which combines various areas such as health transition, disease transitions, adaptations and innovations, professional transitions, and so on. The most

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notable transition that happened in Chinese medicine during the twentieth century was the adaptation of apparatus from Western medicine and professionalization according to the Western line. This process caused the creation of a “pluralistic” medical practice in China which combined Western medicine with Chinese medicine. However, the adaptation of apparatus from Western medicine in the practice of Chinese medicine was not the outcome of a “well-thought-out” master plan but the “careful manipulation” of “Chinese medicine’s value as a cultural legacy” (Bullock and Andrews, 2014). As a result, this attempt did not help to promote Chinese medicine as a medical therapy. Instead, it caused a monolithic medical syncretism where Chinese medicine adopted apparatus from Western medicine. Chinese medicine was used as a political trope as well as an economic utility after the foundation of the People’s Republic of China following the communist victory in 1949. The communist party led by Chairman Mao promoted the slogan zhongxiyi hezou ( cooperation of Chinese and Western medicine) which was an ideological attempt to integrate Chinese medicine with Western medicine specialities and vice-versa and had triple-fold significance for the political leadership: Firstly, the new system of hybrid medical practice helped to gain political support from the rural masses for the communist leadership through manipulating the cultural connotation of Chinese medicine in the early years of the regime. Critics also provide evidence that the introduction of the barefoot doctors programme during the late 1960s to early 1980s played a pivotal role in helping Western medicine to spread among the rural masses and root out Chinese medicine practitioners who were not professionally trained (Fang, 2016: 267). Secondly, since the newly introduced medical culture required Western medical practitioners to learn Chinese medicine it could be seen as an attempt to discipline “bourgeois Western influenced doctors” by the political elites; and thirdly, the introduction of integrated medicine also offered economic benefits through providing healthcare services in a setting where Western drugs and technological resources were scarce (Scheid and Lei, 2016; Andrews, 2014).3 The Communist China, at least in the early years of its formation, was not 3 Scheid and Lei have divided the key features in the transition of Chinese medicine in the twentieth century into six periods, although there could have been some overlapping between them: “1911-1948, during which practitioners of Chinese medicine organized the National Medicine Movement to resist the oppressive regulation attempted by the state

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interested in developing Chinese medicine as an independent medical system through promoting therapeutic values and using its theoretical and methodological compatibility. The party leadership was ideologically more eager to establish a healthcare system in China which was based on the principle of Western medical science and already in place in Western countries including Russia, leaving little room for Chinese medicine to develop as an independent system of medical practice under this pluralistic health structure. By the 1980s, the Ministry of Health in China had already started to refer to the three paths of medical practices: Western medicine, integrated medicine, and Chinese medicine, and Chinese medicine acquired many of the “hallmarks of modernity” such as democratization, secularization, professionalization, scientific, and clinical observation (Andrews, 2014: 3–5). In recent years, almost all of China’s major cities have established hospitals practicing Western medicine with Chinese medicine windows or Chinese medicine hospitals having practitioners trained on integrated Chinese medicine courses. Pluralist Chinese medicine, integrated Chinese medicine, hybrid Chinese medicine, or combined Chinese medicine are the different terminologies used by various scholars to describe this newly founded medical practice in China which started during the Mao era. One of the major concerns about the emergence of integrated Chinese medicine is its ideologically corrupt nature. Chinese and Western medicine are not easily integrated at the theoretical and methodological levels: Chinese medicine is historically based on the theory of balance while Western medicine is based on the theory of the germ. Although practitioners of Chinese medicine use diagnostic methodologies from Western medicine, it does not happen vice-versa. Thus, the term integrated Chinese medicine has become used in China to convince patients that Chinese medicine is and strove to assimilate Chinese medicine into the emerging national system of healthcare and education; 1949-1953, which was characterized by attempts to subsume Chinese medicine into a biomedical dominated healthcare system; 1954-1965, during which the CCP, under the direction of Mao Zedong, switched to a policy of supporting the development of Chinese medicine and its institutional infrastructure; 1966-1976, which includes the Cultural Revolution, when activity in the field of Chinese medicine contracted under the guidance of ideological simplification; 1976-1989, the immediate post-Maoist era to the Tiananmen Massacre, spanning the feverish decade of the 1980s, when not only the field of Chinese medicine exploded once more into a myriad of options and possibilities; and 1989-date, during which Chinese medicine has been guided towards integration into the techno scientific networks of a global health care system” (Scheid and Lei, 2016: 245).

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following the path of the already established and standardized Western medicine and as a consequence Chinese medicine has lost much of its “epistemological authority” in the process of integration (Andrews, 2014: 6). The above-mentioned existing literatures on the transition in Chinese medicine during the modern era focus on the twentieth century during which Chinese medicine went through two major interventions: Firstly, professionalization according to the line of Western medicine was introduced to modern institutions; and secondly, the rise of integrated Chinese medicine, which combines Chinese medicine with specialties from Western medicine. The professionalization and institutionalization of Chinese medicine according to the Western line has political and public significance. This effort promoted standardization in Chinese medicine, which was already in place in Western medicine and helped to gain trust from modern and Western-minded patients. At the same time, this initiative justified the vision of the Chinese leadership to develop China through promoting rational and evidence-based science in the medical arena. The rise of integrated Chinese medicine also gave the opportunity for graduates trained under this system to learn and practice Western medicine.

About This Book Chinese medicine and transnational transition during the modern era enhances existing narratives on the transition of Chinese medicine and contributes in a variety of ways. Firstly, this volume introduces the recent developments in the education and hospital practice of Chinese medicine, which could be seen as an attempt to reverse the education in integrated Chinese medicine and revive apprenticeships. Secondly, this volume examines the commodification of Chinese medicine by the drug and health product manufacturers to meet the market demand raised by globalization. And finally, this volume synthesizes the transition in Chinese medicine beyond China’s territory in countries such as Malaysia, the Philippines, and Japan in particular.

Professionalization, Integration, and Hybridity One of the noteworthy developments that has happened in Chinese medicine over the last few years is the revival of the apprenticeship model

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of education within a professionalized and institutionalized framework. This attempt can be seen as rescuing Chinese medicine from defective integrated practice which combines Chinese medicine with modalities from Western medicine. Pei Xue and Jian-Ping Liu in their chapter: The Origin and Systematic Development of Chinese Medicine Education in China from Historic Time to Date, analyse the formal and informal education in Chinese medicine and its systematic development since the dynastic eras. The most notable contribution from this chapter is the analysis on the revival of the apprenticeship system in various Chinese medicine institutes in recent years such as the Beijing University of Chinese Medicine. This is called the “master-apprentice model of education” which can be seen as a reverse of classroom-based education or the formalization of Chinese medicine according to the Western line. This chapter argues that the incorporation of Western medicine in education in Chinese medicine led to a major break from the tradition of family and apprenticeship models. Developing general education courses that integrate both Chinese and Western medicine is a major challenge today. As a result, the Chinese Ministry of Education and the State Administration of Traditional Chinese Medicine jointly issued “Opinion on enhancing clinical teaching in higher TCM education,” which started piloting projects of talent training using the master-apprentice model in 1999 (Huang, 2012). Many TCM tertiary institutions recovered the master-apprentice model of education, and integrated institutional education with it. More specifically, the integration is completed through the careful selection of excellent students from junior undergraduates, and teachers with rich clinical experience or experts with advanced level titles from clinical hospitals, and establishing the relationship of master and apprentice between supervisors and students. Since 2015, the Beijing University of Chinese Medicine has implemented an apprenticeship system in an all-round way. Tutors are designated to train all the students majoring in traditional Chinese medicine at an early stage of the programme, so that the students can gain clinical experience as early as possible. The tutors are responsible for providing guidance for students in their spare-time apprenticeships, including clinical observation, so as to improve students’ independent thinking ability and basic clinical skills in a traditional Chinese medicine clinical setting. When students are still learning theoretical courses on campus at an early stage of the programme they are required to spend a minimum number of hours in their spare time on observing their teachers while they are practicing at clinics and write reflections on

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such clinical experiences. In formal clinical placements at a later stage of the programme, students are required to train as apprentices on a regular basis, including spending a mandated number of hours at a clinic observing their tutors, practicing clinically in wards under the supervision of their tutors, keeping logs, writing reflections, recording typical cases and writing reviews of extracurricular readings. Thus, the apprenticeship model of education in Chinese medicine is implemented throughout the whole process of students’ academic programmes. Under this newly introduced apprenticeship model, students spend their weekends or spare time following their supervisors in clinical practices, assisting pattern identification/syndrome differentiation of Chinese medicine through inspection, listening and smelling, inquiry, and pulse-taking, learning to write prescriptions. This new and recent development has given hope that education and practice in Chinese medicine is addressing its epistemological roots such as unique theory and methodologies under a modern institutional framework. The Evolution and Role of Traditional Chinese Medicine (TCM) in Healthcare System and Integrated Medicine in China by Hong Zhou analyses the integration of Chinese medicine with Western medicine and the current situation of integrated medical practice within the Chinese hospital system. The primary focus of this chapter is to scrutinize the evolution of Chinese medicine within hospital care, the integration of Chinese medicine in mainstream healthcare service, and the challenges during the process of integration. This chapter notes that about ninety percent of general hospitals and seventy five percent of health centres in contemporary China have Chinese medicine departments although there was no Chinese medicine hospital before the foundation of the People’s Republic of China except some private pharmacies operated by individual doctors. To protect Chinese medicine as part of China’s cultural heritage and provide affordable medical services, the central government initiated a Chinese medicine hospital system in 1954. This chapter argues that since then, hospitals specialising in Chinese medicine in China have remained committed to not only medical care but also the social and historic cause of reviving Chinese medicine as an important part of Chinese cultural heritage. This chapter also presents research findings on the development of hospitals specialising in Chinese medicine and the situation of their medical services in relation to Western medicine. As this chapter shows, the adoption of the “Open Door” policy in 1978 had a positive impact on the promotion of Chinese medicine and nearly ninety four percent

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of the hospitals that specialise in Chinese medicine that are in operation today were set up after the reform era.

Commodification and Marketing The commercialization of Chinese medicine and the developing of new products and service niches under the name of Chinese medicine is a trend that developed over the second half of the twentieth century and was initiated by both private and public entrepreneurship. Chinese medicine has been commodified under this trend and become a means of profit maximization for corporations. Various new modalities have been developed around Chinese medicine including industries such as tourism, wellness, and consumer products. Ivette Vargas-O’Bryan in her chapter: Tibetan Healing Traditions, Scientific Commodification, and Cultural Identity, synthesizes the process of how Tibetan medicine has been commodified over the years and promoted as a product for local Chinese customers-tourists and the global market. She argues that the establishment of medical schools and hospitals for Tibetan medicine over the last few years was a state effort to promote Western science in the Tibetan medical arena and persistently contested by the local healing tradition. The tension between commodification and cultural preservation in terms of Tibetan medicine and local healing practices has also been explored in this chapter. She concludes that local Tibetan communities have persistently preserved their traditional healing traditions practicing a kind of integrative method and utilizing a pluralistic system of healing. In the chapter titled Medical Marketplaces, Commercialism, and Chinese Medicine in the Cholera Pandemic in Southeast Coastal China, 1961– 1965, Xiaoping Fang explores the role of local governments in China in regulating the medical marketplace, disciplining medical commercialism, and facilitating the medical institutionalization of Chinese medicine in response to the global cholera pandemic that affected southeast coastal areas of China in 1962. He argues that the top-down state medical system, which was gradually established after 1949, started managing the previously unregulated medical markets as a part of the institutionalization process of Chinese medicine, particularly in rural areas. However, the retrenchment of the medical system after the Great Leap Forward not only aggravated the problem of scarcity in the medical marketplace, but also sabotaged participation in epidemic prevention, the identification of suspect patients, and the reporting of epidemic information. Xiaoping

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concludes that through regionalized regulation, the downward extension of the medical system to villages, and the further institutionalization of medical units, the government cracked down on commercialism among Chinese medical practitioners and facilitated the progress of epidemic prevention. Sijing Pan in her chapter: Chinese Medicine in the Cosmetics Market in China: History, Contemporary Development and Challenges, analyses how various ingredients in Chinese medicine have been used for the preparation of cosmetics from ancient times to date. She adds that the use of various herbal, animal and mineral compositions from Chinese medicine texts for the preparation of cosmetics is nothing new and can be traced back thousands of years. However, applying knowledge from Chinese medicine in the cosmetics industry has become a popular trend in recent years and has been brought about by globalization. She reviews both the history of the use of Chinese medicine for cosmetic purposes in ancient times and contemporary developments and argues that Chinese medicine in cosmetics is popular among consumers from China and elsewhere because of the use of natural ingredients. Companies dealing with Chinese medicine for cosmetic purposes need to improve their level of innovation and strategies in order to compete in the global market given the fact that some of their products do not follow Chinese medicine theories, she concludes.

Transnational Transition The third part of this book explores the transition in Chinese medicine beyond China, to Southeast and East Asia in particular. Although many features of Chinese medicine within China can be found overseas, there are differences because of historical, political, and cultural variations which affect the regulatory framework of a particular country. Md. Nazrul Islam in his chapter: Chinese Medicine in Malaysia after Decolonization: Segregation and Unequal Access, examines the formalization and professionalization of Chinese medicine according to the Western line at the dawn of the twenty-first century which brought about a major transition in the practice of Chinese medicine in Malaysia. He argues that formalization has increasingly segregated Chinese medicine in Malaysia and it has become a middle-class private phenomenon. The bulk of the population from Malaysian society is excluded from education regarding Chinese medicine and healthcare services because of the nature of the country’s health financing and socioeconomic factors. An integrated education system is in

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place which combines Western medicine and Chinese medicine modalities in the curriculum and makes Chinese medicine a hybrid practice. Ethnic and sex preferences also prevail in the educational institutions and healthcare services. Islam concludes that mainstreaming Chinese medicine into the state healthcare system produces a similar health inequality as Western medicine does in Malaysia. The chapter Current Challenges and Issues for Traditional and Complementary Medicine (T&CM) in Malaysia, by Yun Jin Kim explores the conventional teaching and learning of traditional and complementary medicine which has been divided into higher education and skills training. In Malaysia, Chinese medicine is offered and regulated under the Traditional and Complementary Medicine (T&CM) umbrella which is a group of diverse medical and healthcare practices and products that is not considered part of conventional medicine. People in Malaysia do not use Chinese medicine only for general well-being but also substituting conventional medicine, although the effort to mainstream Chinese medicine is still at the initial stage. Malaysian Law defines T&CM as a form of health-related practice designed to prevent and manage illnesses, or to preserve the mental and physical well-being of an individual. Despite rapid growth, the Malaysians primarily sought T&CM healthcare services for the maintenance of wellness and the treatment of minor musculoskeletal disorders such as joint and muscle pain, and rehabilitation. However, efficacy, quality, safety, availability, preservation, and the further development of T&CM of health care in the national healthcare system is a major challenge in contemporary Malaysia. This chapter concludes that the integration of T&CM modalities in the mainstream healthcare system requires a great deal of contribution in research from clinical and behavioural aspects. In his chapter, Imperial Medicine and Ethnicity in an Urban Society: Cholera Epidemics in the Philippines, Yoshihiro Chiba explains the cholera epidemics in the Philippines during the nineteenth and twentieth centuries and the role of Chinese medicine and other medical services in tackling the situation. He argues that the epidemic had come from other Southeast Asian colonies or Chinese port cities such as Canton and Amoy, connecting the Maritime Silk Road which was the setting of the fifth and sixth cholera pandemics that lasted from 1881 to 1896 and from 1899 to 1923, respectively. In response to these epidemics, some voluntary bodies were added as the welfare providers for Filipino, as well as Chinese societies and the Filipinos tended to depend on native

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medicine, and the Chinese Filipinos clans and their hometown associations organized their own medical services. However, the tension between native medicine and Western medicine arose when the Spanish colonial government in the Philippines introduced a centralized sanitary administration which was accelerated during the American colonial regime. This chapter concludes that, up to the early twentieth century a vague distinction can be observed between Western and native medicine in these two imperial eras, apart from Chinese medicine. In other words, indigenous medicine in the Philippines including some of the modalities from Chinese medicine played an important role in tackling cholera epidemics atop of Western medicine during the two colonial and imperial eras. Arnel E. Joven in the last chapter of this collection, titled Perceptions on Illness and Wellness in East Asia: Contemporary Views on Japanese Medical Systems and Traditions, argues that although contemporary Japanese urbanites address the body in light of Western medicine, historic East Asian perspectives on medicine and disease still persist which is predominantly influenced by traditional Chinese medicine and indigenous cosmological models. He analyses individual case studies from selected cities in Japan and looks at the role of Chinese or Kampo medicine and their contemporary practice and popularity among Japanese urban communities. He also attempts to interpret diverse perspectives on the body’s wellness and illness, in seeking to understand the interplay of Western medicine and traditional Japanese systems of medicine which is influenced by the philosophy of Chinese medical heritage in contemporary Japan.

Conclusion From the Han dynasty’s shamanistic tradition to twenty-first-century global commodification, the practice and products of Chinese medicine have undergone a spontaneous process of transition. This volume focuses, in particular, on the transition during the modern era. Although there was scepticism among the political leadership of the Republic of China and contested arguments during the first half of the twentieth century about the future of Chinese medicine, it reversed paradoxically after the foundation of the People’s Republic of China. Both the first and second half of the twentieth century witnessed politicized interventions in Chinese medicine and some of those were self-contradictory. The Republican leadership tried to eliminate most forms of Chinese medicine specialties in view of clearing the path for the development of Western

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medicine. Despite facing resistance, the political leadership was able to develop a health system dominated by Western medical care. The communist leadership after 1949 revolution tried to revive Chinese medicine through manipulating cultural connotations. The introduction of integrated Chinese medicine and the foundation of training colleges for Chinese medicine in Beijing, Shanghai, Guangzhou, and Chengdu in 1956 gave Chinese medicine a new identity. Some scholars have seen this as a scope for Chinese medicine but others remain sceptical. Thus, the twentieth century is the time when Chinese medicine underwent various interventions and transitions initiated by political regimes. This volume analyses the development of the apprenticeship model of education in some modern institutions such as the Beijing University of Chinese Medicine during the first quarter of the twenty-first century and its future. How are the new apprentices going to offer healthcare service after their graduation? Are they going to work under the existing integrated hospital care system or to follow a practice model, which existed during the dynastic era? The commodification of Chinese medicine and the promotion of various products and service niches is also a phenomena that has developed over recent decades with the rise of globalization. Chinese medicine has become a popular name to cater for products and services for tourists in various parts of China and abroad. The cultural corruption and contamination of Chinese medicine is inevitable under this trend. Is this trend going to be the future of Chinese medicinal products and services? The rise of Chinese medicine beyond China’s territory is also a recent initiative and was launched by the ethnic Chinese diasporas and caused by the failure of Western medicine in handling chronic lifestyle diseases. Although some scholars have seen this trend as an outcome of the rise of the new age movement and “consumptive capitalism”4 in the west and its expansion to the east, there is merit beyond this claim. These are the questions we intend to address for future researchers. Acknowledgement I acknowledge BNU-HKBU United International College for providing College Research Grant (Code: 202049) for this study on Chinese medicine and this chapter.

4 A terminology used by Paul Heelas in his book Spiritualties in Life: New Age Romanticism and Consumptive Capitalism (2008).

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References Andrews, Bridie (2014), The Making of Modern Chinese Medicine, 1850–1960, pp. 1−24. Vancouver: The University of British Columbia Press. Bradley, S. (2018), The Silk Road and Sources of Chinese Medicine Expansion, Part 1-Materia Medica. Chinese Medicine and Culture, Vol. 1, Issue 1-29-31. Retrieved from the following link: http://www.cmaconweb.org/article.asp? issn=2589-9627;year=2018;volume=1;issue=2;spage=68;epage=70;aulast=Bra dley and accessed on April 4, 2019. Bullock, Mary Brown and Andrews, Bridie (2014), Introduction. In Bullock, Mary Brown and Andrews, Bridie (eds.), Medical Transitions in TwentiethCentury China, pp. 1–13. Bloomington: Indiana University Press. Chen, Ming (2007), The Transmission of Foreign Medicine Via the Silk Roads in Medieval China: A Case Study of Haiyao Bencao. In Asian Medicine, Vol. 3, pp. 241–264. Leiden: Brill. Chen, Nancy N. (2005), Mapping Science and Nation in China. In Alter, Joseph S. (ed.), Asian Medicine and Globalization, pp. 107–119. Philadelphia: University of Pennsylvania Press. Dong, Hongguang and Zhang, Xiaorui (2002), An Overview of Traditional Chinese Medicine. In Chaudhury, Ranjit Roy and Rafel Uton, Muchtar (eds.), Traditional Medicine in Asia, pp. 17–30. New Delhi: World Health Organization (WHO). Dutta, Arijita (2009), Prospects of Ancient Medical Systems in India and China in Today’s World. In Reddy, B. Sudhakara (ed.), Economic Reforms in India and China, pp. 375–390. New Delhi: Sage Publications India Pvt Ltd. Fan, Ka-wai (2013), The Period of Division and the Tang Period. In Hinrichs, T. J. and Barnes, Linda L. (eds.), Chinese Medicine and Healing: An Illustrated History, p. 67. Cambridge: The Belknap Press of Harvard University Press. Fang, Xiaoping (2016), Barefoot Doctors and the Provision of Rural Health Care. In Bullock, Mary Brown and Andrews, Bridie (eds.), Medical Transitions in Twentieth-Century China, pp. 267–284. Bloomington: Indiana University Press. Huang, Xiaolan (2012), Research on the training model for fostering excellent Chinese medicine practitioners under modern education system. Fujian: Fujian Normal University. Hinrichs, T. J. (2013), The Song and Jin Periods. In Hinrichs, T. J. and Barnes, Linda L. (eds.), Chinese Medicine and Healing: An Illustrated History, pp. 99–101. Cambridge: The Belknap Press of Harvard University Press. Huang Di Nei Jing (2009), Translated by Zhu Ming. Beijing: Foreign Language Press. Huard, P. (1970), Medical Education in Southeast Asia. In O’Malley, C. D. (ed.), The History of Medical Education.

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Islam, Md. Nazrul (2017), Chinese and Indian Medicine Today: Branding Asia, pp. 2–3, 13–14. Singapore: Springer. Lin, Fu-shin (2013), Shamans. In Hinrichs, T. J. and Barnes, Linda L. (eds.), Chinese Medicine and Healing: An Illustrated History, pp. 67–69. Cambridge: The Belknap Press of Harvard University Press. Lin, J. Y. (1995), The Needham Puzzle. Economic Development and Cultural Change (January): 269–292. Maddison, Angus (2005), Growth and Interaction in the World Economy: The Roots of Modernity. Washington, D.C.: The AEI Press Published for the American Enterprise Institute. Scheid, Volker and Lei, Sean Hsing-lin (2016), The Institutionalization of Chinese Medicine. In Bullock, Mary Brown and Andrews, Bridie (eds.), Medical Transitions in Twentieth-Century China, pp. 244–266. Bloomington: Indiana University Press. Zhang, Fan (2012), Systemization of Science and Technology. In Zhang, Chuanxi (ed.), The History of Chinese Civilization, Vol. 2. Cambridge: Cambridge University Press.

PART I

Professionalization, Integration, and Hybridity

CHAPTER 2

The Origin and Systematic Development of Chinese Medicine Education in China from Historic Time to Date Pei Xue and Jian-Ping Liu

Introduction For at least 5000 years, traditional Chinese medicine (TCM) has made remarkable contribution to people’s health and medical care. TCM education is not only an important part of TCM course, but also an important component of Chinese education system. TCM education is a professional training for Chinese traditional culture, as well as medical knowledge; it has something in common with general professional education, but has specific development characteristics and rules.

P. Xue (B) · J.-P. Liu Center for Evidence Based Chinese Medicine, Beijing University of Chinese Medicine and Pharmacology, Beijing, China e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_2

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Ancient TCM Education In ancient times, the models of TCM education are various in China, including father-son education, master-apprentice education, and government-established institutional education. These three models are compatible with each other, and complement each other. The earliest government-established medical education in ancient China was clearly documented in Southern and Northern Dynasties (420–589). According to the records in Six Codes in the Tang Dynasty, “Since the Jin Dynasty (265-420 AD), the Teaching Academy has been responsible for teaching the students who are to be future doctors,” which marked the beginning of medical education in China (Jiang, 2007). In the Liu Song period of the Nan Dynasty (420–479 AD), Chinese medicine was officially established as a discipline. In the Qi period of the Nan Dynasty (479–502 AD), a special officer (Baoxueyi) was set in Taichang Monastery to teach medicine. In the Northern Wei Dynasty (368–534 AD), imperial medical teachers (Boshi and Zhujiao) were set in the Imperial Medical Academy. In Sui and Tang Dynasties, it began forming a formal medical institution, called Tai Yi Shu. Tai Yi Shu has different educational systems of Chinese medicine and Chinese material medical, and has definite regulations of enrollment, teachers and teaching. In medical education, the fourdiscipline education system was established, including Chinese medicine, acupuncture, tuina, and exorcism. For each discipline, there was an officer (Boshi) responsible for the overall management and officers (Shi and Gong) responsible for the clinical internship. Besides, for the disciplines of Chinese medicine and acupuncture, there were teaching assistant; for Chinese Materia Medica, knowledge was delivered with on-site practice. Since Song Dynasty, TCM education entered its glorious age. A special administrative organization was established for the management of TCM education, called Tai Yi Ju, and the top educational institution Guo Zi Jian started providing TCM programs. In Yuan Dynasty, a special administrative organization, called Medicine Ti Ju Si, was established for the management of local medicine, and unified TCM education throughout the country. Regarding the assessment and selection of medical students, the government specified that students should be both qualified according to the assessment and preferably out of the sons of registered doctors and pharmacist running a drug store. The medical disciplines were integrated into 10 (originally 13), with each discipline targeting at corresponding

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contents and exam subject. Ming and Qing Dynasty witnessed the reduction of TCM education scale. Till the end of Qing Dynasty, when China faced huge internal and external problems and economic recession, the government-established TCM education gradually disappeared (Yi, 2014). The model of master-apprentice education is characterized by combining theory with practice through following the masters in clinical practice and oral instruction, and focusing on clinical practice. Father-son education model is a common method in master-apprentice education. The model of master-apprentice education is the main model in ancient TCM education. Both father-son medical education and governmentestablished institutional education never exceed the scope of “master” and “apprentice.” The model of master-apprentice education started almost at the same time when medicine came into being. Its features are obviously different from that of government-established institution, including individualized training, oral instruction, teaching by their own example, teaching by an invisible, formative influence.

The Origin of Modern Higher TCM Education Traditional TCM education has made significant contributions in history. However, with the economic and social development, traditional TCM education model cannot meet the requirements of TCM personnel training. By the end of Qing Dynasty, due to the introduction and impact of western medicine, TCM education was in downturn. After the establishment of People’s Republic of China in 1949, the first batch of TCM tertiary institutions was approved by the State Council. For example, Jiangsu Province Advanced School of Chinese Medicine (now Nanjing University of Traditional Chinese Medicine) is one of these institutions. The establishment of TCM tertiary institutions, especially Chinese medicine higher educational institutions, changed the mainstream model of TCM education from master-apprentice model into modern education. Modern higher education of TCM is a milestone in TCM education history, achieving a preliminary scale development and standardization of TCM personnel training and scientific and institutionalized management of education. It successfully integrated TCM education into modern education system (He, 2003). In March 1956, the Chinese Ministry of Health and the Ministry of Higher Education made a plan together for the establishment of

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four TCM tertiary institutions in Beijing, Shanghai, Guangzhou, and Chengdu. In August 1956, the four TCM tertiary institutions were approved by the State Council: Beijing University of Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, and Guangzhou University of Chinese Medicine, which marked the establishment of the first batch of TCM tertiary institutions in China. Since then, TCM higher education entered into a new era. TCM higher education has experienced 60 years of development and exploration since the first batch of tertiary institutions established in 1956. TCM higher education consists of pure TCM tertiary institutions, western medicine institutions with TCM programs/majors, and other comprehensive universities with TCM programs/majors. During the past 60 years, the number of TCM tertiary institutions is increasing. According to 2013 data from the State Administration of Traditional Chinese Medicine, People’s Republic of China, 45 TCM tertiary institutions and another 215 tertiary institutions (93 tertiary institutions of western medicine, and 122 comprehensive universities) provide TCM programs/majors in mainland China.

The Current Status of TCM Higher Education Because much attention has been paid to TCM curricula from Chinese government and the social demand for various talents, TCM tertiary institutions have formed a characteristic modern TCM education system. For example, the Beijing University of Chinese Medicine commits to fostering high-level innovative talents, at this stage provides multidisciplinary programs/majors including Chinese medicine, Chinese Material Medica, Acupuncture, Moxibustion, Tuina, Health Service Management, Medical English, Nursing, and Medical Laws, and provides undergraduate, master and doctoral programs. It has a complete education system covering full-time, continual, distance, and external-oriented education.

Education Level From education level, TCM higher education has developed from pure undergraduate education to multi-level training including undergraduate, master, and doctoral education. In addition, TCM post-doctoral stations in the institutions have been established by Chinese government. For

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example, Beijing University of Chinese Medicine was one of the earliest TCM tertiary institutions in India established in 1956 and offering TCM undergraduate programs since her inception. In 1978 it started the enrollment of master students turning the chapter of postgraduate education in TCM development, in 1983 it enrolled the first group of doctoral students, and in 1995 it became one of the first TCM tertiary institutions providing post-doctoral programs in China.

Programs/Majors Since 1956, the programs/majors in TCM tertiary institutions have experienced a process of development and enlargement. The past pure TCM medical education has become multidisciplinary development to meet the demand of healthcare system. In 1960s, TCM tertiary institutions provided programs/majors of Chinese medicine, Acupuncture, Moxibustion and Tuina. In 1980s, to meet the social demand of TCM talents, TCM programs/majors, on the basis of original settings, divided into more specialized programs/majors according to major TCM subjects/discipline. In 1990s, due to the further deepening of education reform in China, the adjustment of programs/majors is an important part of higher education reform. In July 1998, the Chinese Ministry of Education issued the revision of “The Undergraduate Specialty Catalogue of Tertiary Institutions,” in which six kinds of specialties are related to TCM, including 7 programs/majors: (1) Chinese medicine, (2) Acupuncture, Moxibustion and Tuina, (3) Nursing, (4) Chinese Materia Medica in pharmacy program, (5) Pharmaceutical engineering in chemical and pharmaceutical program, (6) Health Service Management in public administration program, (7) Biomedical engineering in electric information program. After adjustment of programs/majors, the average number of undergraduate programs/majors of TCM tertiary institutions in China is four (not include 7-year program), and 78% of them focused on Chinese medicine, Acupuncture, moxibustion and tuina, Chinese Materia Medica, and Nursing (Wang, 2000). For example, Beijing University of Chinese Medicine provided its first program, Chinese medicine, in 1956; in 1958 it provided Chinese Materia Medica (for both research and trainers) and in 1960 it established the Department of Chinese Materia Medica; in 1982 it established the Department of Acupuncture, Moxibustion and Tuina; in 1983 it opened training classes for talents of TCM management and changed

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the name into the Department of Healthcare Management in 1987; in 1985 it established the Department of Nursing and provided programs of nursing; in 2003 it established the Department of Culture and Law. During the past 60 years, Beijing University of Chinese Medicine has developed from only providing Chinese medicine program at the beginning to having School of Basic Medical Science, School of Chinese Materia Medica, School of Acupuncture, Moxibustion and Tuina, School of Management, School of Nursing, School of Humanities and Culture, International School, School of Chinese Medicine for Taiwan, Hong Kong, and Macau, School of Distance Education, School of Continuing Studies, School of Traditional Chinese Culture, and School of Marxism, with various programs and majors. In addition, to train inter-disciplinary professional TCM talents to meet the demand of social and economic development, Beijing University of Chinese Medicine provides programs of Information Management and Information System, and new specialty in Medical English called TCM international communication.

Length of Schooling For the length of schooling, it is common to set 5-year undergraduate program, 3-year Master program, and 3-year doctoral program. In addition, during the long-term education and teaching practice, TCM education deepened reform continuously, and created new models for the cultivation of innovative talents. Take the Beijing University of Chinese Medicine as an example, which is one of the first group of TCM tertiary institutions established in China and always at the cutting edge of TCM education. In 1991, it started a 7-year Chinese medicine program to foster master-level talents who master TCM theories and clinical skills systematically. In 2007 it adopted a “TCM education reform experimental program.” Students were admitted to this program by an independent student recruitment process that selected applicants from families of TCM practitioners instead of through a college entrance examination. Once enrolled, students were assigned to different supervisors (senior TCM practitioners). This program is a combination of institutional education, master-apprentice education, and father-son education model. In 2011, Beijing University of Chinese Medicine started a 9-year Chinese medicine program called the Qihuang Program. This is a combined undergraduate and doctoral program. During the first 5 years, students are trained according to an undergraduate teaching plan. In the fourth

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year, an entrance examination is held to enroll eligible students directly into the subsequent doctoral program. A new “cultivation model of Chinese medicine” was implemented in 2012. This includes the following programs: excellent doctor of Chinese medicine, excellent doctor of integrative medicine, excellent doctor of Chinese medicine with Jinghua master-apprentice training, and excellent acupuncturist and tuina practitioner. These programs all use an integral training model called “five plus three,” which comprises 5 years of undergraduate training with preclinical courses and 3 years of internship training. Graduates from these programs will obtain a Bachelor of Medicine and Master degree of Clinical Medicine. In 2015, Beijing University of Chinese Medicine implemented new cultivation models of programs toward non-Chinese Medicine majors. For instance, the new Chinese Materia Medica program, which is called as Shizhen Guoyao Program, is an 8-year integral program comprising both domestic and international training and combining bachelor and doctoral education. Another new Chinese Materia Medica program called the “Excellent Pharmacists of Chinese Medicine Program” is a 6-year combined bachelor and master education, and aims to foster highly qualified professionals who have specialized skills in Chinese Materia Medica integrated pharmaceutical care.

Curriculum Though curriculum is a bit different among various TCM tertiary institutions, they all focus on the following categories. For Chinese medicine program, there are fundamental courses of Chinese medicine (e.g., Basic Theories of Chinese Medicine, Chinese Materia Medica, Formulas of Chinese Medicine and Diagnostics of Chinese Medicine), fundamental courses of Western medicine (e.g., Anatomy of the Human Body, Physiology, and Pathology), the Classics of TCM (e.g., Selected Readings of Huangdi’s Canon of Medicine, Treatise on Cold Damage Diseases, Synopsis of Prescriptions of the Golden Chamber, and Warm Diseases), Doctrines of Different Schools in Chinese Medicine, Chinese Medical Classics, and Acupuncture and Moxibustion. For Acupuncture, Moxibustion and Tuina program, there are fundamental courses of basic theories of acupuncture and moxibustion (e.g., Meridians and Acupoints, Selective Readings of Acupuncture Classics, and Acupuncture Theories of Different Schools), fundamental courses of acupuncture and moxibustion in clinical practice (Techniques of

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Acupuncture and Moxibustion, Therapeutics of Acupuncture and Moxibustion, and Medical Qigong), fundamental courses of tuina (Massage and Tuina, Tuina Techniques, and Fundamentals of Chinese Medicine Bone-setting), experiment courses such as Experimental Sciences of Acupuncture and Moxibustion, and Rehabilitation of Acupuncture and Moxibustion. For Chinese Materia Medica program, there are fundamental courses of Chinese medicine (e.g., Basic Theories of Chinese Medicine, Chinese Materia Medica, Formulas of Chinese Medicine), fundamental courses of Chinese Materia Medica (e.g., Pharmaceutical Botany, Pharmaceutical Zoology, Chinese Medicinal Identification, Chinese Medicinal Processing, Chinese Pharmaceutical Preparation, Chinese Pharmacology), and experiment courses (e.g., Chinese Medicinal Identification, Experiments of Chinese Pharmaceutical Preparation, Experiments of Chinese Medicinal Processing).

Education Model: Integrated Institutional and Master-Apprentice Education The model of master-apprentice education is irreplaceable for TCM education. In 1999, the Chinese Ministry of Education and the State Administration of Traditional Chinese Medicine jointly issued “Opinion on enhancing clinical teaching in higher TCM education,” which started piloting projects of talent training by master-apprentice model (Huang, 2012). Many TCM tertiary institutions recovered master-apprentice education and integrated institutional education with master-apprentice education. More specifically, the integration is completed through a careful selection of excellent students from junior undergraduates, and teachers with rich clinical experience or experts with advanced level title from clinical hospitals, and establishing the relationship of master and apprentice between supervisors and students. Since 2015, Beijing University of Chinese Medicine has implemented apprenticeship in an all-round way. Tutors are designated to train all the students majoring in traditional Chinese medicine at an early stage of the program, so that the students can gain clinical experience as early as possible. The tutors are responsible for providing guidance for students in their sparetime apprenticeship, including clinical observation, so as to improve students’ independent thinking ability and basic clinical skills in a traditional Chinese medicine clinical setting. When students are still learning

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theoretical courses on campus at an early stage of the program, they are required to spend a minimum number of hours in their spare time on observing their teachers while they are practicing at clinics and write reflections on such clinical experiences. In formal clinical placements at a later stage of the program, students are required to apprentice on a regular basis, including spending a mandated number of hours at clinic observing their tutors, practicing clinically in wards under the supervision of their tutors, keeping apprentice logs, writing apprentice reflections, recording typical cases and writing review of extracurricular readings. In the master’s program, guidance by tutors is provided in terms of scientific research to improve students’ scientific research abilities and academic competence. By adopting such a progressive training model, we make sure that the apprenticeship is implemented throughout the whole process of students’ academic programs. Therefore, students can spend their weekends or spare time following their supervisors in clinical practice, assisting pattern identification/syndrome differentiation of Chinese medicine through inspection, listening and smelling, inquiry, and pulse taking, learning to write prescription. Besides, special teaching plan is made correspondingly in TCM tertiary institutions, and a series of education reforms are deepened, to response the guiding thoughts of early clinical practice, frequent clinical practice, and theory combing with clinical practice in TCM education.

Status Quo of Integrated Chinese and Western Medicine Traditional Chinese medicine has a long history. After the Opium War, Western medicine was introduced into China, and the two different medical approaches started to coexist. In 1958, President Mao Zedong made an important instruction about “Western doctors learning Chinese medicine” and advocated the idea of integrating Chinese and Western medicine, which has since become one of the leading principles of the country in the field of health. In 2016, President Xi Jinping made an important speech at the National Health and Wellness Conference, in which he pointed out that “we must strive to promote the revitalization of Chinese medicine, adhere to the equal emphasis on both Chinese and Western medicine, and advance the complementary and coordinated development of the two approaches.” Currently, a great number of integrated Chinese and Western medicine practitioners have been trained in

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China, medical institutions established, and major breakthroughs achieved through the combination of traditional Chinese medicine treatment techniques and modern medical technology. The basic theory of Chinese medicine has also been extensively studied at different levels, such as the principles of acupuncture analgesia. The combination of the two great medical theories is an inevitable choice of the history. They both have their own advantages and disadvantages. Exploring the integration of Chinese and Western medicine general education courses is one of the major challenges. How to increase the knowledge in the scientific disciplines of Chinese medicine majors and cultivate the humanistic quality of Western medicine students in limited schedules is one of the key tasks for the development of the field.

The Origin and Development of TCM Education in Hong Kong SAR, Macao SAR, and Taiwan, China Hong Kong SAR, China In the late 1930s, Zeng Tianzhi established the “Scientific Acupuncture College” and Lu Jueyu established the “Practical Acupuncture Institute” in Hong Kong (Feng et al., 2005). In 1991, Hong Kong University offered advanced courses in Chinese medicine through the Hong Kong Institute of Vocational Education, which is the earliest publicly run TCM school in Hong Kong. Hong Kong TCM practitioners are trained through the following training methods: full-time TCM classes training, part-time TCM classes training, master-apprentice training, self-study, TCM training in colleges/universities of Western medicine, and other methods. The establishment of the Chinese Medicine School of Hong Kong Baptist University in 1998 marked the beginning of TCM higher education in Hong Kong. The first group of professional TCM practitioners in Hong Kong graduated with bachelor’s degrees in 2003. The School of Chinese Medicine at the Chinese University of Hong Kong is an example. It is affiliated to the Li Ka Shing Faculty of Medicine, whose students are mainly locals and about 25 in total each year. It offers full-time, part-time, and graduate programs. The undergraduate education is 6 years and includes Chinese medicine and biomedicine courses as well as early and substantial clinical training. It provides two teaching languages in writing, three teaching languages (English, Mandarin, and Cantonese) in speech: Mandarin is applied in TCM courses, Cantonese in

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clinical training and practice, and English in Western medicine and other general courses. Clinical skills training courses are also offered. During the first 5 years, students undergo clinical training with supervisors in Hong Kong to cultivate and establish their Chinese medicine clinical thinking. During the sixth year, students go to mainland China for further clinical training. There is also a tradition of in-the-field investigation that includes gathering herbs in Sichuan and Yunnan Provinces and visiting Chinese herbal farms to understand the source of medicinal materials. In addition, students can have modern TCM courses such as Toxicology of Medicinal Herbs in the school. Part-time programs are provided for TCM practitioners, acupuncturists, and TCM pharmacists who have at least 5 years of clinical work experience, to further improve their professional qualities and clinical skills. The part-time programs include Master of Chinese Medicine (Acupuncture), Master of Medicine (Internal Medicine), Master of Science (Chinese Materia Medica), and Bachelor of Pharmaceutics of TCM. Alongside the development of TCM, graduate programs have enrolled students with various backgrounds of MPhil or PhD degrees, including TCM and biomedical science, to foster the modernization and scientific development of TCM. Macao SAR, China At the early stage, TCM education in Macau mainly depended on fatherson and master-apprentice model, or through training and advanced learning in TCM tertiary institutions in mainland China. Not until 2000 when the School of Chinese Medicine was established in Macau University of Science and Technology did TCM education in Macau enter the time of normalization, systematization, and scale development. So far, this School has formed a complete teaching system covering undergraduate and graduate (master and PhD) programs, and become the educational base for excellent TCM talents in Macau. This School has focused on standardized academic education for undergraduates and graduates since its establishment. For undergraduate curriculum, the School stressed at the combination of professional courses and general education, and the integration of TCM and Western medicine (Zhao and Xiang, 2007). Taiwan, China In 1958, Tan Xingqun established China Medical College in Taiwan, China (the name was changed to “China Medical University” in 1970s), which marked the beginning of TCM higher education in Taiwan (Zhen, 2004). It is also the only TCM tertiary institution in Taiwan. In 1966,

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it provided 4-year program of Chinese medicine for post-baccalaureate; in 1972 it established the Department of Chinese Medicine; in 1975, it started master’s programs; and in 1998 it opened doctoral programs. For the length of schooling, the Chinese medicine program requires 7 years to complete, including 5-year institutional training and 2-year clinical training. In 1997, Chinese medicine program was developed into 8-year integrated Chinese and Western medicine program. It provides 5-year post-baccalaureate Chinese medicine program and Chinese pharmacy program, and requires 184 credits to complete the study. The Graduate School provides 2–4-year master programs and 2-year doctoral programs (Feng and Wan, 2005). For the curriculum, students study all TCM subjects as well as all Western medicine subjects required by Chinese Ministry of Education. In addition, some medical schools provide compulsory or optional courses of TCM in Taiwan. For example, Tzu Chi Medical College and Chang Gung University (also 8-year integrated Chinese and Western medicine program) opened compulsory TCM courses, while Yang-Ming University, National Defense Medical Centre, Taipei Medical College, and Kaohsiung Medical College provide optional TCM courses.

Conclusion Throughout the discussion of Chinese medicine education from her origin, systemic development, modernization, and recent trend it is clear that Chinese medicine education continuously went under a process of transition and it was never static. Chinese medicine education encountered different treatment and status during various dynasties although the modes of transmission did not change much until the modernization of education started during the second half of twentieth century. Chinese medicine stayed predominantly a family practice thought out the generations and or apprenticeship practice over the various dynastic regimes. The modernization of Chinese medicine education during the twentieth century brought western style of education into Chinese medicine. One of the key features of modernizing Chinese medicine education is the introduction of integrated Chinese medicine education that combines Chinese medicine methods with western medicine. Given the fact that both the Chinese and western medicine has own advantages and disadvantages an integrated medical education can promote the best uses of medical sciences. However, exploring the integration of Chinese and western

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medicine general education courses is one of the major challenges. How to increase the knowledge in the scientific disciplines of Chinese medicine majors and cultivate the humanistic quality of Western medicine students in limited schedules is one of the key tasks for the development of the field.

References Feng, Li and Wan, Ping (2005), Comparison of the development of Chinese medicine education between mainland China and Taiwan. Journal of Chinese Medicine, 7: 1247–1248. Feng, Li, Wan, Ping, Liu, Zixian, and Zhang, Junping (2005), The current status and comparison in Chinese medicine education between China and foreign countries. Journal of Tianjin University of Traditional Chinese Medicine, 1: 43–45. He, Xingdong (2003), Tendency of the development and reform of TCM education. Education of Chinese Medicine, 1: 4–6. Huang, Xiaolan (2012), Research on the training model for fostering excellent Chinese medicine practitioners under modern education system. Fujian: Fujian Normal University. Jiang, Xiaohua (2007), Historical study on government-established Chinese medicine education in ancient China. Nanjing: Nanjing University of Traditional Chinese Medicine. Wang, Ziyong (2000), Exploration and thinking of the curriculum for Chinese medicine higher education. Journal of Zhejiang College of Chinese Medicine, 1: 27–29. Yi, Min (2014), Master-apprentice model of Chinese medicine education and its innovative research. Nanjing: Nanjing University of Traditional Chinese Medicine. Zhen, Zhao (2004), Analysis of the characteristics of academic education of Chinese medicine in Taiwan and Hong Kong. Journal of Chinese Medicine, 5: 814–815. Zhao, Yonghua and Xiang, Ping (2007), Exploration of the establishment and development model of the Chinese medicine education system in Macau. Education of Chinese Medicine, 5: 65–67.

CHAPTER 3

The Evolution and Role of Traditional Chinese Medicine (TCM) in Healthcare System and Integrated Medicine in China Hong Zhou

Introduction Traditional Chinese Medicine (TCM) is practiced extensively in China, either alone or in combination with Western Medicine. Most hospitals have wings dedicated to TCM and have TCM physician specialists who are available for consultation. Likewise, TCM is used in health clinics and extensively by the general population (Geiger et al., 2009). TCM focuses on prevention of disease. It is a holistic medicine that has been practiced for 5,000 years, and it is still popular in China and the world. It is based on the concept of maintaining the balance of 2 forces “Yin” and “Yang” within the body. The Chinese believe that the creation of the world and the continued processes of nature are the forces behind these 2 powers. Yin is the female component associated with passive energy,

H. Zhou (B) School of Management, Hainan Medical University, Haikou, China e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_3

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coldness, night, danger, hardness, evil, and death. Yang is the male counterpart associated with active energy in heat, daylight, and life (Ostoji´c and Saxer, 2016). They present themselves in the 5 elements: fire, water, metal, wood, and earth. To maintain health, one must keep balance of Yin and Yang. This chapter is divided into three parts: First part introduces some basic information on the various methods and specialties use in Chinese medicine and these include Chinese herbal medicine, acupuncture, tuina (Chinese massage), etc. Second part deals with the integration of Chinese Medicine with Western Medicine and the current situation of integration within Chinese hospital system which is one of the major features of transition in Chinese Medicine. This includes the evolution of TCM in hospital care in China, integration of Chinese Medicine in mainstream healthcare service and the challenges Chinese Medicine faces during the process of integration. Final part of this chapter presents research findings on the development trend of TCM hospitals in China and the situation of their medical service innovation, particularly, in relation to Western Medicine.

Major Methods and Specialties in Chinese Medicine There are different methods and specialties practiced in China under the umbrella of Chinese Medicine, a few of them listed below: Herbal Medicine:

A total of 6,000 individual herbs from plants, animals, and minerals are used. They are administered orally in 3 ways. The first method is called decoctions whereby raw herbs are soaked in water in traditional decoction gallipot and boiled and then consumed. The second method is a process whereby processing herbs powders are mixed in a cup of boilingwater and administered. The third method is the consumption of herbal pills. Each treatment is tailored to the individual symptoms of the patient. In the case of trauma patients, it is used to revive unconscious patients, induce vomiting, and help breathing.

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Acupuncture:

Moxibustion:

Cupping:

Guasha:

Tuina/Massage:

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Fine needles are placed on invisible pathways of energy called meridians. When a person is healthy, energy moves smoothly through the meridians. If the energy becomes too strong, too weak, or blocked, illness can occur. Acupuncture stimulates the energy in the meridians and restores balance. Some of its uses are to diminish pain, revive unconscious patients, and act as an aide for addiction. It is also used as an adjunct for anesthesia and can reduce medication use by up to 10%. The mugwort herb is aged and ground to a fluff or processed further into a stick that resembles a cigar. It can be used indirectly with acupuncture needles or by burning it on the patient’s skin atop a slice of ginger to prevent scarring. It is used to warm regions with acupuncture points with the intention of stimulating circulation, causing a smoother flow of blood. This is a method of applying acupressure by creating a vacuum next to the skin, then reducing the vacuum by using a change in heat or by suctioning out the air. It involves placing glass, plastic, or bamboo cups on the skin with a vacuum. It is used to relieve “stagnation” for treatment of respiratory diseases, such as the common cold, pneumonia, or bronchitis. This is a very traditional therapy, involving the 14 meridians of the body. One or two meridians are chosen, depending on the symptoms. A round edged instrument (jade or horns) is used to stroke the back. A black or purple rash (petechiae) appears that signifies that illness is removed from the body. It is used to relieve pain from stiffness, fever, chill, cough, and nausea, to name a few. It is valuable in the prevention of acute infectious illness, upper respiratory and digestive problems, and many acute and chronic disorders. The practitioner may brush, knead, roll, or press and rub the areas between each of the joints known

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as the 8 “gates” to open the body’s defensive “chi” and facilitate movement of energy in both the meridians and the muscles. Range of motion, traction, and massage may then be used with the stimulation of acupressure points. The Chinese are very open to alternative therapies and they seek to integrate those practices valued by them into their care. Although many people in the United States are adopting herbal medicine, massage, and acupuncture for their own treatments, these are still not common practices within the present hospital environment (Wang et al., 2017). Western Medicine and TCM are different healthcare systems that developed within the context of different cultures and perspectives on the natural world. The reductionist approach forming the foundation of western biomedical science arises from ancient Greece and has generated tremendous knowledge of anatomy, physiology, histology, biochemistry, and genetics. In contrast, the Yin/Yang theory, stating that everything in the world is interconnected in a dynamic balance, lays the foundation of TCM’s philosophy, and has been a guiding principle for thousands of years (Ling and Xu, 2013).

The Integration of Western Medicine (WM) and Traditional Chinese Medicine (TCM) There is a global movement calling for the integration of Western Medicine and Traditional Chinese Medicine has become a mainstream effort over the decades. The World Health Organization suggests that health care would be improved by integrating traditional and complementary medicines into the practices of healthcare service delivery and self-health care (Geiger et al., 2009). The WM and TCM are commonly integrated in the contemporary practice of medicine in China. About 90% of the general hospitals and 75% of health centers have TCM departments (He et al., 2015). Even in WM hospitals, around 40% of the medicines prescribed are TCM. Similarly, in the TCM hospitals 40% of all prescribed drugs are from Western Medicine (Lao and Ning, 2015). Meanwhile, over 80% of Chinese patients have received TCM treatment at some point in their lives (He et al., 2015). However, differences exist in typical use of prescribed medications between WM and TCM and can result in the

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incorrect use, thus leading to concerns about the efficacy and safety of integrative treatment. In TCM, the human body is comprised of functional systems that interact with each other and with the external environment. The healthy body is a well-balanced system while illness or injury will disrupt the balance. The pattern of how the balance is disrupted, or more specifically, the comprehensive summary of clinical symptoms and signs gathered by a TCM practitioner using inspection, auscultation, olfaction, interrogation, and palpation of the pulses, is called Zheng. The diagnosis of the particular Zheng is the first step in TCM treatment. The practitioner will choose compound formulae (Fufang ), which are designed under the principle “emperor, minister, assistant, and courier” (Jun Chen Zuo Shi), for the treatment of the particular Zheng (Ostojic and Saxer, 2016). Therefore, correctly explaining Zheng and Fufang using modern concepts is a key issue in the integration of Western Medicine and Traditional Chinese Medicine. In general, the omics technologies facilitate the accumulation of understanding of Zheng and Fufang at the molecular level. Network pharmacology, a strategy for drug design that encompasses system biology, network analysis, connectivity, redundancy, and pleiotropy, helps to integrate this information into human disease networks and drug pharmacology networks. Zheng was illustrated by molecular networks of human diseases, while Fufang was illustrated in the form of TCM pharmacology networks. Subsequently, with the help of computational methods, WM and TCM were evaluated using molecular networks as a common standard. Thus, the gap between WM and TCM could be bridged by the integrative molecular network of diseases and pharmacology. For example, Qishen Yiqi, a Chinese medicine, using network pharmacology and revealed its underlying multi-compound, multi-target and multipathway mode of action. Thus the activity of a TCM drug was illustrated through modern concepts widely used in WM (He et al., 2015). In conclusion, the integrative analysis of human disease networks, WM pharmacology networks, and TCM pharmacology networks can help to find a common language through which to understand WM and TCM, bridging current gaps, and promoting truly integrative treatment.

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The Evolution of TCM in Hospital Care in China Traditional Chinese Medicine is a sector composed of TCM service (by TCM doctors) and TCM products (including Chinese patent medicine, Chinese herbal piece, and Chinese herb). TCM hospitals are medical institutions that treat the patients with TCM service and products to maintain health (Geiger et al., 2009). Before the founding of the People’s Republic of China in 1949, there were no established TCM hospitals, but only private pharmacies operated by TCM doctors. To protect TCM as a national treasure of China and provide affordable medical services, the central government initiated a TCM hospital system since 1954 (Lao and Ning, 2015). Since then, TCM hospitals in China have remained committed to not only medical care but also the social and historic cause of reviving TCM as an important part of Chinese cultural heritage. Despite the interruption of the Cultural Revolution in the late 1960s and 1970s, TCM still made some progress, such as acupuncture anesthesia. Moreover, integration of Traditional Chinese Medicine and Western Medicine was advocated by government to encourage TCM and WM practitioners to learn from each other to improve their medical practices. With the country’s opening to the outside world since 1978, more and more modern medical discoveries, practices, and technologies from the West have been introduced to China, posing even greater challenges to TCM than ever before (Wang et al., 2017). Many TCM hospitals were obliged to adopt more and more WM in outpatient prescription and inpatient treatment (Ling and Xu, 2013). WM drugs, including chemical and biopharmaceutical drugs, have been applied in the TCM hospitals (Ostojic and Saxer, 2016). As a consequence, TCM hospitals have begun to lose their distinct status in China’s medical sector. Facing the challenges of WM and their diminishing identity as an independent medical body, could TCM hospitals orient themselves to a new way of developing their business? This question has drawn close social and professional attention and spurred heated debates. Some advocates, mostly TCM doctors, hold the view that TCM hospitals should opt for a purist model characterized by relying on TCM medical staff and TCM treatment only without WM medication and equipment (Ren et al., 2015). But others insist that TCM hospitals should transform themselves into a general hospital model, with TCM being just a department of the hospital while WM playing the leading role. Outside these opposing

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views, some people believe that TCM hospital should keep TCM as the mainstay and maintain a working alliance with Western Medicine. The debates have continued to linger on over the past decades, but there is still lack of adequate empirical evidence of the development trend, nor systematic information about medical services, as far as TCM hospitals are concerned. While modernization of TCM products has attracted much attention, attention on TCM hospitals is comparatively limited. In particular, it remains indefinite how TCM and WM at TCM hospitals have interacted with each other in the past decades, and the issue of how to innovate medical services therein under these two diverse and distinctive medical knowledge systems is worth further exploration. As medical innovation plays influential role in reshaping medical sector and changing pharmaceutical system, exploratory investigation into TCM hospitals is especially necessary. It is against this background that the present study aims at an informed analysis of the development trend of TCM hospitals in China and the situation of their medical service innovation, particularly, in relation to WM. To meet this research objective, data analysis at both macro and micro levels were implemented to ensure a breadth of knowledge appropriate to the purpose. Integrated quantitative and qualitative methodologies were used to obtain comprehensive and significant result of the innovative changes at TCM hospitals for an informed anticipation of their development trend. Statistical information was collected from official databases to take the long view at macro level. On the other hand, qualitative analysis of interviews conducted in two prominent TCM hospitals was employed to affirm the data result at micro-level. The quantitative study result was collected from two main sources. Firstly, the general trend data of TCM hospitals in China was collected from the China Health Statistical Yearbook database, officially gathered and publicized by the China Ministry of National Health Commission on a yearly basis. With sustained annual accumulation, China Health Statistical Yearbook has been recognized as a reliable source of medical information in China. From the yearbook database, two types of data were extracted: number of TCM hospitals and number of hospital beds. To reflect the historical development trend of TCM hospitals in China, the data collected covers the period from 1950 to 2013. Secondly, the overall data about medical services of TCM hospitals were collected from the database of Extracts of Traditional Chinese Medicine Statistics, which is an official collection of TCM information operated by the State Administration of Traditional Chinese Medicine (SATCM). Through this

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database, data specific to the public TCM hospitals during the period between 2002 and 2013 were extracted in four aspects: (1) outpatient medical fees (including registration fee, drug fee, examination fee, and treatment fee); (2) inpatient medical fees (including sickbed fee, drug fee, examination fee, treatment fee, and surgery fee); (3) TCM and WM drug revenue; and (4) certified TCM staffs (doctors, assistant doctors, and pharmacists). Specifically, the composition of outpatient fees, inpatient fees, and TCM and WM drug revenue was analyzed to reflect the changes of TCM and WM medical services. To deepen the understanding of medical service innovation at TCM hospitals, qualitative study was co-currently conducted. Chengdu TCM hospital and Jiangsu TCM hospital were meticulously chosen as typical cases for the investigation under the rationale that they are two of the earliest TCM hospitals in China established in 1950s as well as the most prestigious ones for their innovative achievements and the leadership role in the TCM society.

Overall Development of Traditional Chinese Medicine Hospitals in China The number of TCM hospitals increased slowly during the 1950–1975 period, but rose markedly after 1977. With only 184 in 1977, the TCM hospital figure climbed to 3015 in 2013, meaning that 93.9% TCM hospitals were set up after the Reform and Opening-up Policy of China. Similar to the quantity hike of TCM hospitals, the number of beds therein has achieved a rapid growth since 1977. Especially after 2005, the number of beds increased dramatically and surpassed the growth rate of TCM hospitals, indicating that TCM hospitals attached more importance to expanding the scale rather than the number in recent years.

Analysis of Medical Fees at the Outpatient As shown in the study, the average outpatient medical fee/person-time at public TCM hospitals has increased about three times during the 2002– 2013 period, out of which drug fees accounted for more than 60%. Specifically, the proportion of the examination fee has exceeded that of the treatment fee since 2003, showing increasing usage of instrumental WM examination at outpatient hospital care.

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Analysis of Medical Fees at the Inpatient As depicted in the study, the inpatient medical fee is much higher than that of the outpatient, suggesting that most of the income of TCM hospitals comes from the inpatient medical service rather than the outpatient. From 2002 to 2013, the average inpatient medical fee had increased more than twice, with an average yearly growth rate of 7.8%. Of the total inpatient medical fee, the drug fee accounted for 42–47%, implying that TCM hospitals are still dependent on drug for profit. In addition, while the proportion of treatment fee and surgery fee has decreased, the proportion of examination fee kept increasing, with an average yearly growth rate of 11.1%, indicating the rising usage of instrumental WM examination in inpatient service at TCM hospitals.

Analysis of Traditional Chinese Medicine and Western Medicine Drug Revenue The study shows that the average drug revenue of TCM hospitals during 2002–2013 has increased about six times. WM drug accounted for about 60% of the total drug revenue, more than TCM drug. But TCM drug income has a faster annual growth rate (20.2%). For outpatient service, the average annual growth rate of TCM drug was 19%, higher than that of WM drug which was 14%. From the beginning of 2004, the proportion of TCM drug income kept increasing exceeded WM in 2009 and reached 60.7% in 2013. Conversely, for inpatient service, WM drug accounted for about 80% of the total inpatient drug revenue. Even so, the average annual growth rate of TCM drug income reached 24.5%, higher than that of WM drug which was 21%.

Medical Staff at Traditional Chinese Medicine Hospitals With increasingly greater number and scale of public TCM hospitals, the total number of doctors increased at an average rate of 5.3% per year, while that of the TCM doctors was only 4.6%. As of 2013 only 50.2% doctors in public TCM hospitals were certified TCM doctors, whereas the proportion of TCM assistant doctors took up only 20–30%. For pharmacists, the number of TCM pharmacists grew at a faster yearly rate than that of the total pharmacists, accounting for 56% of them in 2013.

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Findings from the Qualitative Analysis Apart from the statistical data described above, the qualitative investigation also generated meaningful information pertinent to the outpatient and inpatient services, the TCM and WM drug usage, and the TCM medical staff development. TCM is dominating the Outpatient: TCM Diagnosis with WM Examination. In the outpatient departments of TCM hospitals, most departments used TCM medical treatment. The hospitals in case study took advantage of the characteristic features of TCM to draw more patients. One of the interviewees described the situation as below: As a TCM hospital, our main advantage or main business comes from our featured TCM outpatient service, using featured TCM treatment and drugs to serve patients….In terms of reliance on TCM, 70% of all the outpatient cases has used or involved TCM treatment. For some TCM specialists, the percentage of TCM application could go beyond 80 percent even 90 percent. (Interviewee of Jiangsu A)

WM was mainly applied in medical examination through using modern WM devices in support of the diagnosis of TCM. In general practice, TCM doctors made a preliminary diagnosis based on the TCM theory. WM examination result was used to confirm or modify their diagnosis. As informed in one of our interviews: Most of our hospital profit comes from the fee charged on drug, surgery, and examination, among which examination accounted for the biggest revenue. Examination includes medical filming, B ultra-sound, and laboratory testing, etc. In the end, it is mainly TCM that provides diagnosis and prescription. (Interviewee of Jiangsu B)

In outpatient treatment, the TCM hospitals have followed the principle of TCM-over-WM priority, i.e., “whenever TCM is therapeutically viable, do not use WM; and where necessary, integrate WM into TCM,” in line with the overriding objective of “consolidating the TCM characterized by benefiting from the assistance of WM.” WM pre-dominating the inpatient: WM surgery with TCM for rehabilitation. By contrast, WM contributed more in the inpatient treatment. In the inpatient departments of TCM hospitals, WM rather than TCM was mostly applied to treat patients and brought financial benefits to the hospital as well. Especially, WM surgery was applied to treat more urgent cases in the inpatient,

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whereas TCM inpatient services are usually used as Non-Communicable Disease management or pain management. As acknowledged by the interviewees: WM is mainly used in inpatient departments. For example, to perform a surgery, we have advanced instruments and techniques. But to recover after the surgery, we will incorporate TCM to optimize the patient care for better recovery. (Interviewee Jiangsu A) The inpatient of TCM hospital emphasizes both TCM and WM. To some extent, we emphasize more on WM, like surgeries, etc. But before and after the surgery we will apply TCM. (Interviewee Jiangsu B)

Relying on WM Drugs While Innovating TCM Drugs The interviewees admitted that as a major part of hospital income WM drug was used more than TCM in their hospitals. However, to highlight the special characteristics of a TCM hospital, they also made an effort to recreate TCM drugs, including Chinese herbal pieces, Chinese proprietary medicine, and hospital preparations. As described by one of the interviewees: We have used the Chinese herbal piece exclusively with small packaging, which helps to improve drug quality and patients’ rights to know about their treatment. Moreover, in recent years, we have invested in R&D and improved dozens of hospital preparations formulas, processing techniques, quality standards and packaging, which significantly upgraded the internal quality and external image of TCM drugs. (Interviewee Chengdu B)

Cultivating the TCM Medical Staff The TCM hospitals under study believed that the unique features of TCM hospital care could not be maintained without qualified staff knowledgeable in TCM. The hospital leadership insisted on using mentorship system to train TCM doctors even if they had got a degree from TCM universities. As one described it: Our hospital strengthened our cultivation of TCM doctors through improving our staff development mechanism. For example, we have set

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up the Experience Sharing Workshops by veteran TCM doctors. We also required new TCM doctors to follow senior TCM doctors in clinical services to acquire their TCM experience and knowledge. (Interviewee Jiangsu C)

The directors being interviewed hold that such in-house training system could facilitate maintaining TCM traditions and also benefit the TCM innovation. As clearly expressed by one of them: Most of the current TCM doctors have learned WM. So they could integrate traditional theory of TCM with anatomy, modern pharmacology and physiology of WM, which differentiated themselves from conventional TCM doctors. In clinical service, they could combine TCM and WM to realize the modernization of TCM. (Interviewee Jiangsu A)

On the other hand, the TCM hospitals in question tried to cultivate the needed TCM knowledge and skills of the WM doctors. In both of the hospitals, the WM doctors were required to learn TCM if they had never had TCM education background before. TCM hospitals were transforming themselves from past small and specialized medical institutions to comprehensive and diversified medical service providers. As such, TCM hospitals are compelled to innovate to meet the rising demands of patients and the competition pressures from general hospitals that apply WM in the main services. As the quantitative and qualitative data showed, all the TCM hospitals in China today were providing both TCM and WM medical services to the outpatient and the inpatient. There are several reasons for such kind of change. Firstly, the political impact of the “integrating medical services of both TCM and WM” policy in 1970s brought WM as necessity into TCM hospital system. Later on more and continuing policies were issued to boost the integration of WM into TCM. For example, the “Basic Standards for Medical Institutions” publicized by the Ministry of National Health Commission in 1994 explicitly required first-class TCM hospital to be equipped with adequate WM instruments. Secondly, the transformation from planning economy to market economy brought market pressures to TCM hospitals for utilizing WM. In the traditional planning economy, all the costs of TCM hospitals were covered by the government. However, the transformation to market economy forced hospitals to compete with each other. While government still supplied financial supports to some extent,

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it could not afford the full expense of TCM hospitals. Moreover, TCM medical service on the whole costs less than their WM counterpart, and therefore, brings insufficient financial resources for TCM hospital. For survival reasons, TCM hospitals had to bring in WM to provide more profitable medical services, such as medical examination. Thirdly, patients were getting hospitalized with most of the traditional way of TCM and requesting more advanced medical services. Lastly, the TCM practitioners themselves also had motivation to learn from WM. They generally recognized the limitations of TCM in some aspects and hoped that the WM knowledge and technologies could benefit their practice of TCM. All the factors collectively pushed TCM hospitals into providing TCM and WM medical services simultaneously. The study showed that, while the situation necessitated TCM hospitals’ inclusion of WM into their medical service, they were still trying to maintain their special TCM features. WM medical services were mostly conducted in the inpatient, or the outpatient departments where surgery or immediate medical treatment was called for. A case in point of the most welcome WM presence in TCM was medical examinations. In both of outpatient and inpatient services, instances of using WM in medical examination kept rising. However, medical examination was only used to facilitate the diagnosis made by TCM doctors in the outpatient, where, most notably, TCM medical services still predominated. Doctors diagnosed illness and prescribed treatment by following TCM creed and techniques, which was still upheld firmly by TCM hospitals. On the one hand, such practice reflected the apprehension of TCM hospitals about losing the professional legitimacy and the government recognition, particularly, legal and financial support. In addition, it suggested that TCM hospitals were aware of using TCM medical service as its competitive edge to win over patients with strong belief in and preference for TCM. Due to the shortage of fiscal supply, TCM hospitals opted to rely on their pharmaceutical revenue to cover their operational expenses. Compared with the more expensive and profitable WM drugs, TCM drugs bring less income. Despite the disadvantage, the study showed, TCM hospitals tried not only to improve TCM drugs to generate more revenue but also to strengthen the hallmark of TCM on their products. These undertakings were evidenced by their practice to improve Chinese herbal pieces and hospital preparations, a prime example being the production and

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packaging of Chinese herbal pieces in cooperation with good manufacturing practice (GMP) known as new GMP of WM drugs, which not only increased profits but earned more credit from the quality-minded customers. This study also revealed the challenge to the qualification of the TCM staff. SATCM in 2007 introduced the “Guide for evaluating TCM characteristics of TCM hospital,” requiring that certified TCM staff (doctors and pharmacists) must account for more than 60% of total medical staff in TCM hospitals. But the study data showed the current percentage was still below the government requirement, meaning there was a shortage of qualified TCM medical staff. Apart from the rapid expansion in hospital scale, there are several reasons for the shortage. First, TCM universities now train students for TCM doctors through a more WM-oriented system, overemphasizing WM knowledge and skills at the expense of TCM. Second, the current TCM certification tests rests heavily on acquisition of WM knowledge, which is not easy for the applicants who were trained as TCM professionals. Therefore, it was deemed imperative for TCM hospitals to establish their own training and certifying systems to cultivate medical staff who were experts on both TCM and WM through mentorship teaching to cultivate TCM medical staff even if they had got university degrees, as well as improving the maintenance and innovation of TCM medical services. At the same time, it must realize that there are still challenges for TCM hospitals ahead. First, the challenges of TCM product quality are affecting the medical service of TCM hospitals. In the past years, especially the quality challenges of Chinese herbal piece has significantly influenced the medical effects of TCM service, which raised much public concerns and complaints on medical service at TCM hospital. Second, while government provides many supports to TCM hospitals, it is increasing its expectations on TCM hospitals. It is obvious that governments at different levels are requiring more significant improvement from TCM hospitals, which has raised much pressure on TCM hospitals. How to respond to such kind of rising expectation will become a main challenge in the near future. Form this study, management implications for different parties could also be provided. For TCM hospitals, they should refer to WM logic to reinterpret their own TCM logic to establish their competitive advantages. Appropriate combination of two kinds of medical model will bring many innovations for TCM medical service. For general hospitals, they can

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also learn from the innovative practices of TCM hospitals to enrich their medical service. Considering their comparative advantages in medical equipment and facilities, if general WM hospitals would like to introduce the innovative treatment from TCM hospitals, it is obvious that these hospitals will be able to apply these practices to a broader context. Here are several limitations that could be resolved in future studies. First, this study found out the obvious differences between TCM and WM with respect to the inpatient as opposed to outpatient, which necessitates a further study on the interaction between TCM and WM in single therapeutic areas to deepen the understanding of the disparity. Second, this study has not addressed the relationship between financial stability and medical service innovation. As financial factors have become influential determinants for portfolios of TCM and WM medical service, further exploration into the impact of financial factors on TCM medical service innovation at TCM hospitals needs to be conducted. TCM hospitals in China maintained as a unique and popular medical care provider through offering both TCM and WM services and strive to incorporate WM to support and strengthen TCM. In particular, they opted to blend WM with TCM to recreate a new type of TCM medical service. The future survival and development of TCM hospitals are contingent on to what extent they could maintain the traditional characteristics of TCM and whether its medical innovation could be realized concurrently.

Implications for Policy Makers and Public Service Traditional Chinese Medicine on the whole costs less than their Western Medicine counterpart, and therefore, brings insufficient financial resources for TCM hospital. Despite the disadvantage, TCM hospitals tried not only to improve TCM drugs to generate more revenue but also to strengthen the hallmark of TCM on their products. In the inpatient departments of Traditional Chinese Medicine hospitals, Western Medicine rather than TCM was mostly applied to treat patients and brought financial support to the hospital as well. Especially, WM surgery was applied to treat more urgent cases in the inpatient, whereas TCM was mainly used to facilitate the patient’s recovery after his surgery.

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Integrated TCM and WM in Hong Kong Hong Kong, which is known as a typical representative of “one country, two systems,” is also a typical representative of “one region, two medical systems.” The integration of Traditional Chinese Medicine and Western Medicine is the Chinese version of integrative medicine (Geiger et al., 2009). Integration of Traditional Chinese Medicine and Western Medicine in Hong Kong provides a valuable reference for the development of integrative medicine in the world. The development of TCM in Hong Kong and an integrated Traditional Chinese Medicine and Western Medicine model in the University of Hong Kong-Shenzhen (HKU-SZ) Hospital were introduced. In the folk of Hong Kong, as a treasure of Chinese culture, TCM had been deeply rooted in the minds of the people and used in their daily life. For example, one can easily find Chinese medicine pharmacies and clinics in the streets and alleys, which had existed for decades or even hundreds of years in Hong Kong. In addition, almost in every family of Hong Kong, the Chinese Hong Kong people have a habit of stewing soup with Chinese herbal medicine. As a folk medicine, TCM showed a tenacious vitality in the society of Hong Kong. Nevertheless, TCM had not been recognized by the Hong Kong Government as part of the health system. In August 1989, the Hong Kong Government appointed the Working Committee on Chinese Medicine to provide advice on how to promote the proper use and good practice of Chinese Medicine in Hong Kong. Following its suggestions, the Hong Kong Government appointed the Preparatory Committee on Chinese Medicine in April 1995 to make recommendations on the promotion, development, and regulation of Chinese medicine in Hong Kong (He et al., 2015). After 1997, the Basic Law of the Hong Kong Special Administrative Region indicated the direction of the future development of Chinese medicine. Article 138 of the Basic Law writes that “the Government of the Hong Kong Special Administrative Region shall, on its own, formulate policies to develop Western Medicine and Traditional Chinese Medicine and to improve medical and health services. Community organizations and individuals may provide various medical and health services in accordance with law.” Two years later, the Chinese Medicine Bill was passed by Legislative Council in 1999 and the Chinese Medicine Council of Hong Kong was established in the same year. Since then, Hong Kong has possessed a special law and institution for the management of Chinese Medicine.

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After more than 10 years, the development of Chinese medicine in Hong Kong has carried all before one. Eighteen Chinese medicine clinics were set up in each district of Hong Kong. Three local universities, namely the University of Hong Kong, the Chinese University of Hong Kong, and Hong Kong Baptist University, had offered fulltime bachelor degree courses on Chinese medicine. Every year, the Research Grant Council and Hospital Medical Research Fund provide research fund for mechanistic studies of Chinese medicine and clinical studies of TCM interventions. In April 2012, the Chinese Medicine Division of the Department of Health was designated as the World Health Organization Collaborating Center for Traditional Medicine. This was a significant support for Hong Kong’s role as an international center of Chinese medicine. In February 2013, the Chinese Medicine Development Committee was established to give recommendations to the government on the direction and long-term strategy of the future development of Chinese Medicine in Hong Kong, especially on the five areas, including enhancing the professional standards and status of Chinese Medicine practitioners; strengthening research and development of Chinese Medicine; promoting treatment with integrated Traditional Chinese Medicine and Western Medicine; expanding the role of Chinese Medicine practitioners and Chinese Medicine in the public health system; and introducing Chinese Medicine in hospital services (Lao and Ning, 2015).

Integrated Traditional Chinese Medicine and Western Medicine Model in the HKU-SZ Hospital In 2012, based on the agreement between Shenzhen Government of mainland China and the HKU, a conventional hospital, known as the HKU-SZ Hospital, was built by the Shenzhen Government and managed by the HKU. A department of Chinese Medicine was established after the hospital recruited the Chief of Service, Professor Lixing Lao who also serves as the director of the School of Chinese Medicine, HKU in late 2013 (Wang et al., 2017). In January 2014, the Department of Chinese Medicine started its outpatient service. There is uniqueness of the Department of Chinese Medicine in this hospital. Its operation of integrated Traditional Chinese Medicine and Western Medicine is different compared with mainland China and Hong Kong. In mainland China, the

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model of integrated Traditional Chinese Medicine and Western Medicine is the integration of these two medicines into one doctor’s practice; in other words, a patient may receive treatments of TCM and WM given by a single doctor. Contrary to the mainland China, the model of integrated Traditional Chinese Medicine and Western Medicine in the HKU-SZ Hospital is the integration of these two medicines into one patient care, known as patient-centered health care. The patient would receive TCM treatment and WM treatment from the best TCM doctor and WM doctor, respectively. Since the establishment of the Department of Chinese Medicine, it now consists of 15 doctors, including 3 doctors from the School of Chinese Medicine of the HKU and another 12 doctors from the firstclass A-level hospitals in mainland China. The mission and value of the Department of Chinese Medicine of HKU-SZ Hospital is “to contribute to health and well-being” by providing the patient-centered, mind-body wellness-oriented care to every patient through integrated clinical practice with evidence-based, holistic and syndrome differentiation-featured Chinese Medicine, herbs, acupuncture, and other modalities, and there are some characteristics in the daily operation (Ling and Xu, 2013). All medical staffs from the Department of Chinese Medicine are trained in Chinese Medicine and are familiar with WM. They can use the basic investigational laboratory tests to assist them making diagnosis, but they have no rights to prescribe Western medication. The hospital emphasizes the importance of cooperation of medical team. TCM doctors collaborate with WM departments for patient care and professional Chinese and Western medical cares are provided by Chinese Medicine and WM doctors, respectively. All the acupuncture treatment is enforced by clean needle techniques with disposable acupuncture needles, and both raw Chinese herbs and herbal granules are allowed to be prescribed. The number of patients has increased month by month in the Department of Chinese Medicine since its establishment. The care model of integrated Traditional Chinese Medicine and Western Medicine has been widely recognized by the public in Shenzhen City. In the future, the Department of Chinese Medicine will take measures to promote the development of the integration model in the following 6 aspects: Provide inpatient service for patients after stroke and surgery. Set up Tuina special clinics, and provide pediatric Tuina service. Facilitate teaching and training for undergraduate students.

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More projects on experience inheritance from senior Chinese Medicine doctors. Establish interdisciplinary research team and conduct clinical research on integrative medicine. Promote concept of Chinese Medicine in disease prevention for the community.

Future Development of Integrative Medicine in Hong Kong In Hong Kong, a Chinese Medicine department similar to that of HKUSZ Hospital is being formed in Gleneagles Hong Kong Hospital and is expected to start operating with the hospital in 2017. In that time, the model of integrated Traditional Chinese Medicine and Western Medicine in HKU-SZ Hospital will be implemented in Hong Kong and provide integrative medical service for the public. Speaking at the opening ceremony of International Chinese Medicine Summit in Hong Kong on May 8, 2018, Hong Kong chief executive Yuee Lam said: “the Special Administration Region (SAR) government has been actively promoting the development of Traditional Chinese Medicine in Hong Kong. Since the return, we have continuously promoted the development of policies and regulations, talent cultivation, scientific research innovation and TCM services. At the same time, we also promote the time-honored culture and benefits of TCM to the public through encouraging academic communication, health education lecture, health promotion and exhibition activities etc. The government has made promoting the development of TCM in Hong Kong one of our priorities.” (Yuee Lam, Internatinal On line, 2018) Mrs. Lam said that strengthening the development of TCM would not be impossible without innovation and technology. It is obvious that the SAR government is vigorously promoting innovation and technology. The two technology innovation platforms set up in Hong Kong Science and Technology Park, one of which is the medical technology innovation platform, will provide greater impetus for the development of TCM in Hong Kong.

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References Geiger, Juliet; Grandlich, Cheryl; and Wolfe, Deanna (2009), When West meets East: The experience of the society of Trauma nurses. Journal of Trauma Nursing, 16(1): 13–17. He, B; Zhang, G; and Lu AP (2015), Integrative network analysis: Bridging the gap between Western medicine and traditional Chinese medicine. Journal of Integrated Medicine, 13(3): 133–135. Lao, L and Ning, Z (2015), Integrating traditional Chinese medicine into mainstream healthcare system in Hong Kong, China—A model of integrative medicine in the HKU-SZ Hospital. Journal of Integrated Medicine, 13(6): 353–355. Ling, Shuang and Xu, Jin-Wen (2013), Evidence Based Complement and Alternative Medicine. Published online https://doi.org/10.1155/2013/761987, Model Organisms and Traditional Chinese Medicine Syndrome Models. Ostoji´c, NP and Saxer, S (2016), Policies towards implementation of positive changes and the introduction of integrated health care for health systems. Journal of Integrated Medicine, 14(6): 409–411. Ren, Jun; Li, Xun; and Sun, Jin (2015), Is traditional Chinese medicine recommended in Western medicine clinical practice guidelines in China? A systematic analysis. BMJ Open, 5(6). Yuee Lam (2018), Proactively Promoting the Development of Traditinal Chinese Medicine in Hongkong. Internatinal On Line, 2018.8.5. Wang, L; Suo, S; and Li, J (2017), An investigation into traditional Chinese medicine hospitals in China: Development trend and medical service innovation. International Journal of Health Policy Management, 6(1): 19–25.

PART II

Commodification and Marketing

CHAPTER 4

Tibetan Healing Traditions, Scientific Commodification, and Cultural Identity Ivette Vargas-O’Bryan

Prevailing Scholarship: Attending to the Complex Convergences Scholars in anthropology, history, and religious studies have been drawing attention to the issue of commodification in Tibetan medicine in China. Social and cultural anthropologist Martin Saxer (2013) provides probably one of the most exciting groundbreaking works on the major changes in Tibetan medicine in terms of the growth of the pharmaceutical industry in China. The studies of medical anthropologist Vincanne Adams (2007) and Adams et al., (2010) have made major inroads on illustrating the tenuous line between commodification and standardization efforts at Tibetan medical institutions in China and the loss of cultural integrity. Mona Schrempf’s essay (2010) “Between Mantra and Syringe: Healing and Health Seeking Behavior in Contemporary Amdo” as well as her other sustained ritual studies provide other lenses relating to the balancing

I. Vargas-O’Bryan (B) Austin College, Sherman, TX, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_4

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act between Western biomedicine and local cultural beliefs or on the subject of Chinese politics and Tibetan traditions that are often encountered in communities on the verge of change and struggles for survival. It is, however, important to keep in mind the ethnic politics underlying any such commodification efforts in what are considered sensitive minority areas (Hilman 2019; Goosaert and Palmer 2010; Hofer 2009; Cingcade 1998) in order to better understand that commodification in China is a political as well as economic enterprise to keep cultural unity. My own work on the ongoing efforts by both Tibetan medical institutions and local healing religious communities to collaborate as a way of modeling what historically is read in medical texts and for the sake of maintaining a balance with the environment that affects all inhabitants provide examples of the complexity of the situation. This study expands to the realm of cultural heritage politics in terms of local healing and ecological relationships and that of museums (Blumenfield and Silverman 2013; Harris 2012) as factors that contribute to commodification in Tibetan areas.

Introduction As a mélange of cultural, religious, ecological, and medical practices, Tibetan healing traditions cannot be confined under one institutional umbrella since often institutions bifurcate for the sake of standardization and classification. Although the application of science and biomedicine and the commodification of traditional ethnic medicine have directly impacted Tibetan medical institutions in China molding them into fixed representations, the broader notion of Tibetan healing traditions intersect these ossified projections and commodified medical spheres thus sustaining unique cultural-religious and ecological dimensions. For the purposes of this chapter, Tibetan healing traditions will be understood as subsuming formal medical training and clinical practice as well as sustaining a religious-ecological approach to life. The religiousecological approach distinguishes Tibetan cultural identity as distinct from others in China and can be a sphere of fruitful dialogue in terms of healing practices, environmental concerns, and economic development in China. Here, I briefly explore how Tibetan healing traditions negotiate a balance between medical commodification, cultural sustainability, and ecological-dialogical spheres.

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Tibetan Healing Traditions in China: A Brief Introduction In general, Tibetan healing traditions comprise both Tibetan medicine (as practiced by amchis 1 at medical institutions) and local healing practices (done by amchis, lamas,2 mediums, and other practitioners). They appear in written Tibetan medical texts, Buddhist sutras,3 Bon4 texts, or in oral compositions in Tibetan religions. These traditions appear in the Tibetan cultural areas of China, the Himalayas, Nepal, India, Bhutan, and Mongolia with new transformations of these traditions in the West. Healing theories and practices may be derived from Buddhism or Bon, Indian Hindu traditions, Central Asian religions, Chinese traditions, Greco-Islamic traditions, or a combination of any of these, and/or local animistic traditions not under these categories. Healing (Tibetan. gso ba) is understood as a transformation from a negative or debilitating psycho-physiological state, which includes diagnosis from Indian Ayurvedic medical views, religious ideas, and animistic beliefs about the environment, to reach a state of balance or health. Tibetan healing traditions are most often promoted in China as a scientific, medical system with medical doctors, hospitals, and clinics, and Tibetan materia medica (Janes, 2002) and just as a medical system for the Tibetans. Often Tibetan medicine is understood through the lenses of Chinese medicine and biomedicine and is promoted with cultural labels for political and commodification purposes without much investigation into the complex intersections of cultural identity, and religious and ecological views that permeate Tibetan healing traditions. Because of the major efforts by the Chinese state to scientisize Tibetan medicine and political concerns about cultural unification and unrest in certain Tibetan areas, Tibetan healing traditions are often presented under a commodified, idealized institutional lens.

1 Tibetan for physician. 2 Buddhist monk or high level practitioner. 3 Sanskrit for scripture. 4 I am distinguishing Bon from Buddhist texts. For the purposes of this paper, Bon refers to native traditions as well as a separate, organized tradition alongside Buddhism.

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Commodification and the Spectacle of Minority Cultural Identity in China As political economists and anthropologists have often noted, commodification itself is a process by which goods and services are converted into exchangeable forms. It involves privatization, alienation, valuation, and displacement of members of a society. As the anthropologist-geographer David Harvey writes, Capital is a process and not a thing. It is a process of reproduction of social life through commodity production….Its internalised rules of operation are such as to ensure that it is a dynamic and revolutionary mode of social organization, restlessly and ceaselessly transforming the society within which it is embedded. The process masks and fetishizes, achieves growth through creative destruction, creates new wants and needs, exploits the capacity for human labour and desire, transforms spaces, and speeds up the pace of life. (Harvey, 1990, p. 343)

The commodification of minority cultural areas in present-day China reflects much of what has been quoted especially the “reproduction of social life through commodity production” including cultural masking and fetishizing. From the perspective of the state, the maintenance of national unity is often the reasoning for efforts in this direction. Since the early 1990s, the Chinese state began to promote commodification through tourism as a way to facilitate economic development and cultural sustainability among ethnic minorities. National development priorities have affected traditionally insular communities by opening them to tourism and market forces with investment by local and foreign entrepreneurs (Mitchell, 2003, pp. 1–10; Timothy, 2011, pp. 15–45). Often Western scholarship has focused on how these efforts have adversely redefined the value of community traditions, local natural resources, and even minority bodies (Cingcade, 1998; Yeh, 2013). Lijiang is a prime example of a location where Chinese tourists have flocked for several years shopping in kitschy stores and watching Naxi concerts, the latter often held and maintained by the local Naxi elders who remember the songs, play the traditional instruments, and retell the narratives all reconfigured into a staged, timed performance for their changing Chinese tourist audience. In this location is also a museum with a library where local Naxi display Dongba pictographs that narrate Naxi religious

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beliefs and ritual practices touristically advertised as cultural artifacts for public consumption. As in the case of the Naxi, identity formation in ethnic minority communities is most often seen as a constant negotiation between narratives of lived experience from within ethnic minority communities on the one hand, and market forces and cultural stereotypes from outside the communities on the other. Other ethnic groups like the Jingpo in Southwest rural Yunnan Province provide a challenging example of the tension between ethnic local cultural resilience and the pressures of external state-sanctioned commercialization (see https://globalchinaexbt.wordpr ess.com). Although national tourist industries promote themselves as preserving local ethnic minority cultures and economic development, their methods of doing so often emphasize the “Otherness” of ethnic minorities by reifying an ethnic group’s traditions. Much effort is made on both sides (tourist agencies and local people) to create a spectacle for the reception of others, often Chinese tourists and Westerners abroad, that the gradual loss of the memory of local identity goes unnoticed. Because of alienation, redefinition of cultural spaces, and reification of cultural traditions, the efforts by minority groups to preserve and redefine from within often go unnoticed by the tourists themselves, who are provided a tourist roadmap to these cultures without much local agency. Even Western scholarship often report on one side of the picture, the exploitation of minorities, and not the resilience of the particular groups.

Commodification and Commercialization of Tibetan Areas In the case of Tibetan areas of China, we have a rather complex picture of commodification, reification, and spectacle superimposed by political pressures and sometimes with negotiations between the state and local communities. For several years, government policies have promoted rapid economic development of Tibetan areas including commercialization for public consumption and globalization of local products, religion, and medical traditions (Cingcade 1998; Hillman, 2019). The longstanding political concerns about cultural stability in Tibetan areas have provided even more of an impetus for policies that emphasize national unity and secularization. As is typical of commodification and heritage tourism in

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other parts of the world, religious edifices and institutions are prime vehicles of particular national policies and provide the perfect picture for reified symbols, through museumification, of an old past serving the needs of an economically developing and touristic China (Kolas and Thowsen, 2005, pp. 44–91; Timothy, 2011, pp. 127–148; Graburn and Jin, 2017, pp. 1–24). As several scholars have noted, this has led to the direct manufacture and transformation of Tibetan culture by Chinese entrepreneurs, Tibetans themselves, and Westerners with diverse effects (Cingcade, 1998, pp. 1–24; Schell, 2000; Kolas, 2008; Dodin and Rather, 2001). This has also prompted a plethora of Chinese and Western imaginative projections onto the culture, idealizing Tibetan culture and its many traditions (Schell 2000).

Commodification and Scientisation of Tibetan Medicine Commodification in Tibetan areas has not been restricted to just social goods and religious symbols and edifices, Tibetan medicine’s thriving medical tradition has also been included in this process. Commodification has had diverse effects on Tibetan medicine either bolstering, restricting, or compromising its efficacy, authenticity, or traditional knowledge (Adams et al., 2010). As part of state cultural unity policies, Tibetan medicine has not only been subsumed as a Chinese treasurehouse and prime example of ethnomedicine since the time of Mao, but has undergone several years of secularization, standardization, and commodification through the lenses of science and biomedicine much like other areas of China (Janes, 2002; Goossaert and Palmer, 2010). In Tibetan urban areas of China like those in Qinghai Province and Lhasa in the Tibetan Autonomous Region with Tso Ngon University of Tibetan Medicine, Tibetan Medical Hospital of Qinghai in Amdo, and the Mentsikhang (Sman rtsis khang) in Lhasa represent areas of highly centralized training, often using Chinese-style biomedical standards for the use and production of hybridic materia medica in order to promote Tibetan medicine as a Chinese and global commodity. However, institutions like these have also compromised “Tibetan medicine” as authentic or sustainable on many levels. For example, on one side, the requirement to standardize and verify clinical practice based on Chinese-style or Western biomedical standards becomes a means for the popularization of Tibetan medicine in China

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and abroad in the West emphasizing the use of strict standards of practice (Li, 2017). Popularization in terms of local touristism also works on another level. Because Tibetan medicine, like in the case of “precious pills,” is often perceived as having special healing powers by the Chinese and Tibetan public due to the belief that they have been blessed by lamas or even by amchis at a renowned hospital like the one in Lhasa. On the down side, commodification has not always worked in Tibetan medicine’s favor with devastating adverse effects. The pharmaceutical industry is, as Stephen Kloos has noted, “being transformed into a massproduced commodity for domestic and international markets” (Kloos, 2014; Saxer 2013; Liu et al., 2009, Tsering, 2005; Janes, 2002). Production practices at the Tibetan Medicine Pharmaceutical Factory under the Mentsikhang in Lhasa have been accused by the public of overcultivation and homogenization thus leading to a lack of confidence in the efficacy of their products. The demands of local and global commodification have also impacted natural resources in Tibetan highlands and grasslands in order to satisfy demands for medical products with outcomes in terms of ecological and cultural erosion and displacement of local communities (Yeh 2013; Craig and Glover, 2009). Commodification has also produced uneven distribution and miscegenation of Tibetan medical practices in both urban and rural areas. In rural areas of Tsang or Shigatse regions of western and central TAR, the commodification of the official Chinese healthcare system has had adverse effects on Tibetan medical practitioners. Most of these now work as “hybrid practitioners and incorporate Chinese-style biomedicine” into their practice producing unequal access and diverse quality of Tibetan medicine as compared to Chinese style biomedical care in these areas. As Theresia Hofer has noted, the reintroduction of the Cooperative Medical Services (CMS) scheme is responsible, along with several social and political factors, in the sidelining of Tibetan medical practices in rural areas (Hofer, 2009). Commodification of Tibetan medical practices is also evident under the auspices of museum institutions. The establishment of museums of medicine serves as a visible example of this especially in highly touristic and dense Tibetan areas like Xi¯anggélˇıl¯a and Qinghai. The museum in the old (new) town of Xi¯anggélˇıl¯a (formerly called in Tibetan, Gyalthang and Zhongdian in Chinese) in Diqing Autonomous Region, an area prominently marked for Tibetan cultural commodification through tourism, presents one of two examples of the museumification of Tibetan medicine.

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Before the fire in 2014, this 1,300-year-old Tibetan village in China’s southwestern province of Yunnan, a stopover on the ancient southern Silk Road, became a major hub for Chinese tourists, Tibetan expat businessmen, Western scholars, and Chinese religious-seekers and nature enthusiasts. For many Chinese tourists, this area served as an alternative experience, a kind of haven distinct from the urban artificial constructions and overcrowding of Chinese urban society. In 2001, this small Tibetan autonomous county officially changed its name to Xi¯anggélˇıl¯a (Shangrila) after a local Chinese man read the British novel Lost Horizon. This area became a major destination for Chinese tourists to experience what some have thought of as an authentic Tibetan area. As evident in this area, Chinese state-supported enterprises have created tourist hot spots with newly constructed model Tibetan villages designed in traditional Tibetan style for tourists to stop by on their way to spectacular landscape views. In this particular area, tourists also have the choice to get drunk on Tibetan chang (beer) while experiencing audience-engaged Tibetan performances of traditional and patriotic songs and dances. Some Tibetan entrepreneurs in the area walk a fine line between being businessmen and cultural preservers establishing Tibetan restaurants, cultural centers, art schools as well as supporting the performance of rituals. The Museum of Tibetan Medicine in Xi¯anggélˇıl¯a houses Tibetan medical implements and displays photos of amchis and Buddhist images in the main museum. On one of the side corridors, there are several waiting rooms with Tibetan and Sino-Tibetan amchis practicing Tibetan medicine, taking pulse and dispensing Tibetan pills to museum goers/patients. The museum/clinic image is at once a direct statement of the ossified representation of Tibetan medicine and culture facilitated by commodification. The other major example of museumification of Tibetan medicine is the Qinghai Tibetan Medicine Museum in Xining, China which advertises in several tourist sites (see, e.g., https://www.easytourchina.com/ scene-v945-qinghai-tibetan-medicine-culture-museum). This institution in a major Tibetan hub with a medical institution that advertises itself as having over 20,000 cultural relics and diverse displays on Tibetan culture, astronomy, and medicine. It also has a 618 meter-long thangka 5 scroll, the longest in the world, charting Tibetan history.

5 Tibetan cloth painting.

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Both museum cases in two different Tibetan regions display Tibetan healing traditions as predominantly medical traditions with the typical doctors, medical implements, and materia medica. As is evident in the history of museums and particularly dealing with Tibetan culture and science, museums often provide the function of not just serving the public by creating awareness of a culture, but also have control over how the culture and its healing traditions are represented, almost fixing their representations in time and space (Fisher, 2011; Harris, 2012; MacDonald, 1998). Overall, commodification efforts in China reconstruct Tibetan medicine as exotic ethnic medicine and yet unifies the culture as Chinese culture for an accessible Chinese public and for global consumption, placing it into familiar, scientific terms. However, nowhere in these commodification examples is there mention or a display of other aspects of Tibetan healing traditions that are evident throughout Tibetan medical texts like the Rgyud bzhi or practiced in local contexts, many of which are considered major traditional Tibetan conceptions of illness etiology and health or healing treatments. For example, missing from displays or discussions of Tibetan medicine are spirit pathogens and rituals to pacify spirits, of environmental concerns linked with health conditions, of klu/ gdon rituals, and other such descriptions. Although there is a mystical aura to the potency of Tibetan materia medica or a lama’s rituals in the eyes of the public, commodification does not tap into traditional (and less empirical) knowledge in Tibetan healing traditions, which has been central to Tibetan cultural identity for centuries.

Tibetan Healing Traditions: Marking Cultural Identity and Religio-Ecological Dialogue Tibetan healing traditions are not just medical traditions, but represent a distinct cultural identity in relation to the natural environment. These traditions turn attention inward and across ecological dimensions. As my past work has noted, Tibetan healing traditions do not stop at the institutional level, they pervade the ecological and natural environment expanding our sense of illness etiology and healing (Vargas-O’Bryan, 2010). Although Tibetan medicine and Buddhism are heavily advertised as commodities for the tourist market (both Chinese and Western), there is still a major concern among local Tibetan communities to maintain a relationship of respect with their spirit environment because of impacts

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on health. Two case studies first begun in 2010 present Tibetan healing traditions’ own ecological framework. Despite the major efforts in economic development through construction projects and tourism in Xi¯anggélˇıl¯a, the prevalence of local Tibetan healing traditions in the area are clear in the rituals that converge religion and local beliefs regarding the environment. One example among several was encountered in a small village outside of the new town of Xi¯anggélˇıl¯a a few years ago and still persists today. In a visit to one of the homes nearby a small temple, I noticed that the land was surrounded by large, oddly shaped trees and a creek meandering the back of the house. I was told that years ago, the village experienced an unexplained illness that could not be contained by any ordinary biomedical treatment. Although claimed by my host that this was local superstition, he noted that everyone in the community claimed that the local spirits (klu) inhabited the area around this home, especially the trees and the creek, based on dreams recounted by local people. Klu (Sanskrit. n¯ aga) inhabiting the landscape is a familiar belief in Asian Buddhist scriptures, and Tibetan Bon texts and medical traditions. Thought to inhabit the landscape, these spirits are believed to inflict disease when they are not respected, that is, a lack of respect toward their environment, their home being used outside their natural purposes. In this case study, the local lamas in the village in question conducted a ritual and relocated the klu to a more appropriate place where they would not be bothered by human intervention. This would also ameliorate accusations of attracting or housing the klu imposed on the residence’s family by the local community. The owner of the house was obligated to offer rituals for the spirits on a regular basis to keep them appeased as the tradition often holds toward local spirits. After this relocation, the illness stopped and everything returned to normal. My observation of local village rituals like this one, annual fasting rituals (Tibetan. smyung gnas ), and the collection of local oral legends drew my attention to their link with illness and healing. In the many Tibetan Buddhist narratives associated with fasting rituals, healing is seen as a negotiation between a living environment (its spirit inhabitants) and the practitioner in order to restore and maintain order. The opening of Chapter 11 of the Rgyud bzhi, a twelfth-century Tibetan medical text attributed to the Medicine Buddha, states: Then again, Brahmin Rig pa’i Ye shes thus spoke: ‘Kye! Great Brahmin, listen! In the time of the last five hundred degenerate years, when the

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degenerate kalpa arises, human beings are in poverty as their provisions decline. Having plowed arid grassland for farming, sa nyan are turned up. Chu gnyan are disturbed by transforming natural water bodies into artificial garden lakes and ponds. Shing gnyan are deforested and rdo gnyan are uprooted or overturned. Contaminating hearth, burning impure substances, reckless slaughtering of animals in (spirit homes), and disturbing gnyan sa with the hope to subdue enemies by Buddhist and Bon priests who have no time to practice in the proper manner, all result in agitating nagas, gnyan and earth spirits, gods and raksasah. Poisons merely spread through touch, sight, breath and thought. The time comes for the rise of tsi ti dzva la [i.e. leprosy]. It is disgusting to see and fearful to think about. Merely hearing of these [illnesses] causes sadness, vision of one’s own corpse, and separation from loved ones.’6

This chapter in the renowned medical text reflects a preoccupation with balance that may be tipped off due to ecological crises and improper behavior or practice. On a traditional cultural level, these well-known maliferous and yet healing entities called klu (and the larger category gdon) offer a glimpse of Tibetan notions of illness, healing, and religious beliefs in relation to the natural environment. As subject of their own spiritual spatial history, klu and other spirits remind Tibetans of their ecological and moral responsibilities toward the land and its inhabitants. However, in terms of modern economic Tibetan zones in China,

6 The eighty-first chapter of the Instructional Tantra (known as Man ngag gi rgyud) entitled gdugpa klu’i gdon nad gso ba (The Cure for the gdon disease of the malevolent klu) describes spirits as one of the primary causes of disease alongside karma, seasonal changes, habits and behavior, and poisons. It also immediately draws attention to the critical connection between religious teachings and the embodied spirit environment as fundamental medical concerns. Tibetan text:

lanciglngabrgyathama’idustshaddu//bskalpa’ichanyams‘byungba’ibcud shorbas// mirnams zathangbrinasdbulpor‘gyur//sagnyanrlognasspangthazhingdu‘dru// chugnyandkrugsnasde’u gsingrdzingdubskyil//shinggnyangcodcingrdognyanrtsaba‘degs// migtsang‘thabgzhobshandmar‘zolnyogspyud// banbonnuspasgrubpa’ilongmednas// gnyansadkrugspasdgrarnamsthrullare// detsheklugnyansabdag lhasrin‘khrugs// regmthongkharlangsbsampa’idug‘phrospas//tsitidzva la‘barba’ibskalpadar// mthongbasskyugbrobsamspasskyi‘jigsshing//thosnayangarangrorang gismthong// . My translation. G. Yuthog Yontanmgonpo (1993), 392–393

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the lingering question is: “Why are local inhabitants close to a thriving economic area preoccupied with ecological imbalances and health?” In an earlier study, I argued that in rapidly economically developing cultural contexts, modern diagnoses and treatments of klu’i gdon nad (diseases associated with klu’gdon) in medical contexts in both Lhasa, Tibet, and Dharamsala, India are done as a collaboration between Tibetan amchis at medical institutions and Tibetan lamas at temples (VargasO’Bryan, 2010). These examples not only reflect traditional relationships between the medical and religious domains and beliefs, but also forge a balance with modernization and commodification efforts.

Balancing Commodification and Tibetan Healing Traditions With these prevailing traditional beliefs, commodification cannot fully penetrate or replace the natural (including the cultural) with the artificial or constructed. Tibetan communities continue to balance their external commodified spectacle of themselves with their internal religiousecological identities. There is, however, the potential for constructive and balanced negotiations that could take place between commodification agents and local communities to facilitate economic development alongside cultural sustainability among ethnic minorities in China. The “living heritage model” employed by organizations like ICCROM (International Centre for the Study of the Preservation and Restoration of Cultural Property, https://www.iccrom.org/) developed for sacred sites in Southeast Asia takes into account how communities that live in the vicinity of ancient structures form an integral part of the site. This model has the potential to influence policy-makers and communities to have a mutual stake at maintaining the environment for the sake of all concerned. Although Tibetan healing spiritual agents are not visible, the continuing beliefs in their existence and the Tibetan link with the healing “naturalspiritual” environment provide some possibilities for more balanced and authentic cultural sustainability.

Conclusion As Volker Scheid has noted in his work on the history and modern manifestations of traditional Chinese medicine, all medical systems possess theoretical knowledge and a history of progressive transformations. The

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premise of understanding Tibetan healing traditions over more narrowly defined medical traditions is to get a sense of the plethora of cultural views, theories, practices, and practitioners that negotiate with and resist static state-sanctioned classifications. Tibetan healing traditions with pervasive religious beliefs and ecological concerns are not so much about representing a reified original or essential nature of a culture, which is what is constructed when a tradition is commercialized through tourism and museumification as if a culture needs to be ossified in order to be valued and appreciated. Tibetan healing traditions are about restoring and maintaining order between oneself and the environment in all its manifestations.

References Adams, V. (2007). “Integrating Abstraction: Modernizing Medicine at Lhasa’s Mentsikhang.” In Proceedings of the Tenth Seminar of the IATS, 2003. Brill’s Tibetan Studies Library 10(10): 29–45. Adams, V., Schrempf, M., and Craig, S. (eds.). (2010). Medicine Between Science and Religion: Exploration on Tibetan Grounds. Berghahn Books, New York. Blumenfield, T., and Silverman, H. (eds.). (2013). Cultural Heritage Politics in China. Springer-Verlag, New York. Cingcade, M. (1998). “Tourism and the Many Tibets: The Manufacture of Tibetan ‘Tradition’.” Sage Publications Journal 13(1): 1–24. Craig, S., Cuomu, M., Garrett, F., and Schrempf, M. (eds.). (2010). Andiast: International Institute for Tibetan and Buddhist Studies, pp. 379–404. Craig, S., and Glover, D. (2009). “Conservation, Cultivation, and Commodification of Medicinal Plants in the Greater Himalayan-Tibetan Plateau.” Asian Medicine 5: 219–242. Dodin, T., and Rather, H. (2001). Imagining Tibet: Perceptions, Projections and Fantasies. Wisdom Publications, Cambridge. Fisher, G. (2011). “In the Footsteps of the Tourists: Buddhist Revival at Museum/Temple Sites in Beijing.” Social Compass 58(4): 511–524. Foucault, M. (1979). Discipline and Punish: The Birth of the Prison. Vintage Books, New York. Goosaert, V., and Palmer, D. (2010). The Religious Question in Modern China. University of Chicago Press, Chicago. Graburn, N., and Jin, L. (2017). “Tourism and Museums in China.” Asian Journal of Tourism Research 2(1): 1–34. Harris, C. (2012). The Museum on the Roof of the World: Art, Politics and the Representation of Tibet. University of Chicago Press, Chicago.

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Harvey, D. (1990). The Condition of Postmodernity: An Enquiry into the Origins of Cultural Change. Blackwell, Oxford. Hillman, Ben (2019). “Ethnic Tourism and Ethnic Politics in Tibetan China.” In Identities. Harvard Asia Pacific Review, pp. 3–6. Hofer, Theresia (2009). “SocioEconomic Dimensions of Tibetan Medicine in the Tibet Autonomous Region, China Part Two.” Asian Medicine 4(2) (December): 492–514. Janes, C. (2002). “Buddhism, Science, and Market: The Globalisation of Tibetan Medicine.” Anthropology & Medicine 9(3): 267–289. Kloos, Stephen (2014). https://www.stephenkloos.org/research/re-assemblingtibetan-medicine/. Accessed 15 April 2014. Kolas, A. (2008). Tourism and Tibetan Culture in Transition: A Place Called Shangrila. Routledge, Oxford. Kolas, A., and Monika P. T. (2005). On the Margins of Tibet: Cultural Survival on the Sino-Tibetan Frontier. University of Washington Press, Seattle. Li, Y. (2017). “Standardisation Helps Integrate Eastern and Western Medicine.” Telegraph (2 June). https://www.telegraph.co.uk/news/world/china-watch/ culture/growth-of-tibetan-medicine/. Liu, Y., Dao, Z., Yan, C., and Long, C. (2009). “Medicinal Plants Used by Tibetans in Shangri-la, Yunnan, China.” Journal Ethnobotany and Ethnomedicine 5 (May 5): 1–15. MacDonald, S. (1998). The Politics of Display: Museums, Science, Culture. Routledge, New York. Mitchell, S. (2003). Tourism and Development in Yunnan. Yunnan Fine Arts Publishing House, Kunming. Saxer, M. (2013). Manufacturing Tibetan Medicine: The Creation of an Industry and the Moral Economy of Tibetanness. Berghahn Books, New York. Schell, O. (2000). Virtual Tibet: Searching for Shangri-la From the Himalayas to Hollywood. Holt Books, Port Robinson, ON. Schrempf’s, M. essay (2010). “Between Mantra and Syringe: Healing and Health Seeking Behavior in Contemporary Amdo: Healing and Health Seeking Behavior in Contemporary Amdo. In V. Adams, M. Schrempf & S. Craig (eds.), Medicine Between Science and Religion—Explorations on Tibetan Grounds, pp. 157–184. London and New York: Berghahn Publications. Timothy, D. (2011). Cultural Heritage and Tourism: An Introduction. Channel View Publications, Bristol. Tsering, Tashi (2005). “Designing Modernization to Promote Traditional Tibetan Medicine.” Trin-Gyi-Pho-Nya 2 (6 January). Vargas-O’Bryan, Ivette (2010). “Legitimizing Demon Diseases in Tibetan Medicine: The Conjoining of Religion, Medicine and Ecology.” In Studies of Medical Pluralism in Tibetan History and Society. Journal of the International Association of Tibetan Studies.

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Yeh, E. (2013). Taming Tibet: Landscape Transformation and the Gift of Chinese Development. Cornell University Press, Ithaca.

CHAPTER 5

Medical Marketplaces, Commercialism, and Chinese Medicine in the Cholera Pandemic in Southeast Coastal China, 1961–1965 Xiaoping Fang

Introduction In the years between the Great Famine (1959–1961) and the Cultural Revolution (1966–1976), not only did Mao’s China experience starvation, class struggles, and constant political campaigns, it was also swept by one great pandemic—El Tor cholera. This pandemic was very significant because it was the first global pandemic to affect China after 1949. It first broke out in Sulawesi, Indonesia, in 1961 and then quickly spread to the other islands of Indonesia, then to Sarawak and Sabah on the island of Borneo, as well as Malaya, the Philippines, Taiwan, Hong Kong, mainland China, North and South Korea, Burma, Thailand, and Cambodia.

X. Fang (B) School of Humanities, Nanyang Technological University, Singapore, Singapore e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_5

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The pandemic reached Vietnam by 1964 and moved west to reach India and the Middle East by 1966, and then went on to Europe, Africa, and the Americas, becoming the seventh global cholera pandemic in history. It is generally argued that troop movements, internal migration, and the return of the Chinese population in Indonesia were key contributing factors to the outbreak of the El Tor cholera pandemic in China in 1961. The pandemic mainly affected southeastern coastal China, spreading rapidly through the provinces of Guangdong, Fujian, Zhejiang, and Shanghai in July 1962. Following a large-scale but clandestine government campaign, the pandemic was contained in southeast coastal China by 1965. For the duration of the pandemic (1961–1965), Wenzhou Prefecture in Zhejiang Province was the worst-hit area in southeast coastal China, according to available statistical data. Zhejiang was also among the provinces with the highest incidences of the disease out of all those affected by cholera at the time (Didelot et al. 2015). El Tor cholera first broke out in Rui’an County in Wenzhou Prefecture on July 5, 1962—this was the first reported cholera case in Zhejiang Province. By 1962, there were 10,747 reported cases of El Tor cholera and 606 people had died in Wenzhou Prefecture. The cholera cases in Rui’an County, Pingyang County, and Wenzhou City accounted for 97% of the total number within the Zhejiang Province (Wenzhoushi weishengzhi bianweihui 1998). As the first global pandemic to affect China after 1949, the study of the 1961–1965 cholera pandemic is significant in the field of the history of epidemic prevention in China. Current scholarship mainly analyzes epidemic prevention in China during the late nineteenth century and early-twentieth centuries through the perspectives of colonial medicine, nation-building, and geopolitics. For example, Ruth Rogaski examines the development of public health and epidemic prevention in different colonial medical schemes in the treaty-port city Tianjin after the midnineteenth century (2004). Carol Benedict investigates the rise of Chinese state medicine in the plague during the New Policies Reform of the late Qing (1996). William C. Summers explores the geopolitics of the Great Manchurian Plague of 1910–1911 (2012). Research into epidemic prevention in Mao’s China after 1949 mainly focuses on ceremonial and regular epidemic prevention schemes through the perspectives of sociopolitical mobilization. Ceremonial campaigns included the Patriotic Health Campaigns that were initiated during the Korean War in 1952 and targeted the “five pests” (flies, mosquitoes,

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mice and rats, lice, and bedbugs) and environmental hygiene. Each spring, local governments at each level would launch “Big Clean-Up” campaigns nationwide and mobilize people from all walks of life to participate (Rogaski 2004: 293–298). Regular campaigns were ordinary schemes for eradicating endemic parasitic and infectious diseases, such as schistosomiasis (Gross 2016). These campaigns had their periodical targets and work duty requirements and were supported by medical and public health systems and facilities. Emergency campaigns entailed an immediate response to outbreaks of epidemics and pandemics. Once the outbreak of an infectious disease was reported, medical personnel throughout the whole medical network could be mobilized to combat the crisis immediately. These three programs were mandatory and reflected the Chinese Communist Party’s (CCP) skill at political mobilization. During this process, the state sought to demonstrate its power and capacity in these interventionist models. However, compared with the studies of ceremonial and regular epidemic prevention campaigns, there is still no detailed research on epidemic prevention and medical emergency schemes in Mao’s China. Notwithstanding, in the Severe Acute Respiratory Syndrome (SARS) situation of 2002–2003, commentators on China’s handling of the crisis have noted that the SARS campaign was reminiscent of public health movements in Mao’s China. Criticisms were even waged against the Chinese leadership of the time, including the accusation that the government had inadequately adopted “age-old” Maoist mass mobilization tactics and political campaigning to cope with a twenty-first-century challenge (Fang and Bloom 2010; Thornton 2009; Perry 2007; Kaufman 2006; Ding 2003). Scholars also examine how the Chinese government reformed the public health and epidemic prevention systems in the post-SARS incidents within changing sociopolitical contexts (Mason 2016). The review of current scholarship on the history of epidemic prevention since the late nineteenth century provides the background knowledge and framework for understanding the 1961–1965 cholera pandemic as a medical emergency, which broke out and spread through southeast coastal China, in particular sociopolitical and medical contexts. In terms of sociopolitical structures, the years between 1961 and 1968 were very significant for China. The Great Leap Forward campaign gave way to the Great Chinese Famine (1958–1961). Starting in 1961, the Chinese government committed to social restructuring in order to overcome political crisis and reconsolidate the legitimacy of its rule, a process referred

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to as “retrenchment and recovery” by Western scholarship and as the “full adjustment of the national economy and sociopolitical relationships” in Chinese Communist historiography (Townsend and Womack 1986; Zhonggong zhongyang dangshi yanjiushi 2011). As major steps toward this, the government reformed and restrengthened its schemes to control population mobility (the hukou, or household registration, system), create organizational units (the danwei, or work unit, system, and the people’s commune system), undertake social surveillance, conduct political indoctrination, and implement economic strategies and policies. Regarding the medical system, these pandemics occurred 12 years after the founding of the new Communist regime. The nascent and fragile state medical system had recently been adjusted following the Great Leap Forward and subsequent famine, during which the state retreated from investing in the public health sector, particularly in rural areas. Furthermore, China had not yet formed its national epidemic prevention system or its response scheme for medical emergencies and pandemics, including the effective collection, dissemination, and control of disease information. However, once the outbreak of the pandemic was reported, medical personnel throughout the whole medical network could be mobilized to combat the crisis immediately. During this process, the state sought to demonstrate its power and capacity in this interventionist model, which not only overcame rural hardship and resistance but also compensated for problematic government campaign choices. The government’s response to El Tor cholera ultimately played a decisive role in shaping the national epidemic prevention system and a response scheme for pandemic emergencies in China in the following decades. This mobilization and interventionist model became the hallmark of epidemic prevention and medical emergency schemes in Mao’s China and significantly impacted on post-Mao China as mentioned above. The response to the global cholera pandemic also played an important role in the development of the three-tiered medical system in rural China during the 1960s and 1970s. Based on the study of Wenzhou Prefecture, Zhejiang Province, this chapter explores how the local Chinese government regulated the medical marketplace, disciplined medical commercialism, and facilitated the medical institutionalization of Chinese medicine in response to the global cholera pandemic that affected southeast coastal areas of China in 1961–1965. It aims to contribute to the further understanding of emergency epidemic prevention campaigns and the relationships between disease, politics, and medicine in Mao’s China.

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Medical Market, Commercialism, and the Fragmented Medical System Up to the early 1950s, Chinese medical practitioners had been practicing medicine independently, until some of them were mobilized to organize district health clinics and township union clinics with the beginning of the Agricultural Collectivization campaign. As self-supporting and self-managing entities, these clinics were responsible for their own profits and losses. Clinics implemented fees for services, undertook individual accounting, managed the facility democratically, and distributed salaries according to the contributions of each member (Fang 2012). For example, in Rui’an County in Wenzhou Prefecture, six medical practitioners set up the county’s first union clinic in 1951. By 1957, there were 25 union clinics and 31 clinic branches by 1957. Many practitioners still practiced medicine outside these clinics to make a living, while others of them were increasingly absorbed into the union clinics. With the implementation of the people’s commune system as part of the Great Leap Forward campaign of 1958, the original union clinics in the seats of the people’s communes (formerly districts) were renamed People’s Commune Clinics and those in management districts (formerly townships) were referred to as branches. All independent medical practitioners were also incorporated into the People’s Commune Clinics (Rui’anshi weishengzhi bianzhuan weiyuanhui 1999). Commune clinics were subsidized by either the state or the county budget, while a few management district clinics still implemented their own independent accounting schemes. Under this new system, the state played a much more active role in the finances and management of medical practitioners than ever before. As a part of the economic retrenchment and social restructuring of the early 1960s, the Communist government transitioned state-funded district and commune clinics to union clinics, which were collective medical units that were responsible for their own profits and losses. Medical staff were encouraged to work as “full-time independent medical practitioners who complement socialist health work” (Jiankangbao shelun 1960). In the meantime, the state retreated from medicine and health in rural areas in terms of investment and subsidies. Under this new system, union clinics in rural Wenzhou and other counties in Zhejiang Province functioned as doctor collectives and implemented a payment scheme of basic salaries plus bonuses (Fang 2012). In addition to these

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fixed monthly salaries, a cap of 40% of the remaining revenue was set on bonuses while the other 60% was divided between the public accumulation fund, the public welfare fund, and miscellaneous uses (Rui’anxian renwei weishengke, October 20, 1961). This new payment scheme prompted medical practitioners in rural union clinics to become more active as their performance directly affected their salaries and thus their family’s living standards. Compared with the fixed salaries at union clinics, it was more attractive for many medical practitioners to resign from the clinic and return home to practice medicine independently, as a way of increasing their income without having to share it with colleagues and clinics. The number of independent medical practitioners thus increased steadily. As Xianjiang District of Rui’an County pointed out in its work summary, a strong “wind of individual work (dan’ganfeng ) was blowing in the countryside.” Some medical staff remained at the clinic, while three staff had already resigned and returned home, claiming that they were going to participate in agricultural production. In fact, they returned home to combine this with practicing medicine, as doing both activities was more profitable (Rui’anxian Xianjiangqu, December 30, 1962). By promoting economic incentives, this reform had a significant impact on medicine and health care in rural areas, one that was largely focused on medical commercialism. As a report from Gaolou District in Rui’an County described, “the economic viewpoint is widespread. The trend toward financial incentives, basic salaries plus incentives (bonuses) … and the mindset of ‘treat more to earn more’ are becoming increasingly evident” (Rui’anxian Gaolouqu weishengsuo, December 14, 1961). This pursuit of profit by medical practitioners resulted in a fragmented medical system, which seriously affected epidemic prevention work. Many medical staff and practitioners were unwilling to undertake epidemic prevention work, arguing that this was not their duty but rather just created extra work for them (Rui’anxian Chengguan yiyuan, November 9, 1963). Some complained that epidemic prevention work could not be done by human beings as it required them to work day and night with no rewards or benefits. It was fruitless but arduous activity that involved handling urine and excrement. Medical staff looked down on epidemic prevention workers, who they described as “plain rice eaters (chi baifan).” It would be popular to have medical proficiency, which is not broken golden bowl (jinfanwan) (Mayuqu weishengsuo, November 12, 1961). This medical commercialism impacted cholera prevention and treatment in 1962. The Deputy Party Chief of the Wenzhou Prefectural

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Committee, Li Wenhui, pointed out during a telephone conference in September 1962, when the cholera was ravaging the prefecture: “Local medical professionals were unable to collaborate with those from other areas. Some were arrogant. Aojiang Clinic in Pingyang County even rejected the medical professionals dispatched by the central government, who were not attended to appropriately. Though there are many medical staff, they did not cooperate well and this caused significant reductions in work” (Wenzhou zhuanqu fangyi zhihuibu, September 6, 1962). At the national meeting for cholera prevention in November 1962, Li Lanyan, director of the Zhejiang Provincial Health Department, admitted that “there was a serious conflict between epidemic prevention and the medical staff of these collective medical entities” (Zhonghua renmin gongheguo weishengbu, November 11, 1962). The behavior of independent medical practitioners during the pandemic was deemed even worse than that of those working for the government-controlled medical system. As the Rui’an County Epidemic Prevention Headquarters noted in October 1962, “some ignorant and incompetent charlatans (including some independent medical practitioners) did not assist the government with its epidemic prevention work. Instead, they tried to make profits by cheating the masses during the cholera pandemic. They cheated them and even caused the death of cholera patients.” For example, the pharmaceutical peddler Li Guoliang was only allowed to sell plaster within the local community and was forbidden from practicing medicine there. He and a former doctor who had been laid off by a medical collective posed as members of a mobile medical team from Wenzhou Medical College and as doctors sent by the county to provide mobile medical services during the cholera pandemic. Under these guises, they sold expensive medicines to villagers, who eventually found out and reported them, leading to criticism from the government. Despite this, the pair pretended they were a mobile medical team from the district health clinic for the second time and were once again exposed, but still managed to treat a seriously ill patient, who became worse following the treatment they prescribed (Pingyangxian fangyi zhihuibu, August 22, 1962). Even well-meaning independent medical practitioners could not report cholera cases promptly as they were scattered around the countryside and were not affiliated with government-controlled union clinics. The actual work of identifying cholera therefore suffered setbacks due to the fragmentation of the rural medical system.

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“Bourgeois Medical Styles”: Medical Institutionalization and Political Discipline The commercially oriented and fragmented medical system posed serious challenges in light of the medical emergency caused by the outbreak of cholera in July 1962. As the existence of a large number of independent medical practitioners was the key factor impairing cholera epidemic prevention work, the government’s first step was to control this group. In Rui’an County, the Epidemic Prevention Headquarters instructed that “…strict management and training of these illegal medical and pharmaceutical practitioners should be implemented, and legal punishments imposed if necessary. Supporting this phenomenon implies cruelty to other people. We should adopt effective measures immediately and stop similar things from happening” (Rui’anxian fangyi zhihuibu, October 28, 1962). The government initially controlled independent medical practitioners by requiring them to register, restricting their mobility, and reducing their numbers. In July 1962, the Rui’an County government instructed that Chinese and Western medical practitioners, itinerant doctors, dentists, and pharmaceutical peddlers should register with local health clinics, which would investigate their applications and assess their medical proficiency before forwarding their applications to the county health bureau for approval. Medical licenses were then issued to practitioners, who were assigned specific geographical areas in which they could offer their medical services. It was also ordered that itinerant medical practitioners who left their own counties should register with the county health department in their destination county and obtain approval before practicing medicine (Rui’anxian weishengke, July 1962). Independent medical practitioners failing to comply with this rule would have their medical supplies from pharmaceutical companies terminated. These measures meant that the room for independent medical practitioners to offer their services in Chinese society gradually became limited and the secure option was to join collective union clinics at the district and commune levels (Rui’anxian Tangxiaqu weishengsuo, November 7, 1963). Along with these reductions in the numbers of independent medical practitioners, the regulation of independent social medical practitioners contributed to the expansion of rural union clinics. However, the collective ownership of union clinics was still quite problematic. With the initiation of the Socialist Education Campaign in 1963, in view of

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rampant medical commercialism and the impact it was having on cholera epidemic prevention, Zhejiang Provincial Health Department decided to coordinate with relevant departments to crack down on speculative and profiteering behaviors among medical and pharmaceutical staff, stop the outflow of independent medical and pharmaceutical practitioners from union clinics, and fully review fee rates for union clinics and independent medical practitioners (Zhejiangsheng weishengting, January 20, 1965). This medical commercialism was also endowed with political meaning. As the Party Leadership Group at the Ministry of Health pointed out, “medical commercialism was a reflection of reactionary conceptions, bourgeois individualism, and pure professionalism in medical and health work. It was a reflection of serious, criticalclass struggle in the medical and health system” (Weishengbu dangzu, April 18, 1963). Medical practitioners with negative political backgrounds became immediate targets. For example, Dr. Lin Jinxian in Rui’an County was charged with being “born into a landlord family and was unable to change his class background, had very serious bourgeois thoughts, practiced medicine illegally, sold medicine, particularly fake medicine, seriously endangered people’s health, disturbed social stability, and was very stubborn.” He was eventually given a five-year sentence (Ruianxian renmin fayuan, January 17, 1965). At the same time, local Party committees at different levels were instructed to take absolute leadership over health and epidemic prevention work. To achieve this, Party committee branches were established in some clinics. Each district Party committee started assigning Party secretaries to district hospitals and allocating cadres to commune clinics while dismissing directors deemed incapable and irresponsible from their posts. It was required that district and commune governments should contact hospitals in each locale once per month (Wenzhoushi fangyi zhihuibu, February 25, 1965). Political study sessions also began to be held three times a week under the direct leadership of the Party committee branch, focusing on texts such as Chairman Mao’s Collections, In Memory of Norman Bethune, and Serve the People (Rui’anxian Tangxiaqu weishengsuo, July 8, 1964). By January 1965, the Zhejiang Provincial Health Department further enhanced this Socialist Education Campaign in collective and state-owned medical and health units to facilitate “thought revolutionization” (sixiang geminghua) and “work revolutionization” (gongzuo geminghua) among medical personnel. The instructions regarding this stated that “the aim

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is to solve key issues, including political directions, roads, the people to be served, attitudes, and the leadership of collective medical units” (Zhejiangsheng weishengting, January 20, 1965). Political classification was applied to facilitate political indoctrination. In Mayu District in Rui’an County, the district clinic classified 82 medical staff into three categories according to their ideological aptitude. Some 23 staff were put in the first category, for those who could differentiate political directions, loved collective interests, worked actively, and were highly politically conscious. Some 37 staff were assigned to the second category, which was for those who were only interested in their own personal gains and ignored collective interests. They were said to be unable to differentiate between political directions and their political thoughts could not keep up with situational developments. Three staff fell into the third category, which was for staff who were very confused by political directions and wanted to go back home to practice medicine independently (Ruianxian Mayuqu weishengsuo, February 14, 1962). Union clinics provided political education and took disciplinary actions according to each staff member’s political category. These political measures greatly facilitated the government’s firm control over medical practitioners within the medical system. Meanwhile, district and commune union clinics were gradually required to adopt the basic format of dividing expertise and bureaucratic management while implementing regulations regarding daily duties, financial work, training, and staff development. In particular, some union clinics began implementing a 24-hour outpatient system. This process contributed to the work of the outpatient department for intestinal diseases, facilitated the collection of stool samples from suspected cholera patients, and kept both confirmed and suspected cholera patients under close surveillance (Fang 2014).

Chinese Medicine in the Cholera Pandemic By punishing bourgeois medical styles, indoctrinating socialist ideologies, and institutionalizing medical practices, the government not only firmly controlled the space of medical practice for social medical practitioners scattered outside the state medical system, but also strengthened the current fragmented medical system in terms of organization and ideological issues. With the expansion and strengthening of the rural medical system, the most obvious immediate result was that the government

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could mobilize a large number of medical practitioners to participate in epidemic prevention work during the cholera pandemic. This change significantly impacted the relationship between Chinese and Western medicine, which challenged the structure of the rural medical community at the time. According to Wu Lien Teh and other scholars, “huoluan” (cholera) referred to “any acute stomach and intestinal disease that appeared suddenly and chaotically (huoran erluan)” in the history of diseases in traditional China. It has been claimed that cholera had appeared in China before 1821, an argument based on historic references to huoluan (cholera) extending nearly 4,500 years ago, and to so-called melonpulp epidemics (kua jang wen) (MacPherson 2002). However, there was no authentic cholera in the modern sense. By the Tang Dynasty, cholera was believed to be caused by polluted food and water. In the Yuan Dynasty, clinical treatments varied greatly and included fresh and aged Ginseng and cardamom, white atractylodes rhizome, and Chinese cinnamon, depending on the severity of huoluan patients’ symptoms. The main problem was that the Chinese materia medica for these prescriptions were often difficult to obtain and so prescriptions usually became extremely expensive during epidemics (Benedict 1996). From the second half of the nineteenth century onward, the history of pandemics in China became entangled with the contest between Chinese and Western medicine. The remedies each of these approaches used to cure acute infectious diseases including cholera and plague were still fairly similar in the nineteenth century (Summers 1994). During the cholera outbreak of 1862, British naval physicians at Tianjin treated the patients of “dry cholera” with saline purgatives to relubricate the intestine. Other proposed treatments included immersing sufferers in hot water, wrapping their abdomens with flannel soaked in turpentine or iodine, and even brandy and spirits. Chinese medicine doctors also combined hot and cold while treatments considering latent imbalances, such as guasha (rubbing or scraping of the skin) with saltwater or alcohol, or scraping the skin with an earthenware blade dipped in sesame oil (Rogaski 2004). Western medicinal practitioners also admitted there to be a similarity between the two styles of treatment (Echenberg 2007). Because of the availability of pharmaceuticals, Chinese medicine gained popularity among many Chinese. By the 1930s, Chinese medicine physicians in Shanghai classified cholera into dry and wet cholera: the former referred to patients who

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didn’t vomit, while the latter described those that did. Patients were told to drink large amounts of cold saline water, while taking yiyuansan powder for the stomach, using salt and Asiatic wormwood (Aicao) to cauterize the umbilical region. To stop vein convulsion, it was suggested their feet and legs be bound with bandages (Wu 1935). Physicians and pharmacists came up with their own remedies: One local physician proposed the following as a quick, efficient prescription for cholera: smash 8 liang (50 g) of flaccid knotweed herb, slice 4 liang of China papaya, buy 2 jin (500 g) of Fuzhen wine (from the Jiangsu Province), use river water to boil them into a decoction, and then use it to wash the hands, feet, and numbed areas of the body (Xiaoshan weishengju 1989). The actual effect of this home remedy was unclear. A Chinese pharmacist who worked from the late 1940s to the mid-1990s first at his home pharmacy and later at the commune clinic and township hospital reported that he did not know of any local prescriptions for cholera (Shao, March 26, 2012). But, according to Francis Lang Kwang Hsu’s observations on cholera in Yunnan in 1930, local prescriptions were fairly similar to the most up-to-date Western methods of treating cholera (Hsu 1952). This phenomenon changed with the application of saline solution and antibiotics for preventing and curing cholera in the 1930s and 1940s (Dangdai zhongguo de weisheng shiye bianji weiyuanhui 2009). Intravenous saline injections became available in the early 1930s, but ordinary residents were too poor to afford them. When cholera broke out in Xiaoshan County, Zhejiang Province, in 1931, local newspapers suggested that residents receive intravenous injections of normal saline to stop frequent and serious vomiting and diarrhea. However, most families could not afford this, as one bottle of normal saline cost the same as a 50-kilogram sack of rice (Xiaoshan weishengju 1989). During the 1932 cholera pandemic, Guangzhou residents could not afford Western medicine and turned to cheaper Chinese patent medicine and then to charitable halls, which could not meet such huge demands. Some even turned to a mechanic who claimed to have a specific prescription for curing cholera, although it actually led to high mortality rates (Poon 2013). Notwithstanding, the pandemics China experienced in the twentieth century sparked ongoing tensions between Chinese and Western medicine, with the latter usually criticizing the former for being unscientific (Poon 2013). The use of saline solution and antibiotics to prevent and cure cholera after the 1940s put Chinese medicine at a clear disadvantage during the

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cholera pandemic. The treatment for El Tor cholera patients was essentially the same as for traditional cholera, in that it depended mainly on replenishing body fluids and electrolytes and supplementing these efforts with antibiotics (MacPherson 1997). There were three main types of cholera patients. The first were moderately and severely dehydrated patients, who were usually given intravenous injections of between 2,000 and 3,000 ml of saline solution (Guangdongsheng weisheng fangyizhan xuanchuan ziliaoke, July 1978). The second type of patients were treated with antibiotics because the El Tor cholera bacterium was very sensitive to tetracycline, doxycycline, chloromycetin, kanamycin, and neomycin, which could shorten the treatment course but did not replace rehydration (Fujiansheng difangzhi bianzhuan weiyuanhui 1995). A third treatment method was oral hydration with glucose containing electrolytes, which was taken orally by mildly dehydrated patients from the late 1960s onward. Severely dehydrated patients were usually switched to this method from intravenous treatment when their blood pressure had returned to normal and they had stopped vomiting (Guangdongsheng weisheng fangyizhan xuanchuan, July 1978). Of these methods, rehydration and the restoration of the electrolyte balance were the most widely applied therapies in the treatment of cholera during the pandemic in the early 1960s. In the Wenzhou area, the favored treatment method was to supplement patients’ fluids using saline, 5% glucose, and natrium lacticum solution. The dosage and speed were administered according to doctors’ instructions (Wenzhou zhuanqu weisheng fangyizhan, October 1963). Even today, all the doctors I interviewed who had taken part in cholera prevention and treatment work vividly recalled how they provided large doses of saline solution to patients via drips in both arms and both legs. The clinic doctor Wei Shanhai of Xinjiang Commune in Rui’an County recounted how “at that time, we mainly used saline solution drips. A drip in just one arm was not enough for acute patients because they dehydrated too quickly. We had to give them saline solution through both arms and even both legs until they stopped vomiting and having diarrhea. For the most serious cholera patient, I used 38 bottles of saline, which seems incredible today” (Wei, December 28, 2017). In contrast, the response from the Chinese medicine community proved embarrassing. After the outbreak of cholera in 1962, the county called on the medical community to strengthen cooperation between Chinese and Western medicine, conduct medical and pharmaceutical

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research, and encourage the different schools, theories, and understandings of Chinese and Western medicine to discuss their ideas and experiences freely with the aim of steadily improve the proficiency of medical and pharmaceutical staff (Xu 1962). Following this directive, Chinese medicine practitioners proposed prescriptions following the treatment principles of “pattern differentiation and treatment determination” (bianzheng lunzhi). These included qiangxin huiyang fa (method for strengthening the heart and restoring yang ) for cholera patients suffering from four cold limbs and weak pulses, qingre lishi jieshu fa (method for lowering fevers, expelling dampness, and resolving summer heat) for patients with nonstop diarrhea and high fevers, and tiaoli piwei xiaodaofa (method for digesting and expelling by attuning and regulating the stomach and spleen) for patients with abdominal swelling. Chinese medical practitioners also proposed acupunctural points to counteract vomiting, diarrhea, irritation, and insanity, reduce fevers and headaches, enhance appetites, improve breathing and urination, and prevent heart attacks and shock. In practice, however, it was very hard to apply these methods. There were three main difficulties: medicines being hard to swallow, patients vomiting after taking decoctions, and patients refusing to take medicine. Administering acupuncture to acute cholera patients was no easy task, either (Guangdongsheng fangyi zhihuibu, Shantou zhuanqu fangyizhan, October 31, 1962). In view of the unsatisfactory effects of the application of antibiotics in some cases, a combination of Chinese and Western medicine was also tried. However, the government admitted that such combinations of Chinese and Western medicine meant that the sole efficacy of Chinese medicine and pharmaceuticals could not be confirmed. As a consequence, Chinese medicine was rarely used with urgent cholera patients. Instead, practitioners only turned to it when their symptoms were relieved or vomiting had stopped. Prescriptions in these cases included magnolia berry (wuweizi), charredFructus Crataegi (jiao shanzha), large head atractylodes rhizome (baizhu), radix paeoniae alba (baishao), and licorice (gancao) (Yishanqu weishengsuo, October 8, 1962). The role of Chinese medicine during the cholera pandemic significantly impacted the fates of Chinese medical practitioners, who were still the main available medical professionals in rural China during the early 1960s (Fang 2012). With regard to traditional medical practitioners during cholera pandemics, Sheldon Watts argued that after cholera vibrio had been identified and the vital importance of water in cholera

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transmission has been confirmed, the control of cholera was reduced to simply isolating patients and every bit of the fecal matter, vomit, urine, or sweat they expelled. He argued that illiterate locally born health practitioners were able to undertake this easy task under the general supervision of competent medical authorities (Watts 1997). To some extent, this was true during the cholera pandemic. A pyramid-shaped system emerged when the urban medical system was grafted onto the rural medical system in response to the cholera pandemic. Within this temporary system, rural medical practitioners who mainly performed inoculations and nursed cholera patients formed the lowest level of the pyramid, medical secondary school students working as assistants made up the middle levels, and the epidemiological experts who analyzed virus strains and urban medical doctors who treated cholera patients were at the top. Despite their position at the bottom of the pyramid, for many Chinese medicine doctors, cholera epidemic prevention became a major opportunity for studying Western medicine technologies, such as injections, drips, diagnostic techniques, and other treatments in partnership with other healthcare workers. All the same, Chinese medicine practitioners, particularly those from older generations, increasingly faced challenges to their positions and authority in local medical communities. To some extent, these challenges made it easier for them join hospitals and clinics within the state medical system, where they could further improve their medical proficiency and thus guarantee their livelihoods. In this sense, the advent of medical technologies significantly facilitated the institutionalization of the medical system in China, together with the regulation of medical practice and political indoctrination, the latter of which targeted medical commercialism during the Socialist Education Campaign. The immediate result of this process was that the pool of intestinal disease patients quickly expanded at the hospital and clinics where most patients sought treatment, and from which stool samples could be collected and submitted to County Sanitation and Epidemic Prevention Station more promptly. Outpatient departments for intestinal diseases and stool sample examinations enabled cholera cases to be targeted and identified more quickly. This was particularly significant for identifying the first cholera case in a given area (i.e., the index case) as it alerted the government to take immediate action.

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Conclusion The response to the global cholera pandemic that affected southeast coastal areas of China in 1961–1965 played an important role in the development of the medical system in rural China. As this chapter has argued, the top-down state medical system, which was gradually established after 1949, started managing the previously unregulated medical markets as a part of the process of institutionalizing the Chinese medical system, particularly in rural areas. However, the retrenchment of the medical system after the Great Leap Forward not only aggravated the problem of scarcity in the medical marketplace, but also sabotaged participation in epidemic prevention, the identification of suspect patients, and the reporting of epidemic information by rural medical practitioners. Eventually, through control of the medical marketplace, medical institutionalization, and political discipline, the government cracked down on commercialism among rural medical practitioners and facilitated the progress of epidemic prevention. The impact of Western medicine on Chinese medicine also significantly contributed to this process.

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CHAPTER 6

Chinese Medicine in the Cosmetics Market in China: History, Contemporary Development, and Challenges Sijing Pan

Introduction At the beginning of this chapter, the definition and classification of Chinese medicinal cosmetics is given. The production of Chinese medicinal cosmetics is based on Chinese medicine theories. In this chapter, the theories of Chinese medicine and their relation to the cosmetics product development are also analyzed with examples. In ancient times, many Chinese medicine prescriptions for cosmetic use were recorded in Chinese medicine classics. The historical preview of the development of Chinese medicine and cosmetics is included in the third part of this chapter. The development of Chinese medicinal cosmetics in modern times is discussed in the next section. The final section of the chapter discusses the disadvantages and challenges that face cosmetic products under the

S. Pan (B) BNU-HKBU United International College, Zhuhai, China e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_6

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Chinese medicine niche in contemporary China. The industry of Chinese medicinal cosmetics has huge potential not only in China but also in foreign countries. The purpose of this chapter is to assist consumers and cosmetics companies in understanding the concepts and potential of Chinese medicinal cosmetics by reviewing the structures and history as well as contemporary situations of Chinese medicinal cosmetics. However, there are some problems in Chinese medicinal cosmetics that have influenced its development in the domestic market and acceptance from foreign markets. The challenges and insufficiencies of Chinese medicinal cosmetics are proposed for cosmetic companies to improve the way of developing Chinese medicinal cosmetics properly.

The Definition and Classification of Chinese Medicinal Cosmetics Chinese medicine has evolved over thousands of years (Qin 2012). Chinese medicine addresses health problems through herbal medicine, acupuncture, moxibustion, cupping, Gua-sha, etc. Although herbs are plant elements, which are most commonly used in Chinese medicine, herbs are not the only substance used in preparing Chinese medicine. According to many prescriptions which are recorded in Chinese medicine classics, animal, and mineral materials are also utilized, like Wu Gong (scolopendra) and Bai Shi Zhi (kaolinite). In this chapter, the term ‘Chinese medicine’ in Chinese medicinal cosmetics only refers to mixtures of herbs, animals, or mineral materials. Chinese medicinal cosmetics nowadays mostly refer to cosmetics, which are made by functional Chinese medicines and chemicals under the guidance of Chinese medicine theories. The detailed explanation of Chinese medicinal cosmetics is discussed in the following section. Chinese medicine prescriptions noted in the historical literature and books are thousands in number, many of which have been applied in Chinese medicinal cosmetics. The classification of Chinese medicine prescriptions is complicated but Chinese medicinal cosmetics can be classified by ingredients and functions. Chinese medicinal cosmetics can be classified in two types based on its ingredients (Huang and Yan 2001). The first type is the Chinese medicinal cosmetics that are only made by ingredients such as animal, botanical and mineral substances. The kind of Chinese medicine that can be applied in certain cosmetics should be based on Chinese medicine prescriptions from the texts. However, many

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consumers think that the inclusion of the customers’ tactile/aesthetic experience in manufacturing modern Chinese medicinal cosmetics is important. For instance, face cream should be white, smooth, easily smeared on the face, and fresh smelling. Another type of Chinese medicinal cosmetics has these kinds of characteristics, because this type of cosmetics is mixed with chemicals. In other words, the components of this type of Chinese medicinal cosmetics are Chinese medicine and chemicals. Another way to classify Chinese medicinal cosmetics is based on function. Chinese medicinal cosmetics can be divided into two categories: those that are applied on skin and those that are applied on hair. These two categories can be divided into a few sub-categories based on the internal functions of Chinese medicine (see Table 6.1). Chinese medicinal cosmetics mainly have nine functions: skin nourishing, protecting and whitening, hair-blacking, slimming, being used as perfumery compound, preservative/antioxidant, emulsifier, and toner (Huang 2001). For instance, the domestic cosmetic brand INOHERB applies functional Chinese medicines, such as Xing Ren (apricot kernel), Shao Yao (paeonia lactiflora), Dan Shen (radix salvia miltiorrhizae) in their cosmetics. Not only domestic cosmetics brands research and develop Chinese medicinal cosmetics, but also international brands, such as fresh. Fresh is a French cosmetics brand which has applied rose in cosmetics for anti-aging. The production of any of the above Chinese medicinal cosmetics should base on Chinese medicine theories. Table 6.1 Classification of Chinese medicine Functions

Chinese medicine examples

Skin nourishing

Ren Shen (ginseng) Huang Qi (milkvetch root) San Qi (panax notoginseng) Bai Zhi (angelica dahurica) Lu Hui (aloe) Dang Gui (angelica sinensis) Huang Qin (scutellaria baicalensis) Ning Meng (lemon) Hong Hua (flos carthami) He Shou Wu (radix polygoni multiflori) Yin Xing (gingko) Gan Cao (liquorice) Chen Pi (tangerine peel) Ding Xiang You (clove oil) Rou Gui Ye You (cinnamon oil) Huang Qin (scutellaria baicalensis) Bo He (peppermint) Gan Cao (glycyrrhiza) Mai Dong (ophiopogon root) Jiang Huang (curcuma) Hong Hua (flos carthami)

Skin protecting Skin whitening Hair-blacking Slimming Perfumery compound Preservation/Antioxidant Emulsifier Toner

Noted This table is prepared by the author and based on her reading and understanding of the reference from Huang (2001)

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Chinese Medicine Theories of Producing and Using Chinese Medicinal Cosmetics Normally, most of Chinese medicinal cosmetics are cosmetics that include functional Chinese medicine. However, Chinese medicinal cosmetics are not simply cosmetics with natural animal, botanical and mineral ingredients. Cosmetics with natural materials are not equal to Chinese medicinal cosmetics. Only cosmetics products based on theories of Chinese medicine and Chinese medicine prescriptions can be called Chinese medicinal cosmetics. Chinese medicinal cosmetics are a part of Chinese medical cosmetology. Gao and Dang (2000) noted in Chinese Medical Cosmetology, Huang Di Nei Jing (The Yellow Emperor’s Canon of Internal Medicine) provides the theoretical foundation for the development of Chinese Medical Cosmetology. Huang Di Nei Jing is one of the classics of Chinese medicine and stared writing from the Qin dynasty to the Han dynasty. Huang Di Nei Jing has two volumes, Su Wen and Ling Shu. The book records the relationship with the viscera and meridians, pathogenesis, symptoms of diseases, diagnosis methods, therapeutic methods, and theories. Chinese medical cosmetology is developed based on the following Chinese medicine theories. From the perspective of Chinese medicine, body surface problems should treat and prevent from internal and external of human body because human should be treated as an organic whole (Yao 2015). The human body is mainly combined with tissues and viscera. Chinese medicine theories believe that, on the one hand, normal physiological activities of the human body rely on each organ in the human body which does its own duty and plays its own role. On the other hand, the physiological equilibrium of the human body relies on the complementary synergies of organs. From the perspective of Chinese medicine, the body surface, such as face, hair, nails, etc., can be regarded as a whole. As a result, diseases and body surface problems can be diagnosed by observing the five senses of the organs because of the interrelation and interrelation effects between tissues and viscera. In other words, the imbalance of viscera, Qi, and blood causes body surface problems. For example, Practitioners of Chinese medicine can diagnose by observing the color of the tongue (Wu et al. 2006). The color of the tongue reflects the conditions of viscera. For instance, the imbalance of viscera causes body’s hydration metabolism and fluid accumulates in the body. As a result,

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the face becomes oily and has acne because of dampness in the body. Some Chinese medicine has functions of damp-removing and toxicityclearing like Yi Ren (adlay). This kind of Chinese medicinal cosmetics can relieve body surface problems, like acne, which is caused by the imbalance of viscera. Body surface problems can be treated with Chinese medicine, such as Chinese herb soup, acupuncture, and moxibustion. The combination of internal and external treatment has a greater effect than if only one treatment method is used. Volume 4 of Ben Cao Gang Mu includes a chapter on prescriptions for solving hair problems, like loss hair and gray hair. These prescriptions include internal and external use. For example, the internal use of Bai Hao, Qing Hao (herba artemisiae annuae), and Xiang Fu (rhizome cyperi) can help hair to grow and hair to blacken. Additionally, putting a mixture of oil which is extracted from Bai Ren Zi (seman platycladi), Xin Yi (flos magnolia), and Song Ye into water and applying this water on the scalp can stimulate hair growth. According to Huang Di Nei Jing , the theories of Chinese medicine also emphasize regard for human beings and the environment as a whole. Human beings live in the environment and any change to the of environment has a direct influence on the human body. The influence of the environment on the human body is manifested in two aspects: firstly, the environment influences the functional activities of the human body, and secondly, the social environment influences the human body. The influence of the environment on the physiological functions of the human body directly causes body surface problems. In the following section the twofold interconnectivity on the environmental impact on the human body and the impact of the social environment on the human body is discussed in detail: 1. Environmental factors Environmental factors primarily include seasonal, durational, and geographical factors. The seasonal changes influence the physiological functions of the human body. The seasonal changes have an effect on the physiological functions of the human body. For instance, Huang Di Nei Jing (The Yellow Emperor’s Canon of Internal Medicine) records that the condition of Qi and blood is reflected on the body surface easily in spring and summer, such as flabby skin and sweating. On the contrary, skin is compact and there is less sweating in winter and autumn. Hence, Chinese medicinal cosmetic companies should apply Chinese medicines which

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have moistening and moisturizing effects in cosmetics in winter and autumn, such as Ren Shen (ginseng). The variation of day and night has an influence on the human body in a variety of ways. The physiological functions of the human body are affected by the variation of day and night. People have more energy during the day and have less energy during the night. According to this rule, people should work in the daytime and sleep at night. In contrast, if people violate this rule, the Qi and blood are imbalanced and the physiological functions of the human body are disordered. For example, people who always work at night have dark circles under their eyes and their skin is darkened. When producing face cream and eye cream, Yin Xing (gingko) should be applied as these Chinese medicinal cosmetics help to remove dark circles from under the eyes and lighten the skin. Geographical factors are another important determinant that influences the on human body. The difference of geographical conditions affects the physiological functions of the human body. In southeast China, the climate is damp and hot. People who live there have delicate skin. However, in northwest China, the climate is cold and dry. People’s skin is rough. The physiological functions of the human body have adaptive changes and gradually stabilize when people live in a place for a long time. If people change their living conditions suddenly, most of them easily feel maladaptive and fall ill. For example, people who get used to living in southeast China and move to northwest China easily suffer from dry skin. 2. Social Factors The social environment influences the on human body by affecting people’s spirit and psychology. A sudden change of social environment causes anxiety and depression, which can accelerate aging, turn people’s hair white or cause hair loss. This kind of person is suggested to use Chinese medicinal cosmetics which contain Huang Qi (milkvetch root). Huang Qi applied in hair cosmetics can stimulate hair growth and blacken hair. Chinese medicinal cosmetics, like face cream, which contain Huang Qi have anti-aging qualities.

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Another essential theory in Huang Di Nei Jing is the theory of Yin and Yang. The theory of Yin and Yang plays an important role in the development of Chinese medical cosmetology and the production of Chinese medicinal cosmetics. Yin-Yang theory uses the properties of Yin and Yang to summarize incidents and phenomena related to each other in nature, and the independence of Yin and Yang to explain the occurrence, development, and changing rules of incidents. According to the Yin-yang theory, normal physiological activities are the result of harmony and balance between Yin and Yang. This is to say body surface problems are caused by the imbalance of Yin and Yang. Huang Di Nei Jing noted the one of the diagnosis methods of illness and disease is to diagnose the condition of Yin and Yang. Using acne could be an example to explain the effect of Yin and Yang on the human body. The imbalance of Yin and Yang of the spleen and stomach causes the accumulation of dampness in the spleen and stomach. In this way, dampness in the human body causes acne on the skin by clogging pores. The interaction of Chinese medicine theories can also be seen from this example.

Chinese Medicine and Its Relation to the Human Body and Cosmetics: A Historical Preview The theories of Chinese medicinal cosmetics were originally from Chinese medicine classics in ancient times. Chinese medicine has five thousand years of history. It first appears in historical records in ancient society and the fundamental theories of Chinese medicine were already developed during the Warring States Period (Qin 2012). Chinese medicine can be used for preventing and treating illnesses and diseases. The theory of Chinese medicine not only treats human beings as an organic whole but also emphasizes human beings and external surroundings as inseparable (Hao et al. 2006; Cai 2006). Human body surface problems, such as pimples, freckles, oily skin, and dandruff, are the result of interaction of human beings (e.g., internal organs of the body) and external surroundings (e.g., weather). The development and production of Chinese medicinal cosmetics apply the theories of Chinese medicine. As a result, Chinese medicinal cosmetics have a holistic and efficacious effect on the human body (Dong et al. 2009). Chinese medicine is basically composed of botanical, animal, and mineral medicines (Dubreuil 2015). The application of Chinese medicine in cosmetics is not only based on the function of Chinese medicine, but also the prescriptions and theories. The

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next part of this chapter reviews the development of Chinese medicine for cosmetic purposes in ancient times with historical references. Chinese medicinal cosmetics evolved with the development of Chinese medicine. According to historical records, the systematic use of Chinese medicine in cosmetics in China can be traced back more than two thousand years (Zhou 2015). However, archaeologists found oracle bone inscriptions in the Sang dynasty which had expressions of make-up and bathing. Oracle bone inscriptions were types of characters used in the Sang dynasty and were based on human behaviors. One is a characteristic of oracle bone inscriptions, which means wash face. This character looks like a person who is bending down and cleaning his face. In other words, the concept of beauty was founded three thousand years ago. The theories which apply to Chinese medicine to cosmetics are extracted from numerous historical Chinese medicine literatures and books. During the past two thousand years, incomputable amounts of Chinese medicinal literature were written based on ancient’s experiences, but few of them were milestones of the development of Chinese medicine and provide guidance and plenty of theoretical foundation for applying Chinese medicine to cosmetic. One of the earliest Chinese medical prescription classics ‘Wu Shi Er Bing Fang’ (Prescriptions for Fifty-Two diseases) was written during the Warring States Period (475–221 B.C.) and unearthed in 1973 from a Han tomb, which was located at Changsha, Hunan province. The book includes more than 280 remedies and 100 diseases (Zhou 2015) and a few prescriptions for cosmetic purposes. For example, a prescription includes Chinese medicine Bai Zhi (Angelica Dahurica Root), Du Heng (Forbes Wildginger Herb), Jun Gui (Cassia Bark), Gan Jiang (Gried Ginger), and Xin Yi (Flos Magnoliae). The mixture can be applied on the face as a mask and used for skin care (Xu et al. 2014; Zhou and Fang 2014). Later, during the Qin and Han dynasty (221 B.C–A.D. 220), the earliest Chinese medicine classic ‘Shen Nong Ben Cao Jing ’ (Shen Nong’s Herbal Classic) written by a few ancient doctors illustrated 365 kinds of herbs for internal and external use and their functions and curative effects (Zhang et al. 2018). The book began orally and information was collected since 221 B.C and its writing finished during the Eastern Han dynasty (A.D. 25–220). The book is about the origins of the development of pharmacological theory in Chinese medicine. The authors classified 365 kinds of herbs into three classes and more than 100 herbs that have cosmetic effects, such as Bo Zi Ren (Seman Platycladi), Bai Zhi (Angelica

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Dahurica), and Sang Er (Jew’s Ear on mulberry tree) (Zhang et al. 2018). Bo Zi Ren and Bai Zhi can be added in skin care products for anti-aging and moisturizing effects. Sang Er can be used to stimulate hair growth. Thus, beauty and make-up have become commonplace in the society in China since the Qin and Han dynasties. Maritime trade brought foreign materials to in China, which can be applied to cosmetic production. In the Jin dynasty (A.D. 265–420), Zhou Hou Bei Ji Fang (Prescriptions for Emergent Reference) written by Ge Hong included few prescriptions, which can be used for beauty. This book describes not only prescriptions but also how to process herbs and animal materials. Chapter fifty-two records many prescriptions which can be used for moisturizing, skin whitening, skin lightening, and treating face problems (e.g. acnes) (Ge 1982). For example, cut Wu Zei Yu Gu (Cuttlebone), Xi Xin (Asarum), Gua Lou (Fructus Trichosanthis), Gan Jiang (Dried Ginger), and Jiao (several hot spice plants) into small pieces and soak into Ku Jiu (Vinegar) for a while, and cook with Niu Sui (Ox Marrow). When Ku Jiu is evaporated, the medicine has the effect of skin whitening (Ge 1982). Later in the Northern and Southern Dynasties, Tao Hongjing wrote a book named Ben Cao Jing Ji Zhu (Annotation of Materia Medica). This book was written based on ancients’ knowledge and experiences, which records more than seven hundred Chinese medicines. The book provides additional explanations of the efficacy of Chinese medicines and supplements and descriptions of beauty effects with some Chinese medicine (Li 2017). In the Tang dynasty (A.D. 618–907), cosmetics and beauty products were more widespread throughout the class system. A famous pharmacologist Sun Si Miao wrote two prescription books: Bei Ji Qian Jin Yao Fang (Invaluable Prescriptions for Ready Reference) (Sun 1982) and Qian Jin Yi Fang (Supplement to Invaluable Prescriptions for Ready Reference) (Sun 1983). The books record more than five thousand three hundred prescriptions and many of them have cosmetic effects. Bei Ji Qian Jin Yao Fang recorded cosmetic prescriptions before the Tang dynasty and further enriched the description of the prescriptions with illustrations. The Jin and Tang dynasties were a period of great national integration and prosperous foreign relations (Li 2017). As a result, during this period, the production techniques from others countries enriched Chinese knowledge and methods of dealing with medicines. It boosted the development of Chinese medicinal cosmetics. For instance, a famous painting Zan Hua Shi Nv Tu (Ladies with Head-pinned Flowers), which is displayed on the

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Liaoning museum webpage shows the make-up and dress of Tang dynasty women living in imperial palaces. Ben Cao Gang Mu (Compendium of Materia Medica) was the most famous pharmacology book during the Ming dynasty (A.D. 1368–1644) written by Li Shi Zhen. The book supplemented types of Chinese medicine and revised information of Chinese medicine based on ancient medicine classics. For example, Li supplemented Mo Li (jasmine), Pai Xiang Cao, Zang Hong Hua (saffron), etc. which are herbs that have cosmetic effects. In volume four of Ben Cao Gang Mu many prescriptions for beauty problems are recorded. There is a chapter named Mian (face) in volume four. In this chapter there are recorded prescriptions for face problems. For instance, using the mixture of Ji Li (fructus tribuli), Ku Shen (radix sophorae flavescentis), Bai Ji (rhizome bletillae), Ling Ling Xiang, and Mao Xiang for washing the face can whiten skin. Moreover, grinding Gua Lou Ren (semen trichosanthis), Xin Ren (bitter apricot seed), and Zhu Yi (pig’s pancreas) and applying on face has anti-aging effects, removes winkles, and lightens the face. During the Qing dynasty (A.D. 1636–1912), the development of Chinese medicine pharmacology was at its zenith in ancient times. Cosmetic and beauty techniques were mainly used at imperial palaces. Many prescriptions used in the Qing dynasty for producing cosmetics are still in use today (Ren 2005).

The Development of Chinese Medicinal Cosmetics in Contemporary China In the twentieth century, after World War II, the world economy recovered, gradually allowing the development of the petrochemical industry. Synthetic cosmetics that were made from mineral oil as the main ingredient, fragrances, pigments, and other chemical additives were introduced (Zhao and Zhang 2011). In 1905, the first mechanized cosmetic industry was established and all cosmetics were produced by machine gradually (Ren 2005). As a result, the application of Chinese medicine in cosmetics was decreased. In ancient times, Chinese medicinal cosmetics progressed with the development of Chinese medicine. After the Qing dynasty, the development of Chinese medicine started to be combined with new technologies. Furthermore, no Chinese medicine classic like Huang Di Nei Jing and Ben Cao Gang Mu was published after then. As a result, Chinese

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medicinal cosmetics was gradually developed with Chinese medicine cosmetology and the cosmetics industries, since China had more contact with other countries and many technologies were developing fast. At the beginning of the founding of the People’s Republic of China, people had low living standards and regarded cosmetics as a luxury. The cosmetics industry was under-developed, as well as Chinese medicinal cosmetics. In the late 1970s, the annual sales of cosmetics in China were around 200 million RMB, less than 1 RMB per capita. Since the 1980s, with the reforms and the opening up of China, the living standards and spiritual civilization of the Chinese have risen rapidly and they are increasingly prosperous economically, culturally, and technologically. In the early 1980s, schools of hairdressing and beauty began to be established throughout the country and led to the rise of Chinese medicinal cosmetics. Zhong Yi Mei Rong Xue (Chinese Medical Cosmetology) compiled by Zhang and Shen (1989) was published. The concept of Chinese medical cosmetology was put forward for the first time. In the same year, Chen et al. (1989) compiled Zhong Yi Mei Rong Da Quan (A Comprehensive of Chinese Medical Cosmetology) and indicated Chinese medical cosmetology originated from the science of health maintenance of Chinese medicine. In addition, the establishment of the Committee of Chinese Medicine Therapy and Cosmetology contributed to the improvement of the cosmetics market in 1989, as well as the Chinese medicinal cosmetics market (Ren 2005). From 1989 to 1990, the average annual growth rate of sales of cosmetics in China was fifteen percent (Ge 1994). In 1990, the total sales of cosmetics were 4 billion RMB in China, which included the sales of Chinese medicinal cosmetics (Yuan 1995). Although Chinese medicinal cosmetics were not popular from the 1980s to the early twenty-first century, there had been considerable development in the intervening years. Chinese medicinal cosmetics were exported to foreign countries in the early twenty-first century. For instance, the Chinese medicinal cosmetics brand Pulanna successfully has a place in the European, American, and Asian cosmetic markets. Pulanna was one of the earliest Chinese cosmetic brands and began exporting their products to foreign countries. In 1987, Pluanna successfully developed Chinese herbal slimming cream, breast beauty cream, and achieved an import license from the Japanese ministry in 1988, making it the first to enter the Japanese market of Chinese medicinal cosmetics. Since then, Pluanna products have been exported to Korea, Thailand, Singapore, etc. In 2001, this brand entered the French cosmetics market. Some Chinese

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medicines are applied to Pulanna’s cosmetics which were recorded in Chinese medicine classics like Ren Shen (ginseng). Ren Shen when applied to cosmetics has a moisturizing effect, which was recorded in Ben Cao Gang Mu. Gao and Dang (2000) edited the book Zhong Yi Mei Rong Xue (Chinese Medical Cosmetology), which summarized the ideas, theories, and techniques of Chinese medicine cosmetology. The publication of this book signalled that the development of Chinese medical cosmetology had entered a new stage. Additionally, Zhong Yi Mei Rong Mei Ti Shi Yong Ji Shu (Practical Technology of Chinese medical Cosmetology) edited by Ren (2006) concluded that Chinese cosmetic technology has had positive effects on the improvement and popularization of Chinese medicinal cosmetics. Driven by the technology of Chinese medical cosmetology, the Chinese medicinal cosmetics industry has been growing prosperously. Even though the Chinese cosmetics industry has continually developed, the brands that have applied Chinese medicine to cosmetics remain few. Chinese medicinal cosmetics were not popular in the early twenty-first century, because the Chinese cosmetics market was under the threat of foreign cosmetics.

The Current Situation of Chinese Medicinal Cosmetics Market Since the beginning of the twenty-first century, the cosmetics industry has boosted rapidly in China, especially foreign brands (Pei and Li 2008; You 2007). As reported by PRNewswire (2015), China has become the second-largest cosmetics consumer market in the world. With the growth of the cosmetics market in China, the high-end trend has appeared among Chinese consumers. Most of them prefer international brand and highend products, and China’s import of cosmetics has grown consistently (You 2007; Hong Kong Trade Development Council [HKTDC] 2019). Since China joined the World Trade Organization (WTO) in 2001, the commitment between China and the WTO offered opportunities for foreign cosmetic companies entering China’s cosmetic market (Nguyen 2012). Market competition between foreign brands and domestic brands has been intensive. Domestic brands have been at a disadvantage since then. HKTDC (2014) reported that in China, nine out of the top ten cosmetic brands were foreign brands.

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Under the threat of foreign cosmetics companies, domestics cosmetic companies have tried to rebuild their brand image in recent years by producing natural plant-based products and modern Chinese herbal products (HKTDC 2019). In recent years, consumer habits have been changing from being price-focused to being driven by the quality (You 2007; Fleaca 2016; HKTDC 2019). Based on this trend, domestic companies effectively apply concepts of Chinese medicine and culture, and extract natural ingredients in their development of cosmetics development; and domestic brands have gradually succeeded in sharing a large part of the cosmetics market with foreign brands (Chen and Zhang 2007; Pei and Li 2008; Research in China [RIC] 2012; HKTDC 2019). For example, INOHERB is a famous Chinese medicinal cosmetics brand and their cosmetics have been applied to functional Chinese medicine with references to Chinese medicine classics, such as Ben Cao Gang Mu and Shen Nong Ben Cao Jin. One of its essence products is popular because it includes a Chinese medicine Hong Jing Tian (root of Kirilow rhodiola) and it has the function of anti-aging, which has the similar function with a foreign brand Estee Lauder. INOHERB shares a part of the cosmetics market in China with foreign brands (e.g., Estee Lauder) because of its natural materials, functional Chinese medicines, and affordable prices. In 2020, Chinese cosmetics brands have a market share of about 56 percent, of which Chinese medicinal cosmetics sales account for twenty percent of the mainland cosmetics market (HKTDC 2020). Apart from domestic cosmetics, some foreign cosmetics have applied Chinese medicine to achieve specific effects. For instance, the Japanese brand ALBION has a skin conditioner especially famous among Chinese consumers. This skin conditioner has applied Yi Ren (adlay) extract for skin whitening, but it is not clear that the application of functional Chinese medicine is based on Chinese medicine theories.

The Challenges and Insufficiencies of Applying Chinese Medicine in Cosmetics According to a report from Hong Kong Trade Development Council (HKDTC) in 2020, the Chinese medicinal cosmetics market still has potential for developing. However, the Chinese medicinal cosmetics industry is facing many challenges. In China, there is no official definition for the term Chinese medicinal cosmetics. In addition, according to the Regulations on Cosmetics Hygiene Supervision, no medical jargon or

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claims of medical efficacy should be used in Chinese medicinal cosmetics’ packaging, instructions, and advertisements. This is to avoid consumers confusing the concept of cosmetics and medicine. The production of Chinese medicinal cosmetics should be careful on no matter its packages or instructions. As a result, many companies of Chinese medicinal cosmetics use the terms of nature and herbal in their advertisements and packages. To some extent, the regulation restricts the application of Chinese medicine in cosmetics. Under the premise of ensuring consumers’ safety and sufficient efficacy tests, it is suggested that domestic cosmetic brands should be encouraged and guided to promote the culture of Chinese medicine by developing Chinese medicinal cosmetics. Additionally, Chinese medicinal cosmetics lack recognition not only among consumers but also cosmetics companies of Chinese medicinal cosmetics. The concept of Chinese medicinal cosmetics is always confused with natural and organic plant-based cosmetics, and cosmeceuticals. These two kinds of concepts are similar, but the differences lie in the use of materials. The materials in natural cosmetics are grown in soil that has not been contaminated by pesticides and fertilizer. No synthetic chemicals, fertilizers, or genetic modification are used during the planting process. In addition to the plant ingredients, organic plant-cosmetics must be made up of organic plant extracts certified as organic. Artificial flavors, colors, and petrochemical ingredients cannot be added to the products, which are harmful to the skin. Chinese medicinal cosmetics can be classified as cosmeceuticals. Cosmeceuticals, also known as medical skin care products, refer to the solution of skin beauty problems from the medical point of view. However, cosmeceuticals are different from Chinese medicinal cosmetics, because Chinese medicinal cosmetics are produced with the guidance of Chinese medicinal theories. The confusion and misunderstanding of Chinese medicinal cosmetics concepts by cosmetics companies causes problems during the process of producing Chinese medicinal cosmetics. For example, cosmetics companies apply herbs to in cosmetics but without following the theories of Chinese medicine. In 2018, Xinhua Net reported an equivocal news item about how a consumer found tranexamic acid to be one of the ingredients in Yunnan Baiyao toothpaste. Tranexamic acid is a kind of Western medicine used to stanch bleeding. However, Yunnan Baiyao Company’s advertising of the Yunnan Baiyao prescription of Chinese medicine in toothpaste has the function to stanch blood. It is doubtful that if the prescription of

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Chinese medicine is based on Chinese medicine theories and it actually has the function of stanching blood. Although consumers confuse the concept of Chinese medicinal cosmetics, natural cosmetics, organic plant-based cosmetics and cosmeceuticals, cosmetics companies have to distinguish the differences. Chinese medicine theories are essential for the application of Chinese medicine in cosmetics. The companies of Chinese medicinal cosmetics should strictly follow the theories of Chinese medicine theories. In Chinese medicine theories, the combination of internal and external use of Chinese medicine has an obvious effect on treating skin beauty problems. However, most of Chinese medicinal cosmetics are for external use on the skin, which reduces the effect of Chinese medicinal cosmetics. Another challenge of applying Chinese medicine in cosmetics is that contemporary research on the mechanism of the effects of Chinese medicine is backward. Each Chinese medicine contains dozens or even hundreds of compounds and the compounds of Chinese medicine prescriptions are more complex. To understand the mechanism of their effect is an efficient way for Chinese medicinal cosmetics to reach an international market, but it is a huge project. Although cosmetics made from Chinese medicines are more natural than those made from synthetic chemicals, it does not mean the safety of Chinese medicinal cosmetics can be ignored. Two environmental factors affect the safety of Chinese medicinal cosmetics. Firstly, not all Chinese medicine is harmless. On the one hand, some Chinese herbs are easily polluted under the influence of the natural environment. On the other hand, during the process of preparation and preservation process, Chinese medicinal cosmetics are easily polluted. For instance, the range of a safe dose of some Chinese medicine components is narrow. The excessive use of Chinese medicine in cosmetics can easily make cosmetics toxic. Secondly, the scale of Chinese medicinal cosmetic enterprises in China is small and there are plenty of small-sized Chinese medicinal cosmetics enterprises in China. Statistical data from HKTDC (2020) reveal that there are five thousand two hundred and seventy-three cosmetic enterprises in China. Domestic brands mostly concentrate on the mid- to low-end market. These small-sized enterprises lack adequate management and have low production capabilities (Hu et al. 2005). As a result, the situation of small-sized Chinese medicinal cosmetics enterprises does not only reduce the production efficiency but also has a great impact

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on the stability of the products. To solve these problems of smallsized cosmetic enterprises, the related government departments should formulate standards for operation and supervise the management.

Conclusion Chinese medicine has a history of more than five thousand years. Chinese medicinal cosmetics can be traced back to the Sang dynasty. The theories of Chinese medicinal cosmetics evolved gradually with the development of Chinese medicine in ancient times. The theories and prescriptions were recorded in Chinese medical classics, which are the fundamentals of Chinese medicinal cosmetics. While consumers focus more on the natural ingredients of cosmetics, Chinese medicinal cosmetics are popular among Chinese consumers. Before the 1980s, Chinese medicinal cosmetics were only developed in China, but since the 1980s Chinese medicinal cosmetics, like Pulanna, have started to develop in foreign countries. Chinese medicinal cosmetics have gained acceptance and are popular in foreign countries. However, to enter the international cosmetics market, Chinese medicinal cosmetic enterprises still need to improve their strategies. Even though many types of Chinese medicinal cosmetics appear on the market, not all of them are developed based on Chinese medicine theories. The theoretical and regulation systems of the Chinese medicinal cosmetics market need to be improved. Chinese medicinal cosmetics have huge potential to enter foreign cosmetics markets. Chinese medicinal cosmetics enterprises can take advantage of Chinese medicinal resources in China to maintain sustainable development. Chinese medicine is one of China’s specialties, much of which can only be grown in China. On the one hand, cosmetics enterprises can try to apply Chinese medicines that have unique functions and can only be grown in China in cosmetics. This kind of Chinese medicinal cosmetics can take advantage of those unique Chinese medicines entering the high-end international market. On the other hand, cosmetics enterprises can apply easily-available and inexpensive Chinese medicine with significant effect to develop popular Chinese medicinal cosmetics, and occupy the cosmetics market on a large scale. Meanwhile, the development of Chinese medicinal cosmetics should be based on the premise of Chinese medicine resources protection and the rational utilization of resources.

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Hu Y.T., Wang X.J., & Chen X.Y. (2005). Cosmetics of Traditional Chinese Herbs: Antiquity and Rising Industry of Traditional Chinese Herbs Industry. Liaoning Journal of Traditional Chinese Medicine, 32(2), 162–165. Li R. (2017). The Formulation and Characteristics of External Use Cosmetic Prescriptions for Moisturizing and Moisturizing face in Ancient Chinese Medicine Books (Doctoral dissertation). Nguyen A.N. (2012). Consumer Behavior Toward Foreign Versus Domestic Branded Cosmetics: A Case Study in Shenzhen, China (Doctoral dissertation, University of Phoenix). Pei H., & Li X.Y. (2008). Development Status and Trend of Global Cosmetic Market (cont.). Detergent & Cosmeti (9), 1–5. PRNewswire (2015, March 2) China Cosmetics Market Report, 2014–2017 . Retrieved January 14, 2020, from https://www.prnewswire.com/news-rel eases/china-cosmetics-market-report-2014-2017-300043914.html. Qin F. (2012). A Review of the Historical Evolution and Development of Traditional Chinese Medicine. Chinese Journal of Ethnomedicine and Ethnopharmacy, 21(8), 12–20. Ren X. (2005). The Origin of Cosmetology in Traditional Chinese Medicine. Asia-Pacific Traditional Medicine (1), 87–91. Ren X. (2006). Practical Technology of Chinese Medical Cosmetology. Military Science Publishing House. Research in China (2012). China Cosmetics Market Report, 2010–2011. Retrieved August 28, 2020, from https://www.researchinchina.com/Htmls/Report/ 2012/6304.html. Sun S.M. (Tang Dynasty) (1982). Invaluable Prescriptions for Ready Reference. People’s Medical Publishing House (PMPH) Sun S.M. (Tang Dynasty) (1983). Supplement to Invaluable Prescriptions for Ready Reference. People’s Medical Publishing House (PMPH). Wang K., & Wu J. (2018, October 24). Yunnan Baiyao Toothpaste Was Exposed to Add Tranexamic Acid: Experts Say “Not Banned Does Not Mean It Can Be Used.” Xinhua Net. Retrieved September 4, 2020, from https://www. xinhuanet.com/2018-10/24/c_1123603300.htm. Wu J., Zhang Y., & Bai J. (2006). Tongue Area Extraction in Tongue Diagnosis of Traditional Chinese Medicine. In 2005 IEEE Engineering in Medicine and Biology 27th Annual Conference (pp. 4955–4957). IEEE. Xu Y.Z., Tang L.L., Zhu M., & Zhang L. (2014). Research on Cosmetology of Chinese Medicine in Prescriptions for Fifty-Two Diseases. Clinical Journal of Traditional Chinese Medicine (7), 735–737 Yao C.P. (2015) Huang Di Nei. Beijing: Zhonghua Book Company. You Q.C. (2007). Status and Development Trend of Chinese Cosmetic Industry. Detergent &Cosmetic, 30(1), 1–3. Yuan M.Z. (1995). Chinese Cosmetics Market. Detergent & Cosmetic (4).

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Zhang D.Z., & Shen Y.S. (1989). Chinese Medicine Cosmetology. Guangdong Higher Education Press. Zhang R.X, Zhang W., & Liu G.S. (2018). Translation and Interpretation of Shen Nong’s Herbal Classic. Shanghai Scientific & Technical Publishers. Zhao K.S., & Zhang X.M. (2011). Cosmetic Chemistry. Taiwan Wu-Nan Culture Enterprise. Zhou D.S. (2015). Discuss the Thought of Prevention on Chronic Disease in Prescriptions for Fifty-Two Diseases. Journal of Hunan University of Chinese Medicine, 35(8), 1–4. doi:https://doi.org/10.3969/j.issn.1674-070X.2015. 08.001. Zhou Z.L., & Fang Y.L. (2014). Proofreading to Bamboo and Silk Literature. Beijing: Xue Yuan Press.

PART III

Transnational Transition

CHAPTER 7

Chinese Medicine in Malaysia After Decolonization: Segregation and Unequal Access Md. Nazrul Islam

Introduction and Methodology Popularly portrayed as “Truly Asia” by the Malaysian tourism board, Malaysia is one of the few countries where the Chinese are the second largest ethnic minority and they account for about 20.8% of the total population.1 Chinese medicine was introduced to the Malay Peninsula through the establishment of diplomatic relationships with China during

Md. N. Islam (B) BNU-HKBU United International College, Zhuhai, China e-mail: [email protected] 1 According to CIA World Fact Book 61.7% of the Malaysian population are Bumiputera or ethnic Malays and indigenous people, and the rest (6.2%) are ethnic Indians—the third largest ethnic minority. A vast majority of the ethnic Malay considers Islam as their religious belief and they make up about 61.3% of the total population, followed by Buddhists (19.8%), the majority of them being ethnic Chinese. The bulk of the ethnic Indians believe in Hinduism and account for 6.3% of the total population (CIA 2018).

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_7

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the medieval period. Historic records of China’s Ming Dynasty suggest that during Admiral Zheng He’s (1371–1433 A.D.) sea voyages, he was accompanied by a Chinese physician named Yu Kuang (Tan 2018). Later history revealed that many plants, animals, minerals, and sea components were brought to China from the Malay Peninsula between 1405 and 1432 A.D., such as rhinoceros horn, ivory, clove, agarwood, nutmeg, and sandalwood, which are commonly used in Chinese medicine but native to Malaysia (Zhang 2011). With the rise of European colonial rule, the Chinese population began to soar during the nineteen century in the Malay Peninsula and it is estimated that from 1800 to 1940 about seventeen million Chinese people entered the Malay Peninsula (Chen 1981). It was in 1878 when practitioners of Chinese medicine were first acknowledged by the government in British Malaya. Subsequently, the first voluntary T&CM clinic was opened in Selangor state (Pei Shan Tang) and Kuala Lumpur (now known as TUNG-Tshin Hospital) at the beginning of the twentieth century (Bao and Hu 2012). In 1955, the Federation of Chinese Physicians and Medicine Dealers Associations of Malaysia established the first college of Chinese medicine to train practitioners in Chinese medicine (Gao and Zhang 2011). A few more colleges and schools were established from the middle to the end of the twentieth century and the education and training were conducted using the apprenticeship (teachers and disciples) model. A majority of these schools operated only in the evening and were known as night schools. It was the beginning of the twenty-first century when education in Chinese medicine started to be formalized in Malaysia through the foundation of schools of Chinese medicine under the mainstream private university system. Almost all of these institutes adopted an educational curriculum for Chinese medicine that is similar to Western medicine. In 2001, the Malaysian government launched the National Policy on Traditional and Complementary Medicine and subsequently set up a Division of Traditional and Complementary Medicine under the Ministry of Health. The Malaysian authorities finally approved the local tertiary institutions to offer Bachelor courses on Traditional and Complementary Medicine (T&CM) practice areas2 in 2009 (MoHM 2015: 17). 2 Ministry of Health Malaysia recognized and approved six practice areas under the Traditional and Complementary Medicine (T&CM) framework and these include: Traditional Chinese Medicine, Traditional Indian Medicine, Traditional Malay Medicine, Islamic Medical Practices, Complementary Therapies, and Homeopathy.

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The Malaysian parliament also passed the T&CM Act in 2016 as the regulatory framework for Traditional and Complementary Medicine services (PoM 2017). This paper is based on primary and secondary data collected through ethnographic field work from February 2018 to July 2019. The major techniques employed for primary data gathering were surveys, interviews with semi-structure questionnaires, and web content analysis of different institutes. Secondary data includes government policy papers, and related statistics from various governmental and non-governmental organizations. Fieldwork was conducted in various locations and establishments on Penang Island, and in Kuala Lumpur city and Selangor state. A total of fourteen practitioners of Chinese medicine and sixteen patients were interviewed. The first part of the chapter scrutinizes the available literature on Chinese medicine in Malaysia and synthesizes key features of education facilities as well as healthcare services. The next part emphasizes the transition within the practice of Chinese medicine and current facilities and cares. Socioeconomic factors, the influence of Western medicine, ethnic and sex preference, and priority among healing choices have been examined. The final part explores the ethnic and sex segregation under the service utilization in Chinese medicine.

Segregation and Inequality Defining segregation has become an increasingly challenging task in sociological literature, which entails various interpretations and twists to the terminology. The measuring scale and tools of segregation are also diverse, such as micro and macro, horizontal and vertical, and so on (White and Borrell 2011). Segregation is influenced by geographical, racial, ethnic, sexual, and socioeconomic factors, which all cause health inequalities. Segregation with regards to access to healthcare services has been widely scrutinized by social scientists and public health experts in Malaysia. Much literature has focused on inequality in accessing health services due to ethnic, religion, and socioeconomic factors. However, the Malaysian health system, both public and private, is dominated by Western medical care and existing academic literature focuses primarily on segregation within the framework of Western clinical care. Disparity in accessing and utilizing healthcare facilities and services in traditional and complementary medicine practice areas, i.e., Chinese medicine, ayurveda, etc. is under examined.

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Segregation and inequality in Malaysia under Western clinical care is multidimensional and related to healthcare needs and priorities, access to health care, healthcare utilization, and health financing/modes of payment. All these areas have direct or indirect relations to the ethnic composition of the country, sex differences, age, socioeconomic conditions etc. Studies show that socially disadvantaged groups such as the elderly, women, ethnic minorities, lower family income groups, and private sector workers have less access to public clinics than their counterparts (Makmor et al. 2018). Socioeconomic inequalities affect the mortality rate among the Malaysian population and a higher mortality rate exists among disadvantaged socioeconomic groups or the poor compared to privileged groups or the rich (Mariapun et al. 2016). The utilization of health care within a particular disadvantaged group such as the elderly is also influenced by education, income, and job status (Zulkefli and Zaidi 2013). As stated before, the Malaysian healthcare system is dominated by Western clinical care and all these outcomes are related to Western medicine. Does Chinese medicine make any difference after mainstreaming and integration within the national healthcare system? The following section scrutinizes the segregation and inequality of access to Chinese medicine care in Malaysia. Chinese medicine in Malaysian health care has a colonial heritage and its presence can be traced back to the nineteenth century. Segregation and inequality of access to health care under the colonial system was a common phenomenon and British Malaya was not an exception. Ling Ooi Goik in his study on British Colonial Health Care Development and the Persistence of Ethnic Medicine in Peninsular Malaysia and Singapore noted that Chinese medicine existed during colonial rule despite the introduction, development, and penetration of Western medicine by the state administration. There was a hierarchy to access health services within the Chinese medicine care during the colonial time. Although the British colonial administration was sceptical, it tolerated the practice of Chinese medicine for economic reasons. Chinese medicine contributed to the health care for the ethnic Chinese community without causing a direct financial burden on the colonial government (Ling 1991). He also argued that despite the introduction of various measures to restrict the practice of Chinese medicine during the later colonial period, Chinese medicine practitioners became organized, resisted the imposition, and coped with the growing competition posed by Western medicine. Ling concluded that because of the presence of uneven and unequal access to healthcare

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facilities, the majority of the ethnic Chinese population in British Malaya had little choice but continue to rely on Chinese medicine (ibid.). Tan Wen Tien et al. in their recent publication on Traditional Chinese Medicine in Malaysia: A Brief Historic Overview of the Interactions between China and Malay Peninsula (2018) also noted hierarchy in the practice of Chinese medicine in Malaysia during the colonial to early decolonization period. They noted that in order to cope with the hot and humid climate in Malaysia wealthy Chinese merchants would import Chinese medicine such as chrysanthemum flowers, honeysuckle flowers, coax, and lotus leaves from China and adopt these ingredients in their diets so as to clear internal heat and damp. On the other hand, the poor Chinese labourers had to rely on charity clinics set up by rich merchants and received consultation from Chinese medicine practitioners hired from China (Tan et al. 2018). Dunn F.L. in his study on Medical Care in the Chinese Communities of Peninsular Malaysia (1974) highlighted social hierarchy among the Chinese medicine practitioners in Malaysia caused by the modernization of Chinese medicine after decolonization. He argued that a number of Chinese sin she 3 practiced in Western style offices and used acupuncture therapies in a modernized and innovative fashion, often with electrical stimulating equipment and complex manipulations of needles, voltage, frequency, and stimulation time. He further stressed that about half of the total Chinese medicine practitioners in Peninsular Malaysia received formal training from Chinese medicine schools in China, Malaysia, or Singapore and became members of the various Chinese Physicians’ Associations. The remaining half of the practitioners learned Chinese medicine under an apprenticeship system and had no formal training and were not members of the Chinese Physicians Association. There was a clear hierarchy among these two groups with the latter being regarded with suspicion by the former (Dunn 1974). Paul C. Y. Chen in his study on Traditional and Modern Medicine in Malaysia also found the existence of various forms of Chinese medicine practice and social hierarchy among the practitioners in Malaysia. He noted that Chinese medicine in Malaysia, mainly in the form of herbs, was dispensed by a variety of people ranging from street medical tea vendors, herbalists of “Chinese medical halls,” to professionally trained

3 Title of the Chinese Medicine Practitioner.

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practitioners who had studied four-year courses at modern institutions (Chen 1981). He further stressed that some physicians in Malaysia who were trained in Western medicine also adopted and used modalities from Chinese medicine such as acupuncture (ibid.). These diverse practitioner groups of Chinese medicine have different socioeconomic conditions and status in Malaysian society. Thus, the segregation and unequal access to Chinese medicine in Malaysia is not a new phenomenon but a process of continuation from the colonial to postcolonial era. However, all the above studies analyzed segregation and inequality in accessing Chinese medicine from socioeconomic perspectives; the colonial policy and attitude, class hierarchy, impact of modernization and so on. This chapter emphasizes the determinants of segregation and inequality to access Chinese medicine such as social class, gender and sex, and ethnicity. This paper argues that access to the practice of Chinese medicine and receiving care in contemporary Malaysia is accessible to the middle class, gendered, and fabricated by ethnicity. The following section analyzes the way through which the practice of Chinese medicine in Malaysia became a middle-class private phenomenon and dominated by ethnic Chinese women in practicing and receiving care.

Chinese Medicine as a Middle-Class Private Phenomenon in Malaysia Defining the middle class in Malaysia falls into various subjective interpretations and judgments. The Malaysian government’s Department of Statistics takes a straightforward economic approach and classifies the Malaysian population into three categories based on their monthly household income: T20 (top 20% household), M40 (middle 40% household), and B40 (bottom 40% household) (DoSM 2016). T20 households refer to those households that had a monthly mean income of RM 16,088 in the year 2016 and shared 46.2% of the national income. The middle income household group, or M40, refers to those households that fell into a monthly mean household income of RM 6,502 and shared 37.4% of the national income in the same year. B40, or the bottom 40% of households are those households that had a monthly mean income of RM 2,537 and contributed only 16.4% of the national income share (DoSM 2016). The World Bank also proposed the idea of the middle class in Malaysia in terms of earning capacity of individual households and suggested that those households earning above the mean income of

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at particular income group could be classified as a middle income group (Sander 2014: 58). According to the Malaysian government’s Department of Statistics Malaysia the average or mean household income of the middle income group, or M40, was RM 6,502 in the year 2016 (ibid.). Those households earning more than this amount in each month could be defined as middle class. According to a World Bank report, 33% of all Malaysian households fell into the middle class (ibid.). However, a mechanical approach in defining the Malaysian middle class has also faced challenges from various corners. As stated before, Malaysia is a multiethnic society and different ethnic groups have diverse earning capacities. The average monthly income of a Bumiputra (Malay and indigenous people) household included in the M40 category in the year 2014 was RM 5,190, while for a Chinese Malaysian household it was RM 7,040 and for a Indian Malaysian household it was RM 5,646 (DoSM 2016). The levels of development in various parts of the country are also diverse and need to be taken into consideration when defining the middle class. A monthly household income of RM 3,860 in an affluent neighborhood in Kuala Lumpur may be considered as urban poor but not in the countryside of the remote provinces. Adopting economic criteria as a major tool in defining the middle class becomes further complicated by factors such as household size and location, educational qualifications, residential location, and occupation. (Surendra 2017). The education and healthcare delivery of under the Chinese medicine in Malaysia is a private venture and exists within the private university and healthcare system. As of 2017, there were seven universities offering a Bachelor of Traditional Chinese Medicine Program in the whole country. Atop of this, there were also three institutes offering a Diploma and one postgraduate program on Chinese medicine (MoHM 2017). All these institutes are privately owned and operate under the Malaysian private university system.4 Private institutions usually charge high tuition fees and children from the middle to top household income groups can afford to study at those institutes. The annual tuition fee for studying a Bachelor of Traditional Chinese Medicine program ranges from RM

4 These ten institutions are: INTI International University, Management and Science University, Southern University College, University Tunku Abdul Rahman, International Medical University, Cyberjaya University College of Medical Science, International Institute of Management and Technology, Xiamen University Malaysia, Institute of Physical Science, Culture & Arts, and Lincoln University College.

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20,000 to 30,000 (1USD = RM 4.2 app.) depending on the individual institution. For example, Xiamen University Malaysia charges an annual fee of RM 23,000 for a Bachelor of Medicine in Traditional Chinese Medicine course, the International Medical University (IMU) Malaysia charges RM 26,000 (app) for a Bachelor of Science (Hons) Chinese Medicine course, and Southern University College charges an annual fee of RM 20,000 (app) for a Bachelor in Traditional Chinese Medicine course.5 The government-subsidized public education system in Malaysia only offers courses on Western medicine. As of June 2020, there are eleven post-secondary government institutions in Malaysia offering courses on Western medicine. However, there is no public institution currently offering courses on Chinese Medicine or any other practice area of Traditional and Complementary Medicine (T&CM) recognized by the government such as Ayurveda and Homeopathy. There are also twentytwo private university/colleges offering courses on Western medicine in Malaysia. Apart from education and training, the middle-class preference for the practice of Chinese medicine can also be found in healthcare delivery and target service recipients in Malaysia. The rise of the emerging middle class across Asia as a part of the process of globalization has pushed the development of private healthcare delivery. This middle class has a disposable income and is looking for new health products and service niches while Chinese medicine and other modalities under traditional medicine have become a lucrative choice (Islam 2017; Hollen 2005). This new consumption trend has caused segregation in access to Chinese medicine. Most of the practitioners of Chinese medicine run private clinics and/or work as family physicians and are available on call. According to Health Fact Malaysia, there were 143 government hospitals, 2,873 government health clinics, and 343 government 1 Malaysia clinics operating healthcare services under the Ministry of Health as of December 31, 2015 (MoHM 2016: 12–14). However, as of 2016, only fourteen government hospitals and one unit in one Malaysia Low-risk Birth Centre were offering traditional and complementary medicine services (ibid.: 2015). The bulk of the services under Chinese medicine are offered by private clinics which usually charge high fees for their services. These fees are usually paid out of pocket as medical insurance companies are yet to 5 These amounts are counted by the author and based on the information available on the webpages of these three institutions.

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step in with their operations for traditional and complementary medicine services. Private clinics offer various services and packages and their service fees vary from clinic to clinic. For example, One Flower With Five Leaves Sdn Bhd clinic in Kuala Lumpur city offers services such as acupoint therapy, Chinese herbal medicine, meridian scraping treatment, and acupuncture. The clinic charges RM 180 for a new patient who comes from diagnosis and treatment, and RM 80 for acupoint therapy.6 Another clinic from Selangor state Xing Lin TCM center also offers services including acupuncture, moxibuston, cupping, guasha, pestle needle, etc., and demands various charges for different services. The clinic charges RM 40 as a first time consultation fee and RM 25 for a follow-up visit on top of their various service fees such as RM 100 for acupuncture and RM 30 for moxibustoon.7 These amounts of fees are affordable to middle and top income households who are willing to make such out of pocket payments. The rise of the emerging middle class across the big cities in Malaysia as part of globalization has brought the development of products and services for health, the rejuvenation of health and relaxation under the Chinese medicine niche. Apart from offering services under regular modalities such as herbal remedies, acupunctures, and guasha, Chinese medicine clinics are offering new products and services targeting clients seeking care for beauty, slimming, etc. These products have become particularly popular among the middle class who have disposable income and are looking for care using natural and herbal products. Chinese medicine clinics are instrumental in capitalizing on the natural content and minimum side effects of Chinese medicine and have promoted beauty and health remedies under the name of natural treatment. As such, One Flower With Five Leaves Sdn Bhd clinic offers remedies such as face-scraping treatment, head-scraping treatment, and push treatments targetted at middle-class consumers. Similarly, the Xi group (also known as Zhao Xi TCM Centre) in Selangor runs a clinic called the Xi Slim & Beauty TCM center in Kuala Lumpur and offers services such as TCM sliming and TCM beauty. In its flyer, the clinic states:

6 This list of charges for different services was hung in front of the clinic and collected by the author during a personal visit in August 2018. 7 This list of charges for different service was hung in front the clinic and collected by the author during personal visit in July 2019.

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Xi Slim and Beauty is a Traditional Chinese Medicine (TCM) aesthetics establishment which adopts TCM methods for weight loss and beauty therapy. We use TCM therapy that emphasizes the balancing and regulating of the body to achieve good looks through good health.8

It is not surprising that Chinese medicine clinics in major cities across Malaysia are promoting the idea that good looks reflect good health and are maximize their economic vision through the catering of services to middle-class health consumers who have a disposable income. Likewise, Xing Lin TCM Centre in Selangor offers services such as TCM Pain Management, TCM Diabetes Management, TCM Wellness, and TCM Lifestyle Disease Management. All these health needs are related to middle to upper middle class urban lifestyles and private clinics are addressing these health concerns, catering services, and maximizing profit margins. However, this consumption trend has caused also segregation in access to Chinese medicine services in Malaysia. The bulk of Malaysian citizens use public healthcare facilities because of the nature of the country’s health financing. Government health-providing institutions usually charge a nominal fee and offer Western clinical care. Statistics reveal that about sixty five percent of Malaysian patients utilize government healthcare facilities that are dominated by the mainstream Western medicine (Quek 2014: 1). There is an opposite scenario in the utilization of Chinese medicine care, which is exclusively operated by the private healthcare system and is particularly targetted at middle-class health consumers through maintaining an out of pocket payment system and charging high fees for their services. The dominance of the middle class in receiving Chinese medicine services under the Malaysian private healthcare system is further confirmed by the socioeconomic profile of the service recipients. Those interviewed from the One Flower With Five leaves clinics in Kuala Lumpur, Myth Medix Clinic, and the Xing Lin TCM Centre from Selangor represent the middle-class socioeconomic background. Statistics reveal that sixty two and a half percent of those surveyed had completed post-secondary education and have a Bachelor or Master degree. Similarly, fifty percent of those have a monthly income of RM 6000–10,000 or 8 This paragraph is cited from a flyer of Zhao Xi TCM Centre Sdn Bhd and collected by the author during his personal visit to the Xing Lin TCM Centre in Selangor in July 2019.

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above. The service recipients came from a variety of professions including retired government employees, legal executives, financial advisers, accountants, bankers, pediatricians, financial planners, real estate investors, and so on. Sixty nine percent of the service recipients have experience of visiting Mainland China, the Hong Kong SAR, and Taiwan.9 One of the service recipients, who is ethnic Chinese, works as a banker with a monthly salary above RM 12,000 and lives in Selangor state, shared his feelings in the following paragraph: I have been suffering from diabetes for five years, which has no cure and I have to think of some ways to improve it. The reason why I chose Chinese medicine is that it slowly helps me compared to Western medicine. I used Western medicine before and got help to control my diabetes situation but it did not help to improve the health of my body. I won’t say Western medicine is a failure. It helped me to control my level of sugar, but it didn’t improve the condition of my body. I was recommended to try Chinese medicine by my neighbour and have been using this service for a year. I don’t know the exact name of the CM method I am using. I can’t feel anything yet after using CM because I am also taking Western medicine in parallel. My mother uses acupuncture. The situation of Chinese medicine in Malaysia is okay, although it is not really recognized by the government or our company. For example, when I am sick and I go to the clinic for Western medicine, I get a medical certificate but when it comes to Chinese medicine, all the medical certificates are not usable. Also, I cannot use medical insurance and so I need to make out of pocket payments. The health financing system and the laws are still not very favourable to Chinese medicine.

Ethnic Preference Ethnic preference is another feature in the education and practice of Chinese medicine in Malaysia. Malaysia is a multiethnic country and over sixty percent of the population are ethnic Malay and indigenous people. Chinese medicine is popular among the ethnic Chinese, who make up only about one-fifth of the total population. The revival of Chinese medicine at the dawn of the twenty-first century in Malaysia

9 These service recipients were interviewed by the author from the One Flower With Five Leaves Clinic, Myth Medix Clinic, and Xing Lin TCM Center with a semi-structured questionnaire in August 2018 and July 2019.

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is fueled by ethno-politics within the country and is part of the global commodification of traditional medicine. Although the ethnic Chinese population rapidly shrunk after decolonization and comprised just over twenty percent of the total population in the year 2017, they control a large share of the economy and private sector. The ethnic Chinese also have a better socioeconomic status compared to other ethnic groups in Malaysia, such as Malay and Indian. For example, the average monthly income of a Bumiputra (Malay and indigenous people) household in the M4010 category in the year 2014 was RM 5, 190, while a Chinese household was RM 7, 040 and an Indian household was RM 5, 646 (DoSM 2016). This statistics from the Malaysian government’s department of statistics gives a picture of the socioeconomic advantageous position of ethnic Chinese households in Malaysia who can afford the private healthcare facilities and are also the largest consumers of Chinese medicine. Statistics from both the demand and supply side reveal that the ethnic Chinese are the absolute majority of service providers and clients who use Chinese medicine for their health care. Ethnic disparities can also be perpetuated by segregation “restricting educational opportunities” and “concentrating poverty” (Caldwell et al. 2017). One example is that all the students, as of August 2018, enrolled in the Bachelor of Medicine in Traditional Chinese Medicine Program at the Xiamen University Malaysia were ethnic Chinese. Similarly, all the faculty members under the same program were also ethnic Chinese except one who was an ethnic Korean but fluent in the Chinese language and was trained in Chinese medicine at Nanjing University of Chinese Medicine in China. The same Bachelor program has adopted a bilingual mode where the medium of instruction is Chinese/English, although this is unusual across the university where English is used as the mode of instruction.11 Students who are fluent in Chinese have an advantage to enroll in the program. Some of the faculties from the same school are not fluent in English, especially those that come from Mainland China. In August 2018, the author visited Xiamen University Malaysia and found that a total of one hundred and seventy students were enrolled in the Bachelor of Medicine in Traditional Chinese Medicine program

10 M40 refers to the 40% middle income households. 11 Retrieved from the Xiamen University Malaysia, Bachelor of Medicine in Traditional

Chinese Medicine program flyer and collected during a personal visit made by the author.

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and 84.1% of them were Malaysian Chinese, followed by 15.3% Chinese from China (mainland). At the same time, a total of 32 faculty members were working under the program and 62.5% were from China (mainland) followed my 34.4% Malaysian Chinese. Another Statistics from International Medical University (IUM) Malaysia reveal that eighty six percent of their students enrolled in the Bachelor of Science (Hons) in Chinese Medicine program are ethnic Chinese as of July 2019.12 The Centre for Complementary and Alternative Medicine from the same university posted a list of thirteen faculty members working under the Division of Chinese Medicine, all of them are ethnic Chinese and this further confirmed the ethnic segregation in the tertiary education sector in Chinese medicine in Malaysia. The notable presence of ethnic Chinese is not only in education but also in the Chinese medicine branch of Malaysian healthcare delivery. Of those fourteen practitioners interviewed randomly, ninety three percent of them were ethnic Chinese, either from Malaysia or China (excluding Hong Kong SAR, Macau SAR, and Taiwan). The Zhao Xi TCM Centre Sdn Bhd, which runs four different clinics in Selangor state and Kuala Lumpur, listed a total of eleven Chinese medicine practitioners in their flyer of those working in the clinics and all of them were ethnic Chinese, either from Malaysia or China (mainland). This is, however, not the case for offering medical care under Western medicine. Case: Lam Wah Ee Hospital. Lam Wah Ee Hospital is a tertiary acute care hospital on Malaysia’s Penang Island. It has seven hundred beds and is one of the largest private hospitals on the island. Penang is also the only state in Malaysia where the ethnic Chinese population was the single majority ethnic group until the year 2017. The hospital has a Chinese medicine division apart from mainstream Western medicine. There were a total of seventy two13 panel doctors listed on the hospital webpage as of April 2018 in their Western medicine division and eighty one percent of them were ethnic Chinese, followed by eleven percent ethnic Indian and eight percent ethnic Malay. However, there were thirteen panel practitioners listed in the Chinese medicine division 12 These statistics were collected by the author with the help of some students studying under that program. 13 Panel of Doctors-Western Medicine Division, Lam Wah Ee Hospital, Retrieved from the following link: https://www.hlwe.com.my/about_panelDoctors.html#title. And accessed on December 14, 2018.

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of the hospital and all of them were ethnic Chinese. The Chinese medicine practitioners were offering medical services in areas such as acupuncture, dermatology, oncology, medical qigong, cardiovascular medicine, and internal medicine.14

The noteworthy presence of the ethnic Chinese in the Chinese medicine industry in Malaysia was further confirmed by the number of service recipients in two different clinics. Statistics collected by the author during a personal visit to One Flower With Five Leaves Clinic in Kuala Lumpur revealed that a total of forty nine clients received service from August 23 to 30, 2018 and nearly seventy eight percent (38 in number) of them were ethnic Chinese, followed by twenty two percent ethnic Malay. The statistics were similar at the Xing Lin TCM Centre in Selangor where a total of seventy nine clients received various services from July 7 to 13, 2019 and eighty two percent of them were ethnic Chinese, followed by twelve percent ethnic Indian and six percent ethnic Malay.15 There are various reasons behind the ethnic Chinese preference in the Chinese medicine industry in Malaysia: firstly, although Malaysia used to be an English colony until the middle of the twentieth century and English is widely accessible among all the ethnic groups, the ethnic Chinese usually use their own dialect when communicating with each others. Such a trend gives a clear language advantage to the service recipient to communicate with the service provider or the Chinese medicine practitioner. As mentioned earlier, majority of Chinese medicine practitioners in Malaysia are ethnic Chinese. They were trained in Chinese medicine from institutions in China where the Chinese language is the predominant medium of instruction. There are also Chinese terminologies used in the practice of Chinese medicine which are easier to understand if the service recipient has knowledge of Chinese language and culture. This is, however, not exactly the scenario in the practice of Western medicine, where practitioners and patients from all the ethnic backgrounds enter relatively random.

14 These statistics were collected by the author from the information available at the webpage of the Lam Wah Ee Hospital and his personal visit to the Chinese Medicine Division of the same Hospital in February, 2018. 15 These statistics were collected by the author from the registered book of clients of the Xing Lin TCM Center by the author during his personal visit.

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Segregation and Sex Preference Sex preference has become increasingly visible among the service providers and recipients under the Chinese medicine in Malaysia. Historic evidences support that most of the famous Chinese medicine practitioners during ancient and medieval times were male. Qi Bo, the physician of emperor Huang Di who is engaged in a conversation with the emperor throughout the Chinese medical classic Huang Di Nei Jing , is a good example of a Chinese medicine practitioner in ancient China. The famous CM practitioners/scholars of medieval times such as Wang Bing in the Tang Dynasty, or Li Shizhen from the Ming Dynasty who authored another Chinese medicine classic Ben Cao Gang Mu (the compendium of materia medica) are examples of male dominance in Chinese medicine practice (Jingwei 2012). The imperial physician Qi Bo was addressed as Shi fu (master) in Huang Di Nei Jing , which is a term commonly used to address a man having special skills (Huang Di Nei Jing, 2010). Man was represented as a symbol of humanity throughout the book and symbolized a male dominance in historic time of Chinese medicine practice. However, there has been a dramatic shift in recent years and a large number of female have entered into Chinese medicine industry either as practitioners and/or service recipients. Malaysia is not an exception and there are significant numbers of female students currently enrolled and/or graduated from Chinese medicine universities in the country. The Malaysian government has “instrumentalized” gender equality in higher education for economic benefit through enhancing female participation (Morley and Hamid 2017). Statistics from various sources supports that majority of the currently enrolled or recently graduated Chinese medicine practitioners from Malaysian private University system are female. For example, more than seventy two percent of the intakes as of July 2018 in the Bachelor of Medicine in Traditional Chinese Medicine Program at Xiamen University Malaysia are female.16 Another statistics from the International Medical University (IMU) Malaysia reveal that nearly eighty percent out of sixty nine students enrolled as of August 2019 in the Bachelor of Science (Hons) in Chinese Medicine program were female. Zhao

16 Data was collected by the author during a personal visit in August 2018 at the Xiamen University Malaysia through conversations with the students and faculty members and verified by the relevant party.

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Xi TCM Centre Sdn Bhd—a privately owned group has listed a total of eleven panel Chinese medicine practitioners in their company flyer and nearly eighty two percent of them were female. These practitioners are working in four of the group’s clinics in Selangor and Kuala Lumpur; the Xi Fertility TCM Centre, Xi Women’s Health TCM Centre, Xi Slim & Beauty TCM Centre, and Xing Lin TCM Centre.17 Despite a notable quantitative change in women’s participation and the large number of women’s entry into Chinese medicine industry as practitioners, the area of health they are dealing with remains similar as in the past. The Chinese medicine classic Huang Di Nei Jing emphasized issues related to women’s health such as fertility, reproduction, gynecology, and pediatrics. The text in the first chapter on Shanggu Tianzhen Lun (on humans preserving health in ancient times) discussed women’s reproductive health issues at different stages of life. For example, the text states that at the age of twenty eight, women’s vital energy and blood become substantial and the body becomes strongest for reproduction (Huang Di Nei Jing, 2010: 9). The Bachelor of Medicine in Traditional Chinese Medicine Program at Xiamen University Malaysia offers courses such as gynecology with of traditional Chinese medicine as a main course. It is perhaps not surprising, therefore, that contemporary Chinese medicine practitioners are also dealing with predominantly women’s health issues and exclusively focuses on gynecology, fertility, slimming, beauty, etc. Xi Women’s Health TCM Centre specializes in gynecological issues for both young and older women and offers to address disorders including dysmenorrhea, irregular menstruation, infertility, postpartum care, menopause, etc. Similarly, the Xi Slim and Beauty TCM Centre offers services on weight loss and beauty under a TCM slimming and TCM beauty program. Women also make up a large share of service recipients of Chinese medicine. A group of urban middle-class women routinely visit Chinese medicine centres in Malaysia. Statistics from the One Flower With Five Leaves clinic in Kuala Lumpur reveal that more than sixty five percent of their service recipients from August 23–30, 2018 were female. They consumed a range of services including acupuncture, massage, cupping, herbs, etc., for disorders such as pain management, beauty, skin allergy, and maintaining health. The statistics from the Xing Lin TCM Centre 17 These statistics were cited from a flyer collected by the author during a personal visit at the Xing Lin TCM Centre in Selangor on August 2019.

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in Selangor reveal a similar picture where sixty one percent of the service recipients were female out of the seventy nine clients who received service from July 7–13, 2019. One practitioner commented on this trend, that: There are several reasons addressed to this transition and noted by the respondents during interviews: Women are increasingly becoming more health conscious and avoiding Western medicine because of side effects. While Chinese medicine has herbal and natural content with minimum side effects, women are rushing to explore this option. Some female clients also undergo Chinese therapies only to maintain their health and prevent disease.

The noteworthy presence of women in the Chinese medicine industry in Malaysia is a paradigmatic shift of women’s discourse in Chinese medicine. The natural and herbal content of CM has been marketed for profit maximization and has targeted women as prime consumers. Offering courses on TCM gynecology under the university education curriculum has inspired female students to study Chinese medicine hoping for a bright professional career after graduation. At the same time, many female clients have been encouraged to visit Chinese medicine clinics for natural care for maintaining the natural beauty of the body and health.

Conclusion Chinese medicine has expanded increasingly in Malaysia although the Chinese population has not risen proportionally. At the time of Malaysian independence from the British colonial rule in 1957, the ethnic composition in peninsular Malaysia was Malay forty-one percent followed by Chinese thirty-eight percent and eleven percent Indian (Hirschman 1980: 111) However, the ethnic Chinese accounted for just over twenty percent of the total population in the year 2010 in Malaysia (Livepopulation.com, 2018). Although the ethnic Chinese population in Malaysia has declined over the decades there has been continuous growth in the Chinese medicine industry: the establishment of formal education facilities, the incorporation of Chinese medicine into the government healthcare facilities, the foundation of the Traditional and Complementary Medicine Division under the Ministry of Health, etc., are some examples. The formalization and integration into mainstream healthcare delivery has made Chinese medicine an increasingly middle to upper

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middle class private phenomenon. Chinese medicine exists predominantly in the private healthcare system and is accessible and affordable to the middle forty percent (M40) to top twenty (T20) percent of households causing health inequality in contemporary Malaysian society. The prevalence of the ethnic Chinese in the Chinese medicine products and service niches has segregated its practice, and Malaysia’s interethnic integration is not reflected in the Chinese medicine industry. Efforts from various political governments since independence to unite the Malaysian nation irrespective of ethnic and religious identity has not affected the Chinese medicine sector. As various statistics have revealed, the Chinese medicine industry is heavily reliant on the ethnic Chinese population in Malaysia. At the same time, there is segregation among Chinese medicine students, practitioners, and service recipients related to sex. More women are entering the industry than men, exploiting the natural content of Chinese medicine and boosting profit margins for entrepreneurs. Acknowledgements I acknowledge BNU-HKBU United International College, Zhuhai, China for offering a College Research Grant (Code: R201728) for conducting this study. I also acknowledge Dr. Shariffah Suraya Syed Jamaludin and her student Miss See Hui from the Universiti Sains Malaysia, Dr. Yun Jin Kim and Dr. Lim Chee Hoong from Xiamen University Malaysia, Dr. Yeo Show Kau, Dr. Wai, and Miss Liew Siewchin from One Flower With Five Leaves Sdn Bhd clinic, Kuala Lumpur for their sincere support during my fieldwork. Dr. Anthony Wong from the Xing Lin TCM Center in Selangor also generously helped during the final stage of fieldwork for this project. My student assistants: ZENG Ying and YANG Yongjia from 2015 cohort, and HUANG Siqi and CHEN Yinying from 2016 cohort did all the transcription work and I truly appreciate their support. Finally, I acknowledge all the respondents from Malaysia who participated in interviews for this study during interview.

References Bao, Y. and Hu, C.P. (2012), Current Status for Traditional Chinese Medicine Education in Malaysia. World Journal of Integrated Traditional and Western Medicine, Vol. 7, pp. 1082–1083. Beijing University of Chinese Medicine, International School Webpage, Retrieved from the following link: https://guoji.bucm.edu.cn/english/ywjyjx/jyjxyw xljy/jyjxzykc/index.htm and accessed on December 13, 2018.

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Caldwell, Julia T., et al. (2017), Racial and ethnic residential segregation and access to health care in rural areas, Health & Place, Vol. 43, pp. 104–112. Chen, Paul C.Y. (1981), Traditional and Modern Medicine in Malaysia, Social Science and Medicine, Vol. 15A, pp. 127–136. Great Britain: Pergamon Press Ltd. CIA World Factbook (2018), Malaysia Demographic Profiles 2018 [Online]. Available: https://www.indexmundi.com/malaysia/demographics_profile. html and accessed on October 20, 2018. DoSM (Department of Statistics Malaysia) (2016), Key Statistics on Household Income & Expenditure 2016 Malaysia. Retrieved from the following link: https://www.dosm.gov.my/v1/index.php?r=column/cone&menu_id= UllqdFZoVFJhMi9zekpWKzFaSTdvUT09 and accessed on December 17, 2018. Dunn, Fred L. (1974), Medical Care in the Chinese Communities of Peninsular Malaysia. In Proceedings of a Conference on the Comparative Study of Traditional and Modern Medicine in Chinese Societies. Seattle: University of Washington. Emmanuel Surendra (2017), What Does It mean to be Middle Class in Malaysia in 2017, iMoney.my Learning Center. Retrieved from the following link: https://www.imoney.my/articles/middle-class-malaysia and Accessed on December 16, 2018. Gao R. and Zhang, J. (2011), Current Status of Traditional Chinese Medicine in Malaysia. China Foreign Medical Treatment, Vol. 25, p. 192. Hirschman, Charles (1980), Demographic Trends in Peninsular Malaysia, 1947– 75. Population and Development Review, Vol. 6, Issue 1, pp. 103–125. Hollen, Cecilia Van. (2005), Nationalism, Transnationalism, and the Politics of Traditional Indian Medicine for HIV/AIDs. In Alter, Joseph S. (Ed.), Asian Medicine and Globalization. Pennsylvania: University of Pennsylvania Press. Huang Di Nei Jing (2010) (Yellow Emperoro’s Canon of Internal Medicine), Translated by Wu Liansheng and Wu Qi. Beijing: China Science and Technology Press. Islam, Md. Nazrul (2017), Chinese and Indian Medicine Today: Branding Asia. Singapore: Springer. Islam, Md. Nazrul and Kuah, K.E. (2013), The Promotion of Masculinity and Femininity Through Ayurveda in Modern India. Indian Journal of Gender Studies, Vol. 20, Issue 3, pp. 415–434. London: Sage. Jingwei, Li (2012), Condensed Compendium of Materia Medica. Beijing: Foreign Language Press. Livepopulation.com (2018), Population of Malaysia. Retrieved from the following link: https://www.livepopulation.com/country/malaysia.html and accessed on December 16, 2018.

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Lin, J.Y. (1995), The Needham Puzzle. Economic Development and Cultural Change (January): 269–292. London and New York: Routledge. Ling, OoI Giok (1991), British Colonial Health Care Development and the Persistence of Ethnic Medicine in Peninsular Malaysia and Singapore, Southeast Asian Studies, Vol. 29, Issue 2, pp. 158–178. Makmor, T., Khaled, T., Ahmad Farid, O., and Nurul Huda, M.S. (2018), Demographic and Socioeconomic Factors Associated with Access to Public Clinics, Jummec, Vol. 21, Issue 1. Mariapun, J., Hairi, N.N., and Ng, C.-W. (2016), Are the Poor Dying Younger in Malaysia? An Examination of the Socioeconomic Gradient in Mortality, PLoS One, Vol. 11, Issue 6. Ministry of Health Malaysia (2015), Traditional and Complementary Medicine (T&CM) Act-What Should You Know? [Online]. Available: https://npra.moh.gov.my/images/Announcement/2015/NRC-2015day2/TMHS08-P-Ms-TehLiYin-31-07-15.pdf and accessed on November 22, 2017. Ministry of Health Malaysia (2016), Health Facts 2016. Putrajaya: Ministry of Health Malaysia. MoHM (Ministry of Health Malaysia) (2017), Traditional and Complementary Medicine (T&CM) Higher Education Programs and Institutions. Available at: http://tcm.moh.gov.my/en/index.php/education/higher-education and accessed on November 22, 2017. Morley, Louise and Hamid, Bahiyah Abdul (2017), Managing Modern Malaysia: Women in Higher Education Leadership. Retrieved from the following link: https://www.researchgate.net/publication/309018288 and accessed on August 22, 2019. Parliament of Malaysia (2017), Traditional and Complementary Medicine Act 2016. Putrajaya: Government of Malaysia. Quek, D. (2014), The Malaysian Health Care System: A Review, Presented in the Intensive Workshop on Health Systems in Transition. Kuala Lumpur: University of Malay. Sander, Frederico Gil, et al. (2014), Malaysia Economic Monitor: Towards a Middle-Class Society, pp. 57–58. The World Bank: Southeast Asia Country Management Unit. Tan, Wen Tien, et al. (2018), Traditional Chinese Medicine in Malaysia: A Brief Historical Overview of the Interactions between China and Malay Peninsula. Chinese Medicine and Culture, Vol. 1, Issue 2. White, Kellee and Borrell, Luisa N. (2011), Racial/ethnic Residential Segregation: Framing the Context of Health Risk and Health Disparities, Health Place, Vol. 17, Issue 2, pp. 438–448.

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Zhang, Y.J. (2011), Malacca and Its Chinese Community-A Discussion Surrounding Literature in Ming and Qing Dynasty (1405–1911). Kampar: Universiti Tunku Abdul Rahman. Zulkefli, Zurina Kefeli and Zaidi, Mohd Azlan Shah (2013), Health Care Utilization among the Elderly in Malaysia: Does Socioeconomic Status Matters? Prosiding Perkem, Vol. viii, Issue 3, pp. 1141–1152.

CHAPTER 8

Current Challenges and Issues for Traditional and Complementary Medicine (T&CM) in Malaysia Yun Jin Kim

Introduction Ancient Malaysia received its first medical knowledge from Portugal, the Netherlands, and the United Kingdom in the fifteenth century. During this period, traditional Malay medicine was strongly influenced by the animistic culture of Hindu-Buddhism, which originated from India. In Malaysia, one popular form of traditional and complementary medicine is Islamic medicine. It is categorised as traditional medicine since it has been used for centuries. Thus, the relation of Islam to medicine is lesser component of the greater truth springing from the Quran and the Prophet’s

Y. J. Kim (B) School of Traditional Chinese Medicine, Xiamen University Malaysia, 43900, Jalan Sunsuria, Bandar Sunsuria, Sepang, Selangor, Malaysia

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_8

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saying as the primary sources of Muslim theology and practice.1 The context can be historical, cultural, scientific, pharmacological, therapeutic, religious, or even geopolitical.2 Subsequently, with the introduction of Islam and with the arrival of the Chinese, the practice of medicine began to change, incorporating these new set of values. In the nineteenth century, modern Western medicine was introduced by the British and was taken up quickly because of its easy practice and effectiveness. During this period, T&CM also started to appear in Malaysia. The British imported Chinese immigrants mainly for tin mining. Owing to this importation, the Chinese rose and became the second largest community in Malay Peninsula, and with large community comes the need for management health care.3 Many Chinese immigrants were not so fortunate. The British colonial government could not provide them with the necessary medical support. On seeing the sufferings, the rich Chinese merchants pooled together to help the Chinese community. They set up charity clinics and hired TCM practitioners directly from China to Malaysia. They were opened in Pei Shan Tang and Tung Shin Hospital in 1894.4 This was the beginning of TCM in Malaya. The strong cultural identity is an important factor in the development of TCM in Malaysia. In the early twentieth century, T&CM services were still mainly frequented by the Chinese people. However, as time goes by, T&CM become one of the popular traditional and complementary medicines that are accepted by other ethnicities. In 1929, a British botanist named David Hooper published a book “On Chinese Medicine: Drugs of Chinese Pharmacies in Malaya.” Hooper collected 456 types of Chinese medicine samples including 29 kinds of animal products and 12 kinds of mineral medicines from local

1 Edriss H, Rosales BN, Nugent C, et al. Islamic Medicine in the Middle Ages. Am J Med Sci. 2017; 354(3): 223–229. 2 Ahmad K, Afirrin MFM, Deraman F, et al. Understanding the perception of Islamic Medicine Among the Malaysian Muslim Community. J Relig Health. 2018; 57(5): 1649– 16673. 3 Tan W, Wong H, Ng S, et al. Traditional Chinese medicine in Malaysia: A brief historical overview of the interactions between China and Malay Peninsula. Chin Med Cult. 2008; 1: 60–63. 4 Chi YL. Malaysia traditional Chinese medicine. J Shandong Chin Med. 2002; 21: 627–628.

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Chinese medical hall. He then detailed their Chinese, English, and Malay names, as well as classified them by their taxonomy, origin, and function.5 Traditional and complementary medicine (T&CM) refers to a set of healthcare practices (indigenous or imported) that are delivered outside of the mainstream healthcare system. From the World Health Organization’s (WHO) that “primary health care” relies at local and referral levels, on health workers including physicians, registered nurses, midwives, and community government officers,6 primary health care is an approach to health and a spectrum of health services beyond the traditional healthcare system while primary care is just one element within primary health care that focuses on current healthcare service systems. The present status of primary healthcare system in Malaysia and the strides it has made in uplifting the healthcare status of the nation are described,7 as well as in Malaysia T&CM practitioners as needed; suitable trained socially and technically to work as a health team and to respond to the expressed healthcare needs of the community. The WHO has produced strategic reports shown that emphasize the important regulation of T&CM in overall healthcare management. These include the Regional Strategy for Traditional Medicine in the Western Pacific (2011–2020) and the WHO Traditional Medicine Strategy (2014– 2023). The Regional Strategy for Traditional Medicine in the Western Pacific (2011–2020) introduces guidance and principles for countries, stakeholders, the WHO on how to make the potential and ensure the proper use of T&CM in the region. From the WHO Traditional Medicine Strategy (2014–2023) was made the framework to guide and improve countries to integrate T&CM into the national wide healthcare system.8 This strategy report acknowledge the set up the T&CM in improving

5 Hooper D, Burkill IH. On Chinese medicine: Drugs of Chinese pharmacies in Malaya. Garden’s Bull Straits Settlements 2919; 6: 1–80. 6 Karen G, Beverly S, Mier C, et al. Implementation of continuous quality improve-

ment in Aboriginal and Torres Strait Islander primary health care in Australia: A scoping systematic review. BMC Health Serv Res. 2018; 18: 541. 7 Ab Rahman, Sivasampu S, Mohamad Noh K, et al. Health profiles of foreigners attending primary care clinics in Malaysia. BMC Health Serv Res. 2016; 14: 197. 8 World Health Organization. WHO traditional medicine strategy 2014–2023. World Health Organization.

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individual health care and its contribution toward healthcare systems coverage for worldwide.9 In 2007, Malaysia launched and revised the National Policy of T&CM.10 It is stated that T&CM shall be an important component of the Malaysian local healthcare system. It will co-exist with modern Western medicine and contribute toward improving the Malaysian local health and quality of life of all Malaysians. The general directions are as follows: (1) to promote appropriate and relevant integration of T&CM into the Malaysian local healthcare system in order to achieve a holistic approach toward improving health and quality of life11 ; (2) to professionalize T&CM practices and practitioners to improve safety and quality of treatment; (3) to strengthen relevant legislation and regulatory control to ensure better safety and quality in all aspects of T&CM; (4) to formalize T&CM education qualified T&CM practitioners, related healthcare providers, and the public; and (5) to strengthen the T&CM research capacity to support the regulation, development, and professionalization of T&CM in Malaysia12 .

T&CM Clinical Practice in Malaysia T&CM in Malaysia is highly diversified in terms of local heritage, multilanguage, multi-philosophy, ethnic origin, geographical distribution, and stages of development of each practice. T&CM is strongly linked to the local culture and heritage of each ethnic groups in Malaysia. The provision of T&CM medical services in Malaysia is dominated by the private sector with limited involvement of the public sector. The practice of T&CM is defined as a form of health-related practice designed to prevent, treatment, manage ailment, illness or preserve the mental and physical well-being of an individual and includes traditional Malay medicine, traditional Chinese medicine, traditional Indian 9 Oyebode O, Kandala NB, Chilton PJ, et al. Use of traditional medicine in middleincome countries: A WHO-SAGE study. Health policy Plan. 2016; 31(8): 984. 10 Division of T&CM. National T&CM Policy. Ministry of health Malaysia. Available at http://tcm.moh.gov.my/en/upload/NationalPolicy.pdf. Accessed January 13, 2019. 11 Siti ZM, Tahir A, Ida Farah A, et al. Use of traditional and complementary medicine in Malaysia: a baseline study. Complement Ther Med. 2009; 17: 292–299. 12 Ooi GL. Chinese medicine in Malaysia and Singapore: the business of healing. Am J Chin Med. 1993; 21: 197–212.

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medicine, Islamic medical practice, homeopathy, and other alternative and complementary therapies. Identifying an appropriate legislative framework for T&CM practice in Malaysia is one of the Ministry of Health principal considers in order to regulate and professionalize the different T&CM practices in Malaysia. The T&CM supply industry market is growing up. From Malaysia Drug Control Authority (DCA) licensed T&CM manufacturers in 2017,13 136 are licensed traditional medicine manufacturers in Malaysia T&CM industry market. From the Ministry of the Natural Resources and Environment estimated the local herbal market to expand by 15% a year from RM7 billion in 2010 to around RM29 billion by 2020. Based on a survey conducted by the Forest Research and Institute Malaysia (FRIM) in 2012, households in Malaysia consuming herbal products were estimated at 73%, which is lower compared with 80% estimated by the WHO for developing countries.14 On the industrial side, growers of herbal plants were mainly in Pahang, Johor, and Perak. At the national scale, medicinal herbs plantation acreage is projected to increase from 1000 ha in 2010 to 4000 ha by 2020. The performance on the downstream activities showed that there was a significant increase in products being registered with NPCB under traditional use and for general health. On a cumulative basis, the products under traditional medicines/natural products have shown increasing trends since the 1990s, reported to reach 8550 in 2000, and has more than doubled by 2013. Nevertheless, for the natural products, data on an annual basis showed that the number of products registered has been declining, recording 1729 in 2006 to 578 in 2013.15 Reports from Division of T&CM annual report 2017 show approximately more than 20,000 premises providing T&CM care services in

13 Pharmaceutical Services Programme, Ministry of Health Malaysia. Available at https://www.pharmacy.gov.my/v2/en/documents-library/guidelines. Accessed December 20, 2018. 14 Third National Agriculture Policy (DPN3). Ministry of agriculture & agro-based industry Malaysia. Available at http://www.fama.gov.my/en/web/pub/dasar-pertaniannegara-ketiga-dpn3. Accessed June 20, 2019. 15 Farizah A, Mohd ASZ. Issues and challenges in the development of the herbal industry in Malaysia. Prosiding Perkem. 2015; 10: 227–238. Available at www.ukm.my/ fep/perkem/pdf/perkem2015/PERKEM_2015_3A1.pdf. Accessed July 18, 2019.

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Malaysia.16 They are largely established by the private sector (e.g., private universities/colleagues, private medical care center, non-governmental organizations, clinics, private hospitals, private family practitioners et al.). During the self-regulation phase, a total of 16,050 T&CM practitioners registered with appointed T&CM practitioner bodies in Malaysia.17 A national survey in Malaysia reported that 29.3% of the population had utilized some form of T&CM healthcare services through T&CM practitioners in their lifetime and 21.5% had utilized these health care services within the last twelve months.18 More Malaysian females reported utilizing T&CM healthcare services (23.9%) compared to males (19.3%) and a higher rate of utilization was reported among the urban population (22.6%) compared to the rural population (18.2%). Malaysians primarily sought T&CM healthcare services for the maintenance of wellness and the management of minor musculoskeletal diseases.19 An improved personal professionalization of the T&CM industry can be evaluated by the well-declared ethical values, recognized qualifications and competencies, well-management-related professional bodies, appropriate regulatory framework for T&CM medical practice, education and related product market approval, and well-engagement in T&CM research in Malaysia. So, Malaysia government enforcement of the T&CM Act 2016 is an important milestone to the Ministry’s efforts in regulating the T&CM industry and ensuring safety and high quality of T&CM medical service are accessible to nationwide. T&CM has been widely utilized by the world population for decades. A report from Global Industry Analysts, Inc presented20 that the world market size of T&CM industry grew from 89.9 billion US dollars in 2011 to 114.1 billion US dollars in 2014 at a growth rate of 6.0% annually. 16 Division of T&CM, T&CM annual report 2017. Available at http://tcm.moh.gov. my/en/upload/penerbitan/laporantahunan/2017_bi.pdf. Accessed July 15, 2019. 17 Division of T&CM, Traditional and complementary medicine blueprint 2018–2037 health care Malaysia, Ministry of health Malaysia. Available at http://tcm.moh.gov.my/ ms/upload/Blueprint.pdf. Accessed December 18, 2018. 18 Diayati A, Junaidah H. Public health expenditure, governance and health outcomes

in Malaysia. Jurnal Ekonomi Malaysia. 2016; 50(1): 29–40. 19 Kaur J, Hamajima N, Yamamoto E, et al. Patient satisfaction on the utilization of traditional and complementary medicine services at public hospitals in Malaysia. Complement Ther Med. 2019; 42: 4220428. 20 Myeong YS, Ahn SY, Son CG Education for traditional medicine in medical schools in Japan. Korean J Acupuncture. 2016; 33: 12–17.

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According to the Division of T&CM, Ministry of Health database21 more than 16,000 local registered T&CM practitioners have with the eight T&CM practitioner bodies appointed by the Ministry of Health prior to enforcement of the T&CM Act in Malaysia. It is a need to consider Malaysia still has many more unregistered T&CM practitioners in the nationwide. The T&CM Act 2016,22 T&CM industry will make the issues and challenges that difficulty in ensuring effective implementation of the T&CM Act 2016 and the introduction of statutory regulation of T&CM practitioners. It is complexity and diversity of T&CM practices in Malaysia, the lack of trained continued professional development, the lack of facilities to conduct residency training in local and foreigner, the absence of suitable mechanisms for registering T&CM practitioners without formal training. Their issues will be addressed using a phased approach whereby the regulation of the different type of T&CM practice areas will be assessed based on readiness and risks. T&CM premises are not regulated, and its appropriate mechanisms for regulating and monitoring T&CM premises have yet to be identified. The current T&CM Act 2016 and Malaysia Medical Law do not adequately regulate T&CM premises. Most important issues are T&CM in secondary and tertiary healthcare system and potential contribution of T&CM is not ready. T&CM healthcare system delivery is toward public health care system with minimal participation at secondary and tertiary levels, and there is only one private TCM hospital-Tung shin Hospital in Malaysia with inpatient service. This may be due to the undefined role or positioning of T&CM at various levels of health care and the inadequate study of the potential contribution of T&CM toward better health outcomes. It is currently no government hospital set up the T&CM inpatient service. T&CM practices that are offered in the public hospitals in Malaysia at present can be defined as: (1) acupuncture management of post-stroke, chronic pain, and chemotherapy-induced nausea and vomiting, and (2) Malay massage is a form of soft tissue manipulation 21 Division of T&CM, Ministry of Health Malaysia. Annual report 2017. Available at http://tcm.moh.gov.my/en/upload/penerbitan/laporantahunan/2017_en.pdf. Accessed December 20, 2018. 22 Division of T&CM, Ministry of Health Malaysia. T&CM Act 2016. Available at http://tcm.moh.gov.my/ms/index.php/akta-pt-k-2016/akta2016. Accessed December 20, 2018.

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that applies the techniques of kneading, stroking, and pressing as well as application of Malaysia local herbal oils to ease the massage.23 This may also indirectly contribute to unclear career pathways and undefined roles of the T&CM practitioner in the Malaysia public health care system. However, toward better integrative healthcare system in the Malaysia, two of the private specialist hospitals, namely Regency Specialist Hospital (Johor) and Sunway Medical Centre (Subang Jaya), offer T&CM outpatient’s services from July 2019. It will be more private specialist hospital that contributes development for T&CM industry and delivers integrative healthcare system in the Malaysia. For strategic framework for the integration of T&CM into the national healthcare system, Malaysia has yet to well establish a strategic framework that will guide and facilitate the integration of T&CM into the national public health care system. The current incorporation of T&CM medical services in public healthcare facilities is conducted without a proper integration health system plan. It is a need to the financial and the manpower supports in the government sector. Division of T&CM, Ministry of Health tries to meeting with current government hospital settings or requirements standards, employment of T&CM practitioners, patient’s medical history records et al. Current status of Division of T&CM, Ministry of Health Malaysia strategies implement a phased approach to the introduction of statutory regulation of T&CM practitioners in Malaysia. These help to well establish T&CM practitioner bodies and initiate registration of T&CM practitioners from local and foreigners. It needs to well develop the code of professional conduct for registered T&CM practitioners, develop criteria for new recognized practice areas to determine the suitability and readiness of practices to be regulated, and develop an online-based system. It will provide public access to the list of registered T&CM practitioners in Malaysia; this online-based system already well management and implement online certification system for T&CM practitioners in Singapore. The Singapore’s Traditional Chinese Medicine Practitioners Act, which was passed in parliament in 2000, requires all TCM practitioners to be registered with the TCM Practitioners Board. The registration of TCM 23 Sejari N, Kamaruddin K, Ramasamy K, et al. The immediate effect of traditional Malay massage on substance P, inflammatory mediators, pain scale and functional outcome among patients with low back pain: study protocol of a randomised controlled trail. BMC Complement Altern Med. 2016; 16: 16.

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practitioners began in 2001 with the registration of acupuncturists. This was followed by the registration of TCM physicians from 2002.24 From 2018, Division of T&CM and Ministry of AYUSH, India discussed are (1) extending the deputation of traditional Indian medicine (TIM) practitioners from India to Malaysia via Indian Technical and Economic Cooperation (ITEC) scheme; (2) recognition of TIM practitioners working in Malaysia; (3) establishment of AYUSH Academic Chair in a Malaysian institution of higher education; (4) registration of traditional Indian medicine that will be imported to Malaysia; (5) assessing the safety and efficacy of combinatory formulations used in traditional Indian medicine by conducting clinical studies; (6) registration of Homeopathy practitioners and the development of Homeopathic practitioner capacity building module in Malaysia; (7) the opportunity of training for Panchakarma certification in India.25 Regarding the appropriate regulatory framework, guidelines to regulate, and supervision T&CM premises. It continues to need Division of T&CM to discuss in both public and private sectors, to analyze the issues pertaining to the establishment and regulation of T&CM premises, and well develop a guiding for T&CM premises in identified service delivery and their practice areas. T&CM has made a significant contribution to the healthcare system of the Malaysian local community. It continues to be patronized by Malaysian people in their bid to seek management for diseases and in well-being. The T&CM in Malaysia appears to have grown steadily and continuously over recent years. While there are limited data to define the size of the T&CM industry, there is clear, growing, and widespread use of T&CM in the health system. Evaluate the role of T&CM in healthcare management and healthcare promotion at various healthcare levels. It will guide the development of T&CM medical services in various healthcare system settings in Malaysia, also need to evaluate the potential contributions of T&CM in the prevention and treatment of Malaysia’s top disease burden. The identification of the potential contributions of T&CM in optimizing healthcare outcomes

24 Ministry of Health Singapore, TCM Practitioners. Available at: https://www.moh. gov.sg/hpp/tcm-practitioners. Accessed January 25, 2019. 25 Division of T&CM. Traditional and Complementary Medicine Division Annual Report 2018. Ministry of health Malaysia. Available at http://tcm.moh.gov.my/en/index. php/publication/annualreport. Accessed July 17, 2019.

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and reducing disease burden shall include but not be limited to tropical diseases, cardio diseases, cancer, neurologic disorders, diabetes, and psychiatric conditions. Division of T&CM, Ministry of Health Malaysia developed Good Practice Guidelines from the Working Papers on Development of Good Practice Guideline for Acupuncture,26 Good practice Guideline for Malay Massage,27 and Good practice Guideline for Reflexology28 in 2010 and 2011. From the data analyzed on the experience of the T&CM units, the following improvements were identified: (1) the need for a proper and systematic documentation; (2) the need for a standardized approach for the assessment of patients; (3) the need for a standardized treatment plan for a similar condition at all the integrated hospitals and private T&CM clinics. Thus, these guidelines are to support the T&CM practitioners to achieve (1) have a proper and standardized record keeping; (2) have a standardized approach to assessment and treatment of patients; (3) maintain an ethical and professional conduct at all time. These Good Practice Guidelines guide the T&CM practitioners through the examination, treatment, and discharge of patients. It will assist T&CM practitioners in making decisions on the suitable provisions for specific clinical circumstances. They are not standards or rules. It is the responsibility of the individual T&CM practitioners to know and understand these guidelines and apply it to patients’ clinical case, where and when appropriate. To develop appropriate integration models to optimize the contribution of T&CM in healthcare management in Malaysia, it is the need of time to analyze the status of integration, develop a suitable strategic framework, model and plan for integration. This framework should include aspects such as the definition of concepts, stages, pathway, and level of integration, management of health care, funding, referral, healthcare service delivery, governance of multidisciplinary team as well as the

26 Division of T&CM. Good practice Guideline: Acupuncture. Available at http:// tcm.moh.gov.my/en/upload/garispanduan/amalanbaik/GPGAcupuntureAug2010.pdf. Accessed September 30, 2019. 27 Division of T&CM. Good practice guideline: Malay massage. Available at http://tcm.moh.gov.my/en/upload/garispanduan/amalanbaik/TerjemahanGPGMalay Massage.pdf. Assessed September 30, 2019. 28 Division of T&CM. Good practice Guideline: Reflexology Available at http:// tcm.moh.gov.my/en/upload/garispanduan/amalanbaik/TerjemahanGPGRefleksologi.pdf. Assessed September 30, 2019.

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perspectives of key healthcare payers (e.g., patients, government, insurers et al.). Optimize integration and improve the high quality of T&CM medical services offered in the public sector (e.g., government hospital, public clinic et al.). Some private insurance companies in Malaysia and their medical insurance cards conditional covered alternative treatments (such as chiropractic, chiropody, homeopathy, osteopathy, acupuncture, traditional and complementary medicine) due to medical accidents.

T&CM Education in Malaysia T&CM education in Malaysia evolved in 2010 when private institutions of higher education began offering T&CM university level programs accredited under the Malaysian Qualifications Agency (MQA). Formal T&CM education is an important milestone toward standardizing and professionalizing the practice of T&CM in Malaysia, ensuring the safety and quality of T&CM service and toward enhancing public confidence. In the past, T&CM education in Malaysia was largely informal without fixed curricula or established university institutions of learning. Knowledge and skills were handed down through oral communication and apprenticeship. With reference to the Malaysian Qualifications Framework (MQF).29 Figure 8.1, two flows have been identified for the development of T&CM university-level programs. These include the skills pathway and higher education pathway. The T&CM plays a role in providing technical support in the development of these university-level programs. They are the skills, vocational, technical, and academic sectors. Each sector is supported by long-term life learning pathways and is differentiated by learning outcomes, study credits. In total calculated that, MQF classified eight levels of qualification, level one to three (certificate levels) are skills certificates awarded by the manual skills, where academic, vocational, and technical certificates are at level three. Based on in situ training at the training institutions, it contains at least 25% vocational or technical contents. At level four and five are higher education, vocational, technical, skills diploma, encompass capabilities and responsibilities that are wide ranging. At the end, lead to a career, for diploma level education balances theory and industrial training 29 Agensi Kelayakan Malaysia. Code of Practice for Institutional Audit. Agensi Kelayakan Malaysia 2009. Available at http://www2.mqa.gov.my/QAD/garispanduan/COPPA/ COPPA%202nd%20Edition%20(2017).pdf. Assessed 22 December 2018.

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EducaƟon and Training in T&CM in Malaysia

Ministry of Human Resources Skills pathway

NaƟonal Skills Development Act 2006 Department of Skills Development (DSD) Ministry of Higher EducaƟon (MOHE)

Academic pathway

Malaysian QualificaƟons Agency Act 2007 Malaysian QualificaƟons Agency (MQA)

Fig. 8.1 Skills and higher education pathways for T&CM in Malaysia

or practice; and stresses on the installation of values, ethnic, and attitudes to enable students use knowledge, comprehension; and training skills at workplace, study skills in adapting to ideas, processes; and new procedures for career development.30 For Bachelor’s degree at level six, it prepares students for general employment, who may enter into the postgraduate program, and research as well as highly skilled careers. It enables the individuals to learn responsibilities, which require good autonomy in professional decision making. The bachelor’s degree is conferred on individuals who are able to demonstrate knowledge and comprehension on fundamental principles of a related field study, acquired from advanced reference books; use the knowledge and comprehension through methods that indicate professionalism in employment. For Master’s degree at level seven, it provides for the furtherance of knowledge, skills, and abilities obtained at the bachelor’s level. The 30 Ministry of Education Malaysia. Malaysian Qualifications Framework 2nd Edition. Available at www.mqa.gov.my/pv4/mqf.cfm. Assessed 22 December 2018.

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master’s level is usually based on proven capabilities to pursue postgraduate studies in the selected major field. A master’s degree is conferred on students who are able to demonstrate continuing and additional knowledge and comprehension above that of the bachelor’s degree and have capabilities to develop or use critical ideas, usually in the context of valuable research; use the knowledge and comprehension to solve current problems related to the field of study in new mechanisms and multidisciplinary contexts. For the Ph.D. at level eight, it provides for the further enhancement of knowledge, skills, and abilities to conduct independent achievement research. Conferred on students who are able to describe a systematic comprehension, in-depth understanding of a discipline and mastery of skills and research process with scholarly strength. It promotes the technological, social, and cultural progress in a knowledge-based society in the academic and professional contexts. Figure 8.2 shows that the standard for diploma and degree level programs in T&CM has been developed in collaboration with the MQA.31 The program’s standards set the minimum requirement for T&CM programs offered by university institutions of higher education in Malaysia. They are adapted from educational standards established by the countries of origin for T&CM practices, such as traditional Chinese medicine (TCM) from China mainland and traditional Indian medicine (TIM) from India. To ensure these standards are relevant to the Malaysian education environment, continuous assessments and improvements are conducted over time by the Malaysia Qualification Agency. It is in the establishment of suitable program standards for local practices and practices without international benchmarks or country of origin. To status, there are nine private institutions of higher education offering T&CM courses at diploma and/or degree levels in the Malaysia as shown in Table 8.1. Students may study in traditional Chinese medicine, acupuncture or other T&CM clinical courses, like Tui-na, natural medicine, homeopathy, Malay medicine, Malay massage, Ayurveda medicine, Indian medicine, chiropractic, reflexology, aromatherapy, and Islamic medicine. Generally, 31 Division of T&CM, Ministry of health Malaysia. T&CM Education system. Available at http://tcm.moh.gov.my/en/index.php/education/education-system. Assessed 16 December 2018.

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Bachelor of TradiƟonal Chinese Medicine (Acupuncture) Bachelor of TradiƟonal Chinese Medicine

Bachelor of Homeopathy

T&CM educaƟon standards

Bachelor Programme Bachelor of Malay Medicine

Bachelor of Ayurveda Medicine

Bachelor of ChiropracƟc

Diploma in Malay Massage

Diploma Programme

Diploma in TradiƟonal Chinese Medicine (Acupuncture)

Diploma in Islamic Medicine

Fig. 8.2 List of programmed standards for T&CM education in Malaysia

clinical practice training programs, final year practice, or internship in China, Taiwan, or Australia et al. Each institution has created a capabilitydriven curriculum, embedding general skills and continues professional training. Most T&CM institutions set up the bachelor’s degree courses have study duration of 15 semesters (most private university in Malaysia, they open intake the three semesters per year). In a year, there are two semesters of 16 weeks’ study duration (14–15 teaching weeks, zero to one study week, and one or two examination weeks), and one semester

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Table 8.1 List of private institutions of higher education offering T&CM courses in Malaysia Institutions

Bachelor/Master level

Bachelor of Medicine in Traditional Chinese Medicine INTI International University Bachelor of Traditional Chinese Medicine (Hons) Management and Science Bachelor in Traditional University Chinese Medicine (Hons) Southern University College Bachelor of Traditional Chinese Medicine (Hons) Universiti Tunku Abdul Bachelor of Chinese Medicine Rahman (UTAR) Sungai Long (Hons); Campus Master of Medical Science (Chinese Medicine) International Medical Bachelor of Science (Hons) University (IMU) Chinese Medicine; Bachelor of Science (Hons) Chiropractic; Master of Clinical Chiropractic Acupuncture (MSC) Cyberjaya University College Bachelor of Homeopathic of Medical Sciences Medical Sciences (Hons) International Institute of Bachelor in Traditional Management and Technology Chinese Medicine (IIMAT) Institute of Physical Science, Culture & Arts (IPSCA)

Diploma level

Xiamen University Malaysia

Diploma in Traditional Chinese Medicine

Diploma in Traditional Chinese Medicine Diploma in Malay Massage

of seven weeks’ study duration (five to six teaching weeks, zero to one study week, and one examination week). The program consists of academic credits ranging from a minimum of 132 to a maximum of 203 credits (MQA require a minimum of 105 credits), including traditional Chinese medicine subjects, Western medical science, basic science, professional studies, clinical training, medical law, ethics, university-level general education courses, and general MOHE requirement studies. Regarding clinical practice training education, each institution has ten months’ duration (six months in the outpatient department in a traditional Chinese medicine clinic and four months in wards). To encourage students’ clinical practice training, students attend four to ten months of advanced clinical

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practice training at local affiliated hospitals or collaborated institutions in China, Taiwan, or Australia et al. During this clinical practice training program period, students collect patients’ medical history, clinical practice reports, clinical skill training exam and final case presentations or certain university choose graduate examination. On the other hand, Malay medicine, Malay massage, Ayurveda medicine, and Islamic medicine universities or colleges conduct students’ clinical practice training programs in India, Middle East countries, or other collaborated universities, colleges, institutions, or hospitals in foreign countries. From the Division of T&CM institutions lists32 findings are fourteen standards and criteria for diploma and bachelor degree have developed to support the provision of T&CM education programs by both the public and private institutions of higher education. There are nine bachelor’s degree programs and three programs for diploma offered by these higher education institutions. Recently inadequacy of existing education and training in T&CM, it is despite the emphasis on formal education, many T&CM practices still rely on informal education and training systems in Malaysia. These practices are either passed down through successive generations or offered through non-accredited education programs before MOHE and MQA approved. So, T&CM education and training will be relevant and standards of these programs and courses need to be determined relative to current needs and demand. There appears to be unfulfilled demand for postgraduate and bridging courses for T&CM practitioners who work to progress further from the knowledge skills to the academic pathway. The absence of local public or private higher education institutions offering postgraduate coursework and research programs in T&CM needs to be addressed with appropriate policies that support further development and encourage uptake in Malaysia T&CM education and skill training. On the other hand, the adequacy of existing courses to impart the necessary skills and T&CM knowledge to produce competent T&CM practitioners should be reviewed, including ensuring sufficient practical and theoretical components in the continued professional development programs. The adequacy of courses to equip T&CM graduates with the 32 Division of T&CM, Ministry of Health Malaysia. T&CM Higher Education. Available at http://tcm.moh.gov.my/en/index.php/education/higher-education. Accessed December 20, 2018.

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relevant inter-professional skills to communicate effectively with modern Western medical and allied healthcare practitioners should collaborate. The incorporation of T&CM education components into the curricula of medical and other healthcare professionals is highly encouraged to enhance the dissemination of accurate information on T&CM, promote the appropriate use of T&CM, and strengthen mutual understanding and trust from the early stages of professional development. Although it is underlined in the National Policy of T&CM and T&CM Act 2016, it is not mandatory and such arrangements are left to the initiative of medical education providers. Most importantly, the content and delivery of T&CM education as part of continuing professional development of the medical and other healthcare workforce also need to be strengthened to promote mutual understanding. Although the Ministry of health actively organizes seminars and discourses on T&CM, established platforms or forums for engagement and knowledge sharing are limited. Established programs for continuing medical education for healthcare providers have yet to be created in both modern Western medicine and T&CM. There is a need for continuous assessment and evaluation of existing and future educational activities to ensure they meet current needs, are effective, and achieve the indicated outcomes for integration medical purpose. In this situation, Malaysia Medical Association already organized few sessions of T&CM seminar for Western medical doctors and healthcare providers to discuss, but lack of medical law and National Policy. In Malaysia, Traditional Chinese Medicine Association will propose the plan to continuous professional development programs collaborated with T&CM higher education institutions from 2019. It identifies practical and effective ways to facilitate incorporation of T&CM education components into the curricula of other healthcare providers, engage with relevant stakeholders to facilitate the development of continuous professional development course on T&CM with specific learning objectives and outcomes. Government officers who deal with T&CM-related matters are not sufficiently trained and equipped with the necessary skills and knowledge to formulate effective regulations, policies or conduct research on T&CM. In 2018, Division of T&CM well organized the herbal products committee with T&CM herbal industry and private research sectors. It is upgraded to conduct research and quality control of herbal plants and

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products. For the general and public, the public requires accurate and adequate information on T&CM practice area and related products to make well-informed decisions. An assessment of public awareness and knowledge of T&CM is required to advise the way forward in formulating and implementing suitable programs and activities that will enhance well-informed decisions. Division of T&CM also considers career pathways and low student intakes in Malaysia. It is unclear career pathways for T&CM graduate students and professionals in both the public and private sectors is associated with undefined roles of T&CM practitioners in the local healthcare system; strongly need to public service scheme for T&CM practitioners; the absence of data on the demand and supply of T&CM national human resources data, which in turn hinders proper planning of graduate flow by T&CM education providers to meet T&CM industry market demands, and low current student intakes for T&CM courses which affect the long-term sustainability and prospect of T&CM education providers. Most T&CM education in higher education institutions in Malaysia already review and revise existing MQA standards and approved three institutions already completed MQA accreditations. Division of T&CM requests each T&CM higher education institutions needs to well establishment of bridging courses. It will allow T&CM practitioners to progress from the skills pathway to the academic pathway, development appropriate policy support to encourage the establishment of postgraduate or Ph.D. coursework and research programs in T&CM, also encourage and facilitate local or international collaboration to strengthen T&CM teaching capacity and resources in Malaysia. T&CM education in Malaysia is in the midst of systematic reformation. Yet little effort has been made in assessing how students evaluate their training in T&CM, how T&CM education could include modern medical education, or how to make training in T&CM sufficient to meet public expectations. T&CM and Western medicine in education contends with the challenge of bridging significant differences between two medical systems that were historically developed apart. However, their joint use forms an important part of T&CM clinical reality and medical education that should be reflected in Malaysia’s T&CM and Western Medicine educational or clinical development.

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Development of T&CM Skill Training Continues Professional Programs in Malaysia In Malaysia, development of T&CM skill training continues professional programs under the skills pathway, the T&CM has collaborated with the two government sectors are Department of Skills Development (DSD) and industry experts to develop the National Occupational Skills Standards (NOSS). NOSS is consisting of competencies of expected of a skilled employee in Malaysia in a defined occupational specific area. The Malaysian Skills Certificate (MSC) is then awarded to those who qualify. The MSC may be awarded via three ways: First, training in accredited centers, accredited centers refer to providers of skills training approved by the DSD to manage skills training based on the NOSS approved, and to offer the MSC for certain related sectors and continuous professional skill levels. Second, industry-oriented training, this is related to apprenticeship training under the National Dual Training System (NDTS) organized in related industry and skills training institutes. Third, accreditation of prior achievement, a candidate may qualify for the MSC based on past experience (work or related training), without sitting for a written exam. Candidates are however required to submit evidence of their acquired related skills which will be reviewed by government/association appointed by the DSD.

T&CM Research in Malaysia Research and development (R&D) are crucial to evidence support the good integration of T&CM in Malaysia. This ensures that the utilization of T&CM is supported by evidence-based. Here are two main areas in which research is being conducted, one is herbal medicine and the other is T&CM practices. Malaysia has significant milestones in herbal R&D with the establishment of the Herbal Medicine Research Centre (HMRC) at the Institute of Medical Research (IMR) in 2000. The effort by New Key Economic Areas supports to long-term goal embarks on the drug discovery program. Current research activities include: using cell tissues culture in pre-clinical evaluation of herbal extracts; strengthening the capability in the safety evaluation of herbal product using both in vivo as well as in vitro systems; and strengthening the capability in various phytochemical analysis and structure elucidation for the purpose

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of identification of active constituents as well as standardization of herbal products in Malaysia.33 From 2004 to 2014, several observational studies have looked into the Malay postnatal therapies, documentation of the traditional Malay medicine in Malaysia, transliteration, and translation of the old manuscript of the traditional Malay medicine and Islamic medicine.34 There is a further need to create conducive research environments, establish suitable mechanisms for T&CM research, and improve shared knowledge between practitioners of T&CM and modern Western medicine to high achievement the full potential of T&CM research in Malaysia. Current status, the herbal product development in Malaysia is very closely following the pharmaceutical drug development pathway in public and T&CM industry markets. They are considered to be addressed for the elucidation of all chemical compounds in the herbal extracts,35 the identification of all active ingredients,36 the toxicology studies when the herbs have safely been used as food or herbal products37 by the population in Malaysia. Despite the high utilization of T&CM in Malaysia, the overall investment for T&CM research is low because of a perceived lack of importance as a national research priority, lack of integration, low knowledge status in modern Western medicine officers and other scientists for evaluation for T&CM research. For the issues and challenges there are currently weakness of public and private institutions to set up the R&D direction for T&CM research

33 Introduction to Herbal Medicine Research Centre (HMRC). Institute for Medical Research. Available at https://www.imr.gov.my/index.php/en/hmrc. Assessed January 15, 2019. 34 Publication list. Institute for Medical Research. Available at https://www.imr.gov. my/index.php/en/research-a-publication/publication-listing Assessed January 15, 2019. 35 Abdullah R, Diaz LN, Wesseling S, et al. Risk assessment of plant food supplements and other herbal products containing aristolochic acids using the margin of exposure (MOE) approach. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2017; 34(2): 135–144. 36 Ismaile HF, Hashim Z, Soon WT, et al. Comparative study of herbal plants on the phenolic and flavonoid content, antioxidant activities and toxicity on cells and zebrafish embryo. J Tradit Complement Med. 2017; 7(4): 452–465. 37 Rehman, S.U., Choe, K., Yoo, H.H. Review on a traditional herbal medicine, Eurycoma longifolia Jack (Tongkat Ali): Its Traditional uses, chemistry, evidence-based pharmacology and toxicology. Molecules. 2016; 21(3): 331.

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in Malaysia, and to coordinate research collaborations; the shortage of high-quality research that supports the development of evidence-based policies and efficient decision-making processes for Malaysia local grants agency; also, need to increase for dissemination of research finding in T&CM. The overall T&CM research is to improve the T&CM knowledge in government sectors. Therefore, Division of T&CM needs to set up well management grants committee and financial incentives need to consider accelerating T&CM research in Malaysia.

Conclusion The T&CM, a group of diverse medical and healthcare practices and products that are not considered part of conventional medicine, but increased in popularity throughout the world, and co-existed among Malaysia for a long time. In Malaysia shows that people are not only using T&CM for general well-being, also substituting conventional medicine with T&CM, suggesting that it is important to understand why people choose to use T&CM as the mainstream healthcare system. However, the T&CM of this field into the mainstream conventional healthcare system is still its beginning status. From the Laws of Malaysia,38 the T&CM is defined as a form of health-related practice designed to prevent, management, illnesses or to preserve the mental and physical well-being of an individual. Malaysians primarily sought T&CM healthcare services for the maintenance of wellness and the treatment of minor musculoskeletal disorders such as joint and muscle pain, and rehabilitations.39 In the future directions are currently, the use of T&CM is increasing rapidly in Malaysia. Division of T&CM, Ministry of Health Malaysia, health professionals, and the public are considering with challenges and issues about efficacy, quality, safety, availability, preservation and further

38 Laws of Malaysia act 775—traditional and complementary medicine act (2016). Available at: http://www.federalgazette.agc.gov.my/outputaktap/aktaBI_20160310_WJW006 216Act775-BI.pdf. Accessed December 20, 2018. 39 Kumar S, Rajiah K, Veettil SK, et al. A cross-sectional study on knowledge and attitude toward traditional Chinese Medicine (TCM) among adults in selected regions of Malaysia. J Complement Integr Med. 2015; 12(4): 317–323.

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development of T&CM of health care in national healthcare system.40 For future prospective to improve the safety of herbal medications need to be addressed: (1) establishing a global surveillance system to track the origin, characteristics, and processing of herbal drugs; (2) use advanced technologies as quality-control standards during herbal production and processing; and (3) promoting evidence-based T&CM. These functions are serving by consortium for the Globalization of Chinese Medicine, started at the University of Hong Kong in 2003.41 For TCM education in Malaysia is in the midst of systematic reformation. Yet little effort has been made in assessing how students evaluate their clinical skill training in T&CM, how T&CM education could include modern medical education,42 how emphasize T&CM education from different type of education categories,43 or how to make clinical skill training in T&CM sufficient to meet the public expectations. T&CM and modern medicine in education contends with the challenge of bridging significant difference between two medical systems that was historically developed apart.44 However, their integrative use forms an important part of T&CM clinical skill training and medical education that should be reflected in Malaysia’s T&CM and modern medicine educational or clinical skill training development. Thus integration of T&CM in the modern healthcare system requires a great deal of contribution in research from clinical and behavioral aspects. Attitudes of consumers, conventional healthcare providers, T&CM physicians as well as policymakers toward integrating T&CM into the modern healthcare system may act as a bridge linking research and action to acknowledge the role of T&CM in supporting human health in the Malaysia. These challenges and issues for T&CM in Malaysia would 40 Lewith GT, Chan J. An exploratory qualitative study to investigate how patients evaluate complementary and conventional medicine. Complement Ther Med. 2001; 10: 69–77. 41 Liu SH, Chuang WC, Lam W, et al. Safety surveillance of traditional Chinese medicine: Current and future. Drug Saf. 2015; 38(2): 117–128. 42 Zhong W, Zhang M Early clinical education on intevrated traditional Chinese and Western medicine. Zhongguo Zhong Xi Yi Jie He Za Zhi. 1998; 18(7): 438–439. 43 Kim YJ. Observational application comparing problem-based learning with the conventional teaching method for clinical acupuncture education. Evid Based Complement Alternat Med. 2019: 2102304. 44 Mahapatra S, Bhagra A, Fekadu B, et al. Incorporation of integrative medicine education into undergraduate medical education: A longitudinal study. J Integr Med. 2017; 15(6): 442–449.

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be the first-stage information for the establishment of a strategy regarding the enhancement of status of T&CM in Malaysia.

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Division of T&CM. National T&CM Policy. Ministry of health Malaysia. Available at http://tcm.moh.gov.my/en/upload/NationalPolicy.pdf. Accessed January 13, 2019. Division of T&CM. Traditional and complementary medicine division annual report 2018. Ministry of health Malaysia. Available at http://tcm.moh.gov. my/en/index.php/publication/annualreport. Accessed July 17, 2019. Division of T&CM, Traditional and complementary medicine Blueprint 2018– 2037 health care Malaysia, Ministry of health Malaysia. Available at http:// tcm.moh.gov.my/ms/upload/Blueprint.pdf. Accessed December 18, 2018. Division of T&CM, Ministry of health Malaysia. T&CM Education system. Available at http://tcm.moh.gov.my/en/index.php/education/educationsystem. Assessed December 16, 2018. Division of T&CM, Ministry of health Malaysia. T&CM Higher Education. Available at http://tcm.moh.gov.my/en/index.php/education/highereducation. Accessed December 20, 2018. Edriss H, Rosales BN, Nugent C, et al. Islamic medicine in the middle ages. Am J Med Sci. 2017; 354(3): 223–229. Farizah A., Mohd ASZ. Issues and challenges in the development of the herbal industry in Malaysia. Prosiding Perkem. 2015; 10: 227–238. Available at www.ukm.my/fep/perkem/pdf/perkem2015/PERKEM_2015_3A1. pdf. Accessed July 18, 2019. Hooper D, Burkill IH. On Chinese medicine: Drugs of Chinese pharmacies in Malaya. Garden’s Bull Straits Settlements. 1929; 6: 1–80. Introduction to Herbal Medicine Research Centre (HMRC). Institute for medical research. Available at https://www.imr.gov.my/index.php/en/hmrc. Assessed January 15, 2019. Ismaile HF, Hashim Z, Soon WT, et al. Comparative study of herbal plants on the phenolic and flavonoid content, antioxidant activities and toxicity on cells and zebrafish embryo. J Tradit Complement Med. 2017; 7(4): 452–465. Karen Gardner, Beverly Sibthorpe, Mier Chan, et al. Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: A scoping systematic review. BMC Health Serv Res. 2018; 18: 541. Kaur J, Hamajima N, Yamamoto E, et al. Patient satisfaction on the utilization of traditional and complementary medicine services at public hospitals in Malaysia. Complement Ther Med. 2019; 42: 4220428. Kim YJ. Observational application comparing problem-based learning with the conventional teaching method for clinical acupuncture education. Evid Based Complement Alternat Med. 2019: 2102304. Kumar S, Rajiah K, Veettil SK, et al. A cross-sectional study on knowledge and attitude toward Traditional Chinese Medicine (TCM) among adults

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in selected regions of Malaysia. J Complement Integr Med. 2015; 12(4): 317–323. Laws of Malaysia act 775—Traditional and complementary medicine act (2016). Available at: http://www.federalgazette.agc.gov.my/outputaktap/akt aBI_20160310_WJW006216Act775-BI.pdf. Accessed December 20, 2018. Lewith GT, Chan J. An exploratory qualitative study to investigate how patients evaluate complementary and conventional medicine. Complement Ther Med. 2001; 10: 69–77. Liu SH, Chuang WC, Lam W, et al. Safety surveillance of traditional Chinese medicine: current and future. Drug Saf. 2015; 38(2): 117–128. Mahapatra S, Bhagra A, Fekadu B, et al. Incorporation of integrative medicine education into undergraduate medical education: A longitudinal study. J Integr Med. 2017; 15(6): 442–449. Ministry of Education Malaysia. Malaysian qualifications framework 2nd Edition. Available at www.mqa.gov.my/pv4/mqf.cfm. Assessed 22 December 2018. Ministry of Health Singapore, TCM Practitioners. Available at: https://www. moh.gov.sg/hpp/tcm-practitioners. Accessed January 25, 2019. Myeong YS, Ahn SY, Son CG. Education for traditional medicine in medical schools in Japan. Korean J Acupuncture. 2016; 33: 12–17. Ooi GL. Chinese medicine in Malaysia and Singapore: The business of healing. Am J Chin Med. 1993; 21:197–212. Oyebode O, Kandala NB, Chilton PJ, et al. Use of traditional medicine in middle-income countries: A WHO-SAGE study. Health policy Plan. 2016; 31(8): 984. Pharmaceutical Services Programme, Ministry of health Malaysia. Available at https://www.pharmacy.gov.my/v2/en/documents-library/guidelines. Accessed December 20, 2018. Publication list. Institute for medical research. Available at https://www.imr.gov. my/index.php/en/research-a-publication/publication-listing. Assessed 15 January 2019. Rehman SU, Choe K, Yoo HH. Review on a traditional herbal medicine, Eurycoma longifolia Jack (Tongkat Ali): Its traditional uses, chemistry, evidence-based pharmacology and toxicology. Molecules. 2016; 21(3): 331. Sejari N, Kamaruddin K, Ramasamy K, et al. The immediate effect of traditional Malay massage on substance P, inflammatory mediators, pain scale and functional outcome among patients with low back pain: study protocol of a randomised controlled trail. BMC Complement Altern Med. 2016; 16: 16. Siti ZM, Tahir A, Ida Farah A, et al. Use of traditional and complementary medicine in Malaysia: A baseline study. Complement Ther Med. 2009; 17: 292–299.

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Tan W, Wong H, Ng S, et al. Traditional Chinese medicine in Malaysia: A brief historical overview of the interactions between China and Malay Peninsula. Chin Med Cult. 2018; 1: 60–63. Third National Agriculture Policy (DPN3). Ministry of agriculture & agrobased industry Malaysia. Available at http://www.fama.gov.my/en/web/ pub/dasar-pertanian-negara-ketiga-dpn3-. Accessed June 20, 2019. World Health Organization. WHO traditional medicine strategy 2014–2023. World Health Organization. Zhong W, Zhang M. Early clinical education on intevrated traditional Chinese and Western medicine. Zhongguo Zhong Xi Yi Jie He Za Zhi. 1998; 18(7): 438–439.

CHAPTER 9

Imperial Medicine and Ethnicity in an Urban Society: Cholera Epidemics in the Philippines Yoshihiro Chiba

Introduction In the transition from the nineteenth to the twentieth century, the Philippines experienced several cholera epidemics, at least, twice in the 1880s and once in the early 1900s. These epidemics had come from other Southeast Asian colonies or Chinese port cities such as Canton and Amoy, connecting the Maritime Silk Road, which is the setting of the fifth and sixth cholera pandemics in 1881–1896 and 1899–1923, respectively (Hays 2005). These cholera outbreaks serve as the foundation of this study’s discussion of medicine and public health policies in the Philippines under the Spanish and American regimes. In late nineteenth-century Philippines, the Spanish colonial government extensively implemented the maritime quarantine on these epidemics as well as local sanitation in their aftermath. Following the Spanish regime, American public health policies, which emerged from the

Y. Chiba (B) Kanazawa University, Kanazawa, Japan e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_9

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Philippine-American War, put Filipinos under surveillance, in relation to their health management. American cholera measures consisted of house inspections as part of colonial governance. This paper discusses the public health policies carried out by these two empires in Manila and focuses on the cholera measures as well as examines medical practices in distinction of ethnicity.

The Historiography of State and Voluntary Welfare Provision The nineteenth-century Philippines imported a new welfare system from Europe. Compared to Asia where the emperors, to whom land properties were belonged, controlled people through the multilayered networks, such as China and India, the European states were interdependent and configured one coherent pack, in particular, after the treaty of Westphalia (1648). The European states externally depended on the power balance while they internally hold the decentralized power, and pursued the proficiency of governance. During 150 years after the Reformation, the welfare’s “public sphere” expanded and, the state, church and private voluntarism were activated interdependently. Although poor relief and welfare provision were deeply connected as an important social task across great areas of Europe, there were the characteristics on welfare provision between northern, Protestant Europe and southern, Catholic Europe. Protestant countries provided the welfare through agents in municipalities or parishes and their states regulated them. On the other hand, in Catholic countries, welfare provision system related to church was transformed in the Counter-Reformation and, the religious orders and the charitable, fraternity associations tended to play an important role in its provision (Cunningham and Innes 1998). In the seventeenth-century Spain which experienced the CounterReformation, the values on salvation of souls and charity changed and the associations of fraternity, the ideas of solidarity, and the mutual-aid were substantial. Since the reformist Enlightenment, however, spread in the eighteenth-century Spain, the poverty was re-esteemed from a standpoint of both the rationality and usefulness on works and, the indolence was avoided. The old charity system, simultaneously, became centralized and repressive. Although the political ideas of the liberalism, further, expanded in the nineteenth century, the industrialization was more sluggish than the other European countries and the poor increased across the country.

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However, the middleclass people who burgeoned in the provincial cities demanded the welfare provision, not to central, but to provincial government, while the power of church became strong in the fields of welfare in the mid-nineteenth century again (Grell et al. 2005). For the welfare services for Filipinos under the nineteenth-century Spanish governance, the colonial government and the church were the vital players for regulation of welfare provision. In the latter nineteenth century, Manila, which burgeoned as an urban society, first, became the space for establishing a new system of poor relief and welfare provision. The municipalities were transformed for this system in Manila while the provincial governments became a new foothold of civil services for medical services, public health, and poor relief. Besides, the voluntary bodies were added as the welfare providers for Filipinos, as well as Chinese societies. In such the voluntarism, Filipinos tended to depend on native medicine, and, for Chinese, clan and hometown associations must have organized their own medical services. In the cholera epidemics, especially, the self-contained aspects in local economy substantiated in the voluntarism of Filipino societies. Considering the effects of cholera epidemics in urban societies, this study focuses on the Spanish and American intervention on Filipinos’ health management. Through this intervention, the municipalities were established as an operational plot for welfare provision in Manila of the late Spanish era. Local societies around Manila, simultaneously, depended on families and volunteers to respond to such health risks, and religious rituals were given much esteem under control of parish priests. In contrast, in the Philippine-American War, American colonialism established a centralized authoritarian rule to carry out cholera measures basically founded on biomedical factors although possible racist tendencies were applied by the colonial government to deal with Filipino health care. However, American colonial authority, too, used the local government for welfare provision inside Manila although it newly established health district corresponding to a former municipality. As a result, public health policies along with house inspections angered many Filipinos, which increased their sense of nationalism and finally be the chance for change in such policies. So far, some scholars have merely focused on American public health and medical policies in the early twentieth century (Ileto 1988; Sullivan 1988). As a result, the medical and public health system under Spanish control was either ignored or referred to in accordance with American

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colonial records. Therefore, this study, first, analyzes the sequence of Spanish and American governance and compares them to address the gap in research. This would help us comprehend urban Manila as it transitioned from the nineteenth to the twentieth century and overcome certain historical distortions. Second, this paper highlights house inspections by sanitary inspectors as a means to interfere with Filipino life during American rule. While the 1880s saw the centralization of sanitary administration under Spanish governance, it accelerated during the American colonial regime and added Chinese medicine later. Third, this study discusses the medical practices by physicians and families for cholera patients, focusing on state medicine. This article proves that up to the early twentieth century, a vague distinction can be observed between Western and native medicine in these two imperial eras, apart from Chinese medicine. This study also considers Chinese customs and medicine, in addition to Western and Filipino medicine. At that time, Manila had Binondo district where many Chinese resided. In relation to Spanish imperial medicine, the Chinese, as well as the Muslims, were discriminated, with disdain for Chinese commercial practices and restaurants. Even in American era, Chinese residents in Binondo didn’t respond to the Western medicine through public service, so that, up to 1910, Chinese medicine started being provided as free service for the poor. Since the latter nineteenth century, single Chinese men had immigrated from Canton and Fujian. For Chinese societies that kept the clan and hometown networks, the voluntary bodies played an important role in Manila, such as establishing a hospital. Further, in 1904, the Chinese Chamber of Commerce was established and became a representative body for Philippine Chinese. American colonial government, however, included the Chinese into the state medicine, in addition to Filipinos. Therefore, we need to consider the medical services for Chinese, from a standpoint of relationships between the state and the voluntary bodies including clan networks (See 1988, pp. 319–334). The Spanish and American public health policies were similar in several aspects. Under a more centralized health management system implemented throughout the cholera epidemics of the 1880s, Spanish colonial Manila actually established medical institutions such as municipal physicians (médicos municipales) and scientific laboratories, and the American

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empire inherited them. However, America newly added Chinese municipal physician and, complicatedly, took into consideration the ethnic diversity, reflecting their racism.

Cholera and Port Quarantine Cholera measures are regarded by this article as a landmark of public health policy which the Spanish colonial government effected in the late nineteenth century. Starting from 1820, there were multiple cholera outbreaks in the Philippines. Measures against the disease consisted of port quarantine and local sanitation, which other countries carried out as well. Port quarantine was performed gradually after the 1850s, followed by local sanitation in Manila which particularly dealt with the two cholera outbreaks in the 1880s. The Spanish colonial government presented official data on cholera deaths in several provinces in 1882–1883: Manila, 2,108; Zamboanga, 1,719; Pangasinan, 24,187; and Capiz, 9,256 (Resumen de los Fallecidos por Cólera-morbo 1882). While countrywide statistics were unavailable, Pangasinan and Capiz particularly suffered more in terms of cholera fatalities and mortality than they did in the epidemic of 1888–1889. Thus, the 1882–1883 cholera epidemic may not have been a small-scale outbreak in the Philippine context. Meanwhile, there is more elaborate data on the Philippine death toll during the cholera epidemic of 1888–1889 (Table 9.1). Using data by both provincial governments and the General Inspector of Department of Benevolence and Sanitary, the total number of deaths in the country was 75,000, with about 1,600 in Manila. The countrywide figure approached approximately 100,000 that died during the early American colonial control, in 1902–1904. The cholera epidemic of 1888–1889 had several characteristics. First is the high mortality in some Luzon provinces such as Zambales and Tayabas, which are far from traffic key points. The difficulty of obtaining information was likely to lead to delays in cholera intervention. Second, and more important, is that the key trading areas of Pangasinan and Iloilo suffered from an intense prevalence of cholera. Despite the diversified situations within the country, the expansion of trading networks in the nineteenth century steadily put people at risk of contracting cholera.

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Table 9.1 Cholera fatalities and mortality in the Philippines (1888–1889) 1888–1889 Cholera fatalities* Manila Luzon (except Manila) Pangasinan Nueva Ecija Tarlac Zambales Tayabas Pampanga Bulacan Morong Bataan Laguna Cavite Camarines Sur Visayas Mindoro Capiz Iloilo Bohol Mindanao Zamboanga Total

1889 Cholera mortality (yearly, ‰)

Total fatalities

Total mortality (yearly, ‰)

1,603

3.5

14,666

63.0

17,916 1,946 440 2,276 2,254 3,917 2,996 684 442 921 1,142 2,650

22.7 7.0 2.4 13.0 11.4 8.9 6.4 9.2 4.7 3.6 4.8 10.2

13,563 13,992 6,871 6,982 4,186 14,751 16,136 3,388 2,606 11,646 6,378 3,344

34.3 99.7 72.7 79.7 42.4 66.6 68.2 91.0 55.2 89.6 53.5 25.7

1,190 6,727 27,217 1,183

14.0 39.6 42.8 2.3

1,791 6,220 31,158 8,424

42.1 73.1 98.0 31.9

1,134 75,041

n.a. 6.0

n.a. 287,271

n.a. 45.9

* Regards Manila, Nueva Ecija, Talrac, Bulacan, Morong, Bataan and Laguna provinces, lacking of official data of each provinccial government, cholera fatalities were substituted by the data on a publication by Benito Francia, the General Inspector of Benevolence and Sanitation, at that time Sources Datos soble Defunciones por Cólera, 1888–1889 y 1896, n.d.; United States, Bureau of the Census 1905, vol. 3, pp. 13–16

The nineteenth-century Philippines increased its sugar, Manila hemp, and tobacco exports and imported daily necessities such as cotton products. This also led to the increase in the number of entering and departing ships in the country. The 1880s saw these numbers jump tenfold from approximately 200 ships in the early 1820s. The country’s main trading partners in both exports and imports were Britain, China, America, and

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Spain although Spain dropped their share of both imports and exports to 10% of the total in the 1880s (Legarda 1999). The Manila Port opened in 1834 followed by Iloilo, Sual, and Zamboanga in 1855 and Cebu in 1860. The Direction of Marine Sanitation opened its Manila office in 1883 and established offices in Iloilo, Cebu, and Zamboanga in 1886. To visit ships and undertake medical inspections, the Manila office employed five medical doctors, and each of the other ports had two medical doctors (Direccion General de Administracion Civil n. d.). In actual quarantines that reflected Philippine export and import activities, trading with Spain and China, in addition to the Sulu Islands, was cautioned against. With regard to the port quarantine carried out in the late nineteenth century, the Spanish colonial government frequently contacted its own consulates to obtain information on infectious diseases and quarantined passengers and crews on ships. Also, in 1855, the Office of Marine Quarantine was established and issued sanitary certificates to long-passage ships that passed inspection (Bantug 1953, pp. 67–68). In 1881, the Spanish colonial government kept watch over foreign ships entering Mindanao, in coordination with the Sultan of Jolo in Sulu. However, a cholera outbreak occurred in Zamboanga and Jolo in 1882, and spread all over the Philippines, resulting in stricter traffic regulations (De Bevoise 1995, pp. 168–175). For example, in June 1882, the Port Committee directed surveillance over all municipalities along the seashore. The municipal mayors were ordered to monitor not only ship entry from Jolo Island but also the disembarkation of goods and people from those ships. The ships must present an official document specifying a port of departure (Junta del Puerto 1882). In the 1888– 1889 cholera epidemic, meanwhile, Manila issued warnings against ships coming from Zamboanga (Beneficencia y Sanidad 1889). With regard to these actions against ships from Jolo Island and Zamboanga, we need to consider the roles that political fear and discrimination might have played in such circumstances. Trading with Jolo Island, where many Muslims resided, was especially regulated because Spanish colonial power did not actually reach the region (Junta de Sanidad 1881). While the piracy of Sulu Muslims ended in the mid-nineteenth century, the Kingdom of Sulu Islands maintained political independence until the 1880s. In such context, European countries demanded that goods be exported to China and were interested in the resources and trading networks of the Sulu Islands, which Sulu

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Muslims used to trade with the Bay of Bengal, Macao, Canton, Singapore, and Manila. The Sulu Islands ran the risk of acquiring infectious diseases from various direction; at the same time, these were areas that the Spanish colonial government could not control, as well as China. Spanish consulates in China also frequently contacted the Philippines on cholera epidemics and regulated the movement of passengers through an issue of health certificate (Comandancia de Marina y Capitania del Puerto de Manila y Cavite 1877). On the other hand, under American rule, the number of cholera patients and deaths all over the Philippines reached 1,606,252 and 109,461, respectively, from March 1902 to April 1904 (United States, Bureau of Insular Affairs 1904, pt. 2, p. 11; 1905, pt. 2, p. 114; Philippine Islands, Board of Health 1903b, p. 10). The American colonial government attributed the spread of the cholera infection to vegetables imported from Canton, which led to the prohibition of green vegetables imports (Worcester 1902). Further, in 1903, in populated areas such as Binondo and San Nicolas in Manila, cholera was rumored to spread from people who took drinking water from rivers, resulting in greater focus on sanitary measures on drinking water (United States, Bureau of Insular Affairs 1903, pt. 2, p. 7). Regarding the quarantine at Manila Port, cholera patients were discovered in 105 ships, which were then disinfected from September 1902 to August 1903. The following year, 156 ships were disinfected at Manila Port, including those from ports where the cholera epidemic was rampant (United States, Bureau of Insular Affairs 1903, pt. 22, p. 11, pp. 239–241; 1905, pt. 2, p. 111). However, although port quarantine was established in late nineteenthcentury Philippines, which corresponded to an expansion in foreign trade, cholera epidemics expanded in a large scale until the early twentieth century. We need to reconsider whether such measures were available on Spanish and American operations to avoid the spread of infectious diseases such as cholera. In this background, through Spanish and American colonial governance, some cholera outbreaks in the Philippines had been probably caused by the spread from China. Although the Philippine colonial government often received the information on cholera epidemics from the consulates in China, the cooperative efforts between the Philippine colonial government and China had not been seen internationally, at least, up to the early twentieth century.

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Public Health in Manila The urbanization of Manila largely evolved during the nineteenth century. Simultaneously, the pollution in Pasig River worsened, making it impossible for its inhabitants to use its water. Water supply work which received funds donated by Don Francisco Carriedo began in 1878 and was completed in 1882. Afterward, many inhabitants in Manila could consume pipe water from the Mariquina River in the suburbs. In the four estuaries of the Pasig River, dumped garbage and stagnant mud rendered the riverbed shallow, so ships could not enter the river at times. The river was then dredged, and in 1892, a new wharf was constructed. In addition, drainage ditches have been excavated since the late nineteenth century, particularly in Intramuros and its neighboring areas. The ensuring odor caused inhabitants a great deal of trouble, as the filthy water lay stagnant in the drainage. In 1875, drainage work was carried out in Jacinto Street, Binondo, which was famous for its commercial areas. Residents hoped for the work to be finished as soon as possible. Thus, the medical officer (médico titular) covering these areas reported the sanitary trouble to the administrative office of Manila. According to the report, inhabitants suffering from fever because of the stench temporally moved to the neighboring Ermita district. The moats were filled with stagnant water and dead animals, and unsanitary practices by the residents themselves seemed to add to the waste at the bottom of the moats (Corregimiento de la Ciudad de Manila 1875). The cholera epidemic of 1882–1883, which resulted in many deaths, raised awareness of public health in the Philippines. Several health districts were locally established to monitor the health of inhabitants. At this time, Manila held 10 or 11 health districts, which appointed municipal physicians who would provide free medical services for the increasing poor populace. In addition, in each province, public physicians (médicos titulares) took the responsibility of managing public health. In 1883, the General Inspection of Benevolence (Inspeccion General de Beneficencia) was established inside the central government and took charge of sanitation and demographics. The municipal and public physicians who worked locally were especially significant to public health and medicine. After 1885, in the entire Philippines, sanitary councils in municipalities (pueblos) consisting of municipal mayors, physicians or vaccinators, and

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officers of the Guardia Civil, were established under the authority of parish priests (Filipinas 1884, p. 477). In reality, local parish priests were the foremost authority with regard to cholera. During the 1882–1883 cholera epidemic, San Juan del Monte, part of the Manila suburbs, offered an impressive case. Parish priest worked on sanitary affairs, such as the sale of food, prostitution, and the establishment of segregation institutions. Music performances were also recommended to improve residents’ mental health. Further, the Sanitary Commission of San Juan del Monte was formed with the goal to promptly and appropriately care for cholera patients and monitor them with utmost attention. However, it must have been blamed that many officials entered patients’ houses. Families should have taken care of the patients instead. When corpses were laid out at a chapel, people were discouraged from displaying sacrilegious behaviors (Gobernadorcillo de San Juan del Monte 1882). As the case of the Manila suburbs, cholera measures depended on the discretion of local societies. Moreover, patient treatments tolerated native views of life and death, emphasizing religious rituals and kinship relations, rather than biomedical factors. After the cholera epidemic in the Manila province was officially declared over in December 1882, Te- Deum (“Thanks to God”) was recited in the central park as well as in other provinces as advocated by the Spanish colonial government (Resumen de los Fallecidos por Cólera-morbo 1882). In the 1888–1889 cholera epidemic, too, sanitary commissions were formed in provinces and municipalities. These agencies had to report to the central government regarding sanitary measures and their effects. In Manila, the main measures were ship surveillance on rivers, sanitary practice recommendations in houses and ships, and the establishment of cholera hospitals (Inspeccion General de Beneficencio y Sanidad 1889a; Beneficencia y Sanidad 1889). In addition, mid-nineteenth century Manila saw the formation of a few hospitals by the Catholic order, such as Hospicio de San Jose, Hospital de San Lazaro, and Hospital de San Juan de Dios. In the 1890s, the Ch’ungjen Hospital was established for the Chinese in Manila (Wickberg 1965, p.185, p.188). In Chinese community, during 1879, one Chinese municipal mayor of Binondo collected 500,000 pesos and temporarily set up a Chinese hospital near their cemetery for cholera patients. Further, for Chinese in

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Manila, it was important that a benevolent association, named the Shanchü Kung-so, was established in 1870. It administered the Ch’ung-jen Hospital besides Chinese cemetery because the Hospital de San Juan de Dios near their residence used Western medical methods. The Ch’ungjen Hospital which offered charitable services to the poor was financially supported, at first by a tax on newly arriving Chinese immigrants; later, by monthly taxes on Chinese shops and a tax on Chinese returning to China (Wickberg 1965, pp. 184–188). During the Philippine-American War following the Spanish colonial governance, Ordinance No. 30, enacted in March, 1902, provided several measures against cholera in Manila. First, boats and ships were banned from entering Pasig River and its estuaries within Manila after 5:00 p.m. Second, if a cholera patient’s house was made of light materials, these homes were demolished under responsibility and direction of the Board of Health. Third, drinking water from and doing laundry on the Pasig River were prohibited during the cholera epidemic. Penalties and imprisonment were levied against violators of the ordinance (Philippines Islands, Board of Health 1904c). In March, 1902, Manila held 12 health districts to which municipal physicians belonged. Although health districts took measures to prevent cholera, many residents did not follow such regulations. Particularly, those who were against being sent to isolation facilities hid their cholera infection from the authorities (Casas de Socorro 1898; Manila, Board of Health 1904, p. 1). Also, sanitary inspectors, who were under the chief health inspector, carried out house inspections in each health district. For example, in 1903, at least, 145 sanitary inspectors were under the supervision of one chief health inspector who were composed of both Filipinos and Americans (United States, Bureau of Insular Affairs 1903, pt. 2, p. 342; 1905, pt. 2, p. 185). Meanwhile, in April 1904, 14 Filipino sanitary police officers were added to house inspection operations (United States, Bureau of Insular Affairs 1905, pt. 2, p. 186). House inspections increased in May 1902, a few months after the cholera outbreak, and during that month, the number of house inspections suddenly rose from 100,000 to 400,000 per month (Philippine Islands, Board of Health 1902–1905). In the 1903 census, the number of dwellings in Manila was 28,389, which means that each dwelling was inspected more than three times on average (United States, Bureau of the Census 1905, vol. 3, pp. 714–715). In 1903, achievements included 2 million

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Table 9.2 House inspections in Manila (1901–1904)

1901 1902 1903 1904

House inspections and reinspections

Requests for house improvements

House disinfections

Garden cleanings

Cesspool cleanings

Reported patients

312,716 1,948,532* 1,518,952 322,740

9,852 195,385* 182,112 63,871

1,404 18,965 20,506 1,247

6,804 105,555 85,503 21,757

n.a. 7,127** 8,500*** 2,002

n.a. 5,683** 4,137 3,450

* Laking in data of Oct. 1902 ** Laking in data of Jan. 1902 *** Laking in data of June 1903

Sources Philippine Islands, Board of Health 1902–1905

house inspections, 7,336 house disinfections, and 11,256 toilet cleanings (Table 9.2). More importantly, through house inspections, patients were found and reported to municipal physicians. Because cholera patients needed to be isolated, the sanitary inspectors terrified residents. The number of patients found by these inspectors reached a peak of 1,423 persons in June 1903. Sanitary inspectors, who were composed of civilians and the military, visited each house with guns. People hid the corpses of their relatives and friends to avoid giving clues to sanitary inspectors; they also threw the bodies away in rivers and left them in forests (United States, Bureau of Insular Affairs 1903, pt. 2, p. 271; Pardo de Tavera 1902; Buencamino 1902). Even after the Philippine-American War, house inspections aggressively continued in each health district. Municipal physicians belonging to each district controlled public health management. The number of sick individuals reported to municipal physicians is noteworthy: from 3,450 in 1904, the number increased fivefold to 18,450 in 1911 (Philippine Islands, Bureau of Health, 1911–1912). Thus, Filipino life was placed under supervision of the state. However, as American medical officials admitted, no satisfactory medical treatments for cholera existed at the time. By 1905, prevention through appropriate laws and hygiene education had replaced violent measures. As to Chinese communities in Binondo, American policies didn’t vigorously intervene into them to inhibit cholera epidemic in 1902–1903,

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except the regulations such as the drinking water. The government report of 1901 estimated that the Chinese Chamber of Commerce controlled about 60,000 Chinese residents, besides the management of cholera hospital for Chinese. These endeavors caused a low mortality of cholera for Chinese (United States, Bureau of Insular Affairs 1902, p. 392). Next year, it was also reported that the mortality rate of Chinese resident areas was low, following Ermita district where Caucasians and rich Filipinos lived mostly (United States, Bureau of Insular Affairs 1903, pt. 2, p. 6). It is well-known that Chinese people took the hot water as a social custom which lowered their cholera mortality. Through such a bacteriological effect, cholera epidemic did not prejudice Chinese than Filipino societies. In early American colonial governance, municipal physician did not provide the Chinese medicine to Chinese residents. During the period of 1901–1903, Binondo district, too, was assigned to the municipal physician to provide the Western medicine. However, both numbers of visiting medical care and of outpatients were a few in Binondo. From Feb. 1902 to Aug. 1903, the number of visiting medical care and of outpatients was 46, 156 in Binondo; 955, 2,844 in Intramuros, respectively. As a result, medical activities of municipal physician stopped in Binondo in Sept. 1903 (Philippine Islands, Board of Health 1902–1905a). Chinese residents in Binondo did not accept the Western medicine at that time. However, up to 1910, free medical services, based on Chinese medicine, started for the Chinese in Meisic, through Chinese municipal physician named Tee Han Kee. He came as a medical doctor from Amoy in 1902 and was hired by the Board of Health to do sanitary work among Chinese residents in Binondo. And then he served for 19 years as municipal physician and, next, became the director of the Chinese General Hospital (Dayrit et al. 2002, p. 24). In the period of 1910–1914, the visiting medical care and the outpatients numbered 21,706, 51,522 in Intramuros and 2,391,9,733 by the Chinese municipal physician. During this period, regards to the visiting medical care by Chinese municipal physician, 1,830 cases that correspond to 76.5% were, actually, for Chinese patients (Philippine Islands, Bureau of Health 1910–1915). Chinese residents did not accept the Western medicine, but, appropriately, the Chinese medicine, even if they were medical services provided by colonial government. Medical service for the Chinese is likely to be partly reflected by the racism of American colonialism, because Chinese medical service was segregated from the Filipino societies.

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During the transition period from Spanish to American colonial control, sanitary authority became more centralized. Filipino life and health, which had been regarded as private matters, consequently became more controlled in the public space under surveillance of the state. Later, Chinese medical case also started to be put under American colonial control, as well as Filipinos.

Medical Practices A Spanish military physician who went on an inspection tour in Luzon in 1845–1846 described the climate of the Philippines and the Europeans’ acclimation to it. Acclimation factors such as heredity, customs, climate, foods, and ventilation were necessary for Europeans, as these depended on their health conditions and the infectious endemics. These factors also relied on changes in the human body caused by the country’s high temperature and humidity. Their bodies’ constitutions, obtained through exposure to surrounding nature, contribute to their good health. One sanitary discipline for Europeans was to live in houses with wide spaces to take in the east wind. To avoid sunlight, Europeans also stayed indoors. In addition, a diet with enough vegetables, as well as moderate exercise, was recommended. With regard to the natives in central Manila at that time, apartment houses that served as substitutes for nipa houses were also deemed problematic due to their poor sanitation and ventilation (Codorniu y Nieto 1857, pp. 109–114). His understanding was characteristically similar to those in tropical medicine, which emphasized disease and health in the context of nature and culture. The infectious diseases at that time, according to the epidemiological data collected by municipal physicians in Manila during the 1880s, were smallpox, measles, scarlet fever, cholera, typhoid fever, malaria, and beriberi (Beneficencia Municipal de Manila 1889). Patients with these diseases were treated by home remedies, which had been largely important, with treatments being provided by medical physicians, witch doctors, and herbalists. For example, retroactively to the mid-eighteenth century, a Spanish parish priest who stayed in Cavite introduced the role of home remedies in areas without physicians and pharmacists, with practices such as using herb plants to kill fleas and putting alunite or walnuts in a bottle to purify drinking water (De Santa Maria 1882). Up to the late nineteenth century, home health care was promoted by physicians in urban areas. Filipino physician T.H. Pardo de Tavera wrote a

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book on how families can properly nurse their patient at home to alleviate the burden on physicians. Pardo de Tavera argued that patients’ families needed to cooperate with physicians by having adequate knowledge of care and of home disinfection. Home care was a difficult task for families, as they did not have sufficient knowledge of assignments such as providing meals in accordance with the physician’s instructions (Pardo de Tavera 1895). In the late 1880s, a pamphlet was published regarding cholera prevention and treatment, which was advocated in Spain. It recommended that Spanish sanitary discipline, which depended on both bacteriology and miasma theories, be integrated into Philippine society. Consequently, several preventive measures were recommended, such as cleaning houses using lime, segregation of humans and animals, surveillance of Chinese shops, avoidance of Chinese foods, and the purification of drinking water. In addition, sanitary disciplines for individuals included proper intake of foods and alcohol, consumption of heated vegetables and ripe fruits, avoidance of sudden coldness in the morning and the evening, and absorption of fresh air (Filipinas 1888, pp. 5–15). Characteristics of tropical medicine were obvious in this pamphlet as well, but native customs were not remarkably discouraged except in statements expressing concern about Chinese foods and restaurants. According to this pamphlet, in cholera infection cases, the family had to care for their patient in their homes until the physician arrived. The patient should lie on a warm bed in an isolated and ventilated room. Any nutrient intake should be avoided except hot water with or without oil, and enema was also encouraged. After arriving, the physician would just repeat the same treatment. If the symptoms persisted, the patient would be transferred to a cholera hospital (Filipinas 1888, pp. 10–15). In cases where physicians were not in the vicinity, assistant physicians treated the patient, as a case near Manila (Gobernador Civil de Morong 1888). In the Philippines, therefore, physicians provided simple medical care with the family’s cooperation. In addition, medical care by physicians was not distinct from that of native medical practitioners since physicians depended on herbs as well. Manungal oil, alcohol, and quinine were especially used as medications for cholera patients. Manungal oil, extracted from coconut trees, was the purgative used by native witch doctors. This reflected the intimate relations between Western and native medicine in the Philippines.

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An 1890 investigation discussed the scarce medicine supply in many areas where public physicians were assigned (Establecimientos de Botiquines en las Cabeceras de Provincias y Distoritos 1890; Expediente sobre Autorizacion para Regentar un Botiquin de Pasig para Arayat, Pampanga 1884). For example, a pharmacy in Northern Luzon necessitated lime disinfection, analgesic, chamomile, and ointment (Inspeccion General de Beneficencio y Sanidad 1889b). In the same year, the military headquarters of Davao also wanted herbal medicines and disinfectants such as alcohol and carbolic acid (Relation de Medicamentos y Desinfectantes, para las Atenciones del Servicio Sanitario en Comandancia de Davao 1890). The medications provided by Spanish imperial medicine were used as disinfectants or preventive agents rather than the cure. In the late nineteenth century, Spanish imperial medicine generally focused on herbs and hygiene. There were also no viable methods of treating cholera patients in early American colonial Manila. Until 1904, although chemical medications such as benzozone had been used to kill the cholera vibrio bacterium, in addition to manungal oil, they did not provide sufficient evidence of a cure. Even in 1905, cholera infection was controlled by preventive measures through the proper enforcement of laws and sanitary education (Philippines Islands, Board of Health 1904c, pp. 13–14). However, American colonial governance continued free medical service for poor patients. In Manila, municipal physicians attended to poor patients through home remedy or outpatient service. All over the city, after the cholera outbreak, the number of home remedy and outpatient cases rose from 261 and 1,050, respectively, in March 1902, to 1,014 and 3,360, respectively, in April 1902 (Philippine Islands, Board of Health 1902a, p. 12). In 1904, the total home remedy and outpatient cases were 6,225 and 18,934, respectively, at a monthly average of 519 and 1,578, respectively (Table 9.3). Medical activities by municipal physicians increased after the cholera epidemic. Such services were concentrated on the Tondo district where many poor resided. It is not obvious if the Chinese medicine had an effect on cholera patients. But the social customs of the Chinese, such as taking hot tea, were useful for cholera prevention, which urged the low mortality of Chinese in cholera epidemic. In spite of it, the esteem on Chinese life swung between two opposite tendencies. Compared to Filipinos, Chinese customs were given a negative esteem and discriminated, as well as the

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Table 9.3 Achievements of public physicians in Manila (monthly average) (1901–1904)

1901 (February–June) 1902 (February–June) 1902 (July–December) 1903 (January–June) 1903 (July–December) 1904(January–June) 1904 (July–December)

181

Cases of home remedies

Outpatients

252 594 359 302 360 371 667

866 1,785 1,071 1,028 1,126 1,167 1,989

Sources Philippine Islands, Board of Health 1902–1905

Muslims, in the late Spanish era, and vice versa on cholera measures in the early American era. Medical systems saw several similarities between the two regimes because American governance inherited the medical system that Spanish had formed in the late nineteenth century. Manila established several institutions such as free medical services for poor patients. In the background, Filipino physicians were steadily educated through the local university. Although America, like Spain, could not initially offer an effective medical treatment, Western medicine certainly infiltrated urban society through the three cholera epidemics in the 1880s and the 1900s and, simultaneously, added Chinese municipal physician to those institutions.

Conclusion In the Spanish era, local societies around Manila responded to serious health risks through families and volunteers. Under supervision by the Spanish colonial government, the respect was locally paid to religious rituals performed by parish priests. Medical care was generally practiced at the patient’s home, with native plants as medications. Spanish imperial medicine was not separate from native medicine. On the contrary, after the Philippine-American War, when American colonialism started establishing a more centralized administration to carry out cholera measures based on biomedical factors, the American regime demonstrated possible racist tendencies toward Filipino‘s health care. The public health policies along with house inspections, consequently, angered Filipinos, which then increased their nationalistic tendencies from the late Spanish era,

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with the Philippine Revolution, and finally may have led to changes in such policies. However, the public health policies of Spain and America were similar to some extent. In its more centralized rule through the cholera epidemics of 1880s, Spanish colonial Manila actually established some sanitary institutions which were passed on to the American empire. At the turn of the nineteenth to the twentieth century, people in Manila had been using herbal and chemical medication. Although European medical disciplines such as bacteriology became prominent at that time, American medical policies could not ignore native medicine. However, for the Philippines which had historically absorbed Chinese culture, the relation between herbal and Chinese medicine in the Philippines remains obscure in this study. In the late nineteenth century, the Philippines had a strong trading relationship with China and, simultaneously, were put at risk of cholera epidemic. Although, in cholera epidemics of the 1880s, Spanish consulates in China offered information on cholera, the coordinative efforts with Chinese government were not seen even in the 1900s. Further, late nineteenth-century Manila accepted a large amount of Chinese immigrants, particularly from Fukien. However, there is no record that Chinese than Filipino communities more seriously suffered from cholera epidemic, except bubonic plague. On the contrary, cholera epidemics were inhibited from in Chinese communities. They did not entirely accept the Western medicine through governmental free service, but, later, Chinese doctor played a part of municipal physician and did a favor for Chinese poor patients. The relationship of Chinese patients and their own medicine was much the same as Filipinos’ case. During the transition period of nineteenth and twentieth centuries, the distinction of medical practices between Western and Filipino medicine was not clear, but Filipino patients preferred native medicine. As to American imperial medicine, the rulers tried to improve Filipino sanitary customs with house inspections, which was politically significant for American colonialism because Filipino self-governance became one of the most important matters at hand. Self-governance in sanitation was regarded as the training of civic morals; sanitary customs based on static racism were significant not only for health but also for the political appraisal of Filipinos, particularly political independence. In the meantime, America did not entirely intervene into the social customs of Chinese residents. It urged the segmented Chinese societies against American and Filipino ones.

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References Bantug, J. P. (1953). Short History of Medicine in the Philippines during the Spanish Regime, 1565–1898. Manila: Colegio Médico—Farmaceutico de Filipinas. Beneficencia Municipal de Manila. (1889, Mayo). Estado Numérico de las Invasiones de Enfermedades Epidémicas. (Beneficencia y Sanidad). Philippine National Archives. Beneficencia y Sanidad, Direccion General de Administracion Civil. (1889, Mayo 20). Información a Ministro de Ultramar. (Cólera). Philippine National Archives. Buencamino, Felipe. (1902, May 15). Letter to William Howard Taft. (Series3). William Howard Taft Papers. Casas de Socorro. (1898, Agosto). Presupuesto de Gastos de 1897–98. (Beneficencia y Sanidad). Philippine National Archives. Codorniu y Nieto, Antonio. (1857). Topografia Médica de las Islas Filipinas. Madrid: Imprenta de D. Alejandro Gomez Fuentenebro. Comandancia de Marina y Capitania del Puerto de Manila y Cavite. (1877, Julio 22). Informaciaón soble cólera en China para Gobernador General. (Cólera). Philippine National Archives. Corregimiento de la Ciudad de Manila. (1875, Mayo 14). Información soble Alcantarillas para Inspección General de Obras Públicas. (Alcantarillas). Philippine National Archives. Cunningham, Hugh, and Joanna Innes. (Eds.) (1998). Charity, Philanthropy and Reform, from the 1690s to 1850. New York: Palgrave. Datos soble Defunciones por Cólera, 1888–1889 y 1896. (n.d.). (Cólera). Philippine National Archives. Dayrit, Conrado S., Perla Dizon Santos Ocampo, and Eduardo R. de la Cruz. (2002). History of Philippine Medicine with Landmarks in World Medical History. Pasig: Anvil. De Bevoise, Ken. (1995). Agents of Apocalypse: Epidemic Disease in the Colonial Philippines. Princeton: Princeton University Press. De Santa Maria, Fernando. (1882). Manual de Medicinas Caseras para Consuelo de los Pobres Indios, en las Provincias y Pueblos donde no Hay Médicos ni Botica. Manila: Imprenta del Colegio de Santo Tomas. Direccion General de Administracion Civil. (n. d.). Datas para la Guía Oficial de 1891. (Beneficencia y Sanidad). Philippine National Archives. Establecimientos de Botiquines en las Cabeceras de Provincias y Distoritos. (1890, Enero 30). (Médicos Titulares). Philippine National Archives. Expediente sobre Autorizacion para Regentar un Botiquin de Pasig para Arayat, Pampanga. (1884). (Médicos Titulares). Philippine National Archives. Filipinas. (1884). Guía Oficial de Filipinas, 1885. Manila: Establecimiento Tip. de Ramirez y Girudier.

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Filipinas. (1888). Cartilla Higiénica y de Desinfección. Manila: Tipo Litografia de Chofre y Comp. Gobernador Civil de Morong. (1888, Agost 25). Información soble Cólera a Director General de Administracion Civil. (Beneficencia y Sanidad). Philippine National Archives. Gobernadorcillo de San Juan del Monte. (1882, Septiembre 1). Comunicación soble Sanidad Local a Governador Civil de Provincia de Manila. (Médicos Titulares). Philippine National Archives. Grell, Ole Peter, Andrew Cunningham and Bernd Roeck. (Eds.) (2005). Health Care and Poor Relief in 18th and 19th Century Southern Europe. Hants and Burlington: Ashgate. Hays, J. N. (2005). Epidemics and Pandemics: Their Impacts on Human History. California: ABC-CLIO, Inc. Ileto, Reynaldo C. (1988). Cholera and the Origins of the American Sanitary Order in the Philippines, In David Arnold (Ed.), Imperial Medicine and Indigenous Society (pp. 125–144). Manchester and New York: Manchester University Press. Inspeccion General de Beneficencio y Sanidad. (1889a, Abril 25). Expediente sobre la Declaracion de la Existencia del Cólera. (Cólera). Philippine National Archives. Inspeccion General de Beneficencia y Sanidad. (1889b, Junio 12). Comunicación a Jacoba Zobel, Farmacéutico. (Beneficencia y Sanidad). Philippine National Archives. Junta del Puerto. (1882, Junio 16). Instrucciones Sanitarias soble la Declaracion del Cólera en la Isla de Jolo. (Cólera). Philippine National Archives. Junta de Sanidad. (1881, Septiembre 27). Cólera en la Isla de Jolo. (Cólera). Philippine National Archives. Legarda, Benito J. Jr. (1999). After the Galleons: Foreign Trade, Economic Change and Entrepreneurship in the Nineteenth-Century Philippines. Quezon City: Ateneo de Manila University Press. Manila, Board of Health. (1904). Report of Vital Statistics, December, 1900. Manila: Bureau of Public Printing. Pardo de Tavera, Trinidad H. (1895). Arte de Cuidar Enfermos. Manila: Tipo Litografia de Chofre y Comp.. Pardo de Tavera, Trinidad H. (1902, May 5). Letter to William Howard Taft. (Series3). William Howard Taft Papers. Philippine Islands, Board of Health. (1902–1905a). Monthly Report of the Board of Health for the Philippine Islands and City of Manila, January, 1901–December, 1904. Manila: Bureau of Public Printing. Philippine Islands, Board of Health. (1902b, April 10). Health Regulation for the Suppression of Asiatic Cholera. (Record Group 350, 150: 56//11/4). U. S. National Archives.

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Philippines Islands, Board of Health. (1904c). Asiatic Cholera in the Philippine Islands. Manila: Bureau of Public Printing. Philippine Islands, Bureau of Health. (1910–1915). Quarterly Report of Bureau of health for the Philippine Islands, First Quarter, 1910- Fourth Quarter, 1914. Manila: Bureau of Printing. Relation de Medicamentos y Desinfectantes, para las Atenciones del Servicio Sanitario en Comandancia de Davao. (1890, Abril 22). (Beneficencia y Sanidad). Philippine National Archives. Resumen de los Fallecidos por Cólera- morbo. (1882). (Beneficencia y Sanidad). Philippine National Archives. See, Chinben. (1988). Chinese Organizations and Ethnic Identity in the Philippines, In J. Cushman and Wang Gungwu (Eds.), Changing Identities of the Southeast Asian Chinese since World War (pp. 319–334). Hong Kong: Hong Kong University Press. Sullivan, Rodney J. (1988). Cholera and Colonialism in the Philippines, 1899– 1903, In Roy Macleod and Milton Lewis (Eds.), Disease, Medicine, and Empire: Perspectives on Western Medicine and the Experience (pp. 284–300). London and New York: Routledge. United States, Bureau of the Census. (1905). Census of the Philippine Islands: Taken under the Direction of the Philippine Commission in the Year 1903. vol. 3. Washington: Government Printing Office, 1905. United States, Bureau of Insular Affairs. (1900–1905). Annual Report of the Philippine Commission, 1900-1904, Washington: Govt. Printing Office. Wickberg, Edgar. (1965). Chinese in Philippine Life, 1850–1898. New Haven and London: Yale University Press. Worcester, Dean C. (1902, March 22). Report to Secretary of War, U.S.A., on Prohibition against Vegetable Imports (Record Group 350, 150: 56//12/4). U. S. National Archives.

CHAPTER 10

Perceptions on Illness and Wellness in East Asia: Contemporary Views on Japanese Medical Systems and Traditions Arnel E. Joven

Introduction This research looks at how Japanese living in the selected cities view and act on health and illness.1 It is apparent that Japanese urbanites look at their bodies in the light of western scientific medicine. However, historical East Asian perspectives on medicine and disease are predominantly influenced by traditional Chinese medicine and indigenous cosmological models. Chinese medicine in this is specifically identified as “Kampo” in order to distinguish it from traditional Chinese medicine or TCM. This

A. E. Joven (B) Department of History, University of Asia and the Pacific, Pasig, Philippines e-mail: [email protected] 1 This research study was made possible through a generous grant from AsiaPhil, 2012– 2013, under the direction of the late Dr. Lydia N. Yu-Jose.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1_10

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study seeks to identify the extent of how these perspectives are culturebound and how such is manifested in the daily experiences of wellness and/or illness among contemporary Japanese. For this, threads have been identified through analysis of individual case studies in selected cities in Japan. The choice of these places presents a wider scope of analysis as well as provides geographic points of political, economic, and cultural comparison. Since the triple tragedy that struck Japan in March 2011, extensive coverage of the quakes, the tsunami, and the nuclear disaster received warranted media mileage all over the world. Much has been said analysing the tragedy from various scholarly perspectives, apart from numerous personal accounts. What is often missed out are the Japanese’ series of actions to seek wellness in the face of what was then imminent danger. From this critical juncture sets the background of the need to study how the Japanese people view the world of health—wellness and/or illness. What comes to the mind of the Japanese when suffering from body malaise? What activities do the Japanese practice, consciously or otherwise in order to preserve health and avoid disease? How popular is Chinese or kampo medicine among the Japanese today? Japan has been historically and culturally Sinified. Centuries of Chinese cultural influences included the introduction of Chinese medical traditions into Japan. In modern times, Japan has experienced rapid westernisation in commerce and industry at the latter part of the nineteenth century. However, despite extensive modernisation along western lines throughout the twentieth century, the Japanese have continued to culturally manifest both indigenous and Chinese traditions in their daily lives. It is thus futile to discount the powerful and long-lasting influence that Confucianism, Taoism, and Buddhism brought to the Japanese, which provided a compound and composite philosophical view of human physiology and pathology. Even at the height of Japanese medical modernisation in the Meiji and Showa eras, Chinese medicine was legally accepted as a tradition parallel to western medical science. Today, the Japanese manifest two parallel traditions in their society: Chinese and western. This is where the study locates itself in the urgency to identify how manifest these traditions are: using the lens of health and medical perspectives. For the most part, studies on the history and anthropology of medicine and health in Japan have begun to take shape in recent years. While it seems that the Japanese enjoy the benefits of universal health care along the lines of western medicine, scholars take for granted the fact that

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ordinary East Asians continue to patronise traditional medicine before or after they go to modern hospitals and clinics as necessitated. This study attempts to interpret diverse perspectives on the body’s wellness and illness, in seeking to understand the interplay of western medicine and traditional Sinified Japanese systems in contemporary Japan. While it seems apparent that Japanese living in rural areas are likely to resort to traditional medicine in the light of illnesses, it is surprising that most Japanese urbanites overwhelmingly favour traditional medical practices in addition to conventional western medicine. Contrary to American and European scientific principles, both traditional and western medicines in East Asia are taken up in sequence or in combination, with no rejection of either as illicit or questionable. Is this necessarily an aberration? Perhaps, yet it serves as a crucial vantage point to the cultural orientation that the Japanese possess as regards their world view: a fusion of Asian and western sciences. After all, legally-accepted integration of western and local medical traditions is prevalent and quite normal in East and Southeast Asia.

History and Anthropology of Medicine in Japan This research study looks at how the Japanese living in cosmopolitan cities view health and illnesses. There are a number of studies on the history and anthropology of Japanese medicine published in recent years. The following are works on the history: Andrew Edmund Goble’s Confluences of Medicine in Medieval Japan: Buddhist Healing, Chinese Knowledge, Islamic Formulas, and Wounds of War (2011) surveys and traces the “silk road of pharmaceuticals and formulas” from Song China to Kamakura Japan, as well as discusses the role of prominent Buddhist priests in medical-pharmaceutical practices in medieval Japan (Hiroshi 2009: 46–66). Andrew Edmund Goble, Kenneth R. Robinson, and Haruko Wakabayashi edited Tools of Culture: Japan’s Cultural, Intellectual, Medical, and Technological Contacts in East Asia, 1000s –1500s (2009). In two chapters, Chinese medical-pharmaceutical contributions are detailed. Kosoto Hiroshi’s Chapter 8: “Volumes of Knowledge: Observations on Song-Period Printed Medical Texts” and Andrew Edmund Goble’s “Kajiwara Shozen (1265–1337) and the Medical Silk Road: Chinese and Arabic Influences on Early Medieval and Japanese Medicine” detail the inflow and dynamics of Chinese-Buddhist medicine into Japan.

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Ann Janetta’s research paper, “Innovation and Stagnation in nineteenth Century Japan: An Assessment of Contrasting Approaches to Global Changes in Medical Knowledge” discusses nineteenth-century Japanese encounter with Dutch medical texts and the changes that took place in the Japanese medical traditions. Her study is published as a monograph in The Vaccinators: Smallpox, Medical Knowledge, and the ‘Opening’ of Japan (2007). Janetta’s research focuses on the painstaking steps undertaken by Tokugawa physicians to understand western medical textbooks (ranggaku). Her work however stops at the turn of the 1850s. Following it was extensive westernisation following the opening of Japan by the Meiji Period. Extensive studies on epidemics in Japan have also been studied. So far, it is only Michael Shiyung Liu’s Prescribing Colonization: The Role of Medical Practices and Policies in Japan-Ruled Taiwan, 1895–1945 (2009) that examines Japan’s medical policies project, closely following the German staatsmedizin, first in Japan, and later in colonial Taiwan. Though the work focuses on Japanese medical policies in colonial Taiwan, the book’s first chapter chronicles the evolution of Japanese medicine following German medical science. An important lead from this work is that Liu mentions that the Japanese government sanctioned the legal use of traditional Chinese medicine in Japan alongside western medicine. Adam Sheingate and Takakazu Yamagishi’s “Occupation Politics: American Interests and the Struggle over Health Insurance in Postwar Japan” (2006) identify major domestic and international interests that gradually developed into present-day Japanese healthcare system. Though both works chronicle the evolution of medical systems in Japan and the underlying political economy, neither of the two books represent the individual attitudes of the Japanese towards modern medical realities. For this, “Reviving Tradition? East Asian Medicine in Korea and Japan during the twentieth Century” forms a significant resource for this research project. In this article, resurging popularity of eastern medicine is closely tied with reviving local interests in Asian cultural traditions. Further, the work argues that such is a response against what is perceived as imperialistic dominance of everything western in East Asia. Though this study focuses on the argument that “East Asian Medicine” is a revival, the work fails to determine if traditional medicine was in fact “lost” in Korean and Japanese medical practices, especially among rural communities with little or no contact with western conveniences.

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From the works, it looks that limited study has yet been conducted on the social perspectives on health in modern urbanised Japan. Such would form the basis of a regional understanding of the extent of medical cultures that are Sinified as well as westernised. A study analysing the perspectives of a unique yet cosmopolitan Asian culture based on the framework of health phenomenology forms the significance of this study. Though much has been written on the history and anthropology of health in Japan, not much has been written that would paint the picture of how the Japanese view their world of wellness or illness. From this can be obtained a more general perspective of East Asian cosmology given that health has historically and culturally been understood in the context of cosmological laws and universal realities—often associated with religious and philosophical paradigms. As regards medicine in society, Erika Dyck and Christopher Fletcher, “Introduction: Healthscapes: Health and Place among the Disciplines”, Locating Health: Historical and Anthropological Investigations of Place and Health (2010) provides the argument that “individual states of suffering extend outwards into social spaces affording unique perspectives on the otherwise taken-for-granted conditions in which people live” (Dyck and Fletcher 2011: 3). Further, the two argue that human “behaviour is conditioned through health and illness and is further mediated by social context, local practices and resources” (Ibid.). From their study, this research looks into the importance of understanding a myriad of perspectives on health as it reflects underlying political, social, and even economic interplays that affect the very basis of cultural understanding about wellness or illness.

Research Design and Methodology This research looked at individual perspectives from selected Japanese cities: Nara, Kusatsu, Kyoto, Nagoya and Tokyo—on health. Field work data gathering was conducted in 2012 and 2013, with follow-up studies conducted in the succeeding years. The scope of this research project followed through on the interactions among urban East Asians that lead to various yet unified understanding of indigenous, Chinese or kampo, and western medical traditions in their respective localities. The limitation that it is urban areas from where individual respondents are selected is due to the understanding that cities are more or less westernised. The challenge for this study then was to prove the strength of indigenous and

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Chinese medical traditions in the heartland of western culture in East Asia. It may be argued that many more cities could be studied in Japan. However, as a research survey seeking to survey using a phenomenological framework within a limited time frame, this study will only work within the confines of the two cities. At the same time, given that the researcher is a non-native speaker, it was possible to obtain data from areas where the respondents are able to communicate in English more or less, and where expert language and cultural interpreters were readily be obtained. Future researchers are invited to follow up on the research project conducted. The field research followed qualitative research methods in medical anthropology, specifically through extensive interviews and case studies. These specific research methods commonly employed in the social sciences form the basis of working research questionnaires that queried on how the respondents view their health. Whether respondents agreed to a media-recorded interview or not, each planned interview followed the outline of the research questions. While there have been specific questions addressed, the respondents “freely” addressed the questions and provided as much information possible on the topic of health and illness. Initially, twelve respondents were interviewed from various cities in Japan. The choice was random: individuals from varying in age, gender, education, and profession. To elicit a differing view from Japanese respondents, two of the interviewees are foreigners, one American and one Filipino. The choice has so far worked well in seeking for a more objective data fed into the research design. The following Table 10.1 summarises the background of the selected respondents. It is understood that the selected interviews were condensed in the form of qualitative enquiries leading to individual case studies—necessary examples of valuable personal experiences that provided a fuller perspective of the whole healthcare process. In this regard, a witnesses testifying on an event will likely have a much lesser understanding than those who have directly experienced the stories they are narrating. The data solicited from the twelve named respondents constitutes as the main reference for this research. The information they have provided have so far remained consistent, satisfactory, and extensive. Apart from oral interviews, which form the muscle of the research design, the study also looked into quantitative research. Between February and April of 2013, an online survey of random respondents was conducted online via the Survey Monkey, an online survey system. The

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Table 10.1 Brief data of interviewed respondents, 2012 Identification

Place

Profession

Affiliation in 2012

Respondent A Respondent B Respondent C

Osaka Manila Kusatsu

Clinical Nurse Foreign Policy Professor Medical Engineer

Respondent D

Tokyo

Assistant Professor

Respondent E

Manila

Assistant Professor

Respondent Respondent Respondent Respondent Respondent Respondent Respondent

Nagoya Kyoto Yokohama Yokohama Nara Kyoto Tokyo

Graduate Student Surgical Nurse Assistant Professor Nurse Assistant Professor Surgical Nurse Assistant Professor

Miniren Hospital Nanzan University Ritsumeikan University Jissen Women’s University Ateneo de Manila University, Philippines Nanzan University Horikawa Hospital Keio University Flinders University Osaka City University Horikawa Hospital Hosei University

F G H I J K L

online survey, which officially closed as of 30 April 2013, was entitled “Survey on Health Perspectives in Japan: Western, Kampo, and Local Medicine”. The respondents were more localised as the selected survey was focused in the Tokyo metropolis. There were 22 respondents that answered the survey by its 30 April 2013 expiry. The data obtained from the survey supports the initial findings concluded from the earlier qualitative data gathering. As expected, the answers were as varied, yet satisfied the objectives of the study.

Medical Anthropology as Framework of Analysis Medicine defined by David Landy (1977) refers to “those cultural practices, methods, techniques, and substances, embedded in a matrix of values, traditions, beliefs, and patterns of ecological adaptation, that provide the means for maintaining health and preventing or ameliorating disease and injury to its members” (Landy 1977: 170). Medical systems thus refer to the “total organization of its social structures, technologies, and personnel that enable it to practice and maintain its medicine (as defined) and to change its medicine in response to varying intracultural and extra cultural challenges” (Ibid.).

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The heart of this research is cantered on what Dyck and Fletcher (2011) articulate succinctly: “Health adds depth and texture to our understanding of the human condition, in a manner that demands an application of a variety of intellectual tools” (Ibid.: Dyck and Fletcher 2011: 4). Both authors also emphasise the grounding of geographic spaces in analysing health. To be more direct about this, Michael L. Tan (2008) cites Rudolf Virchow on the relationship between medicine and the social sciences: “Medicine is a social science and politics is nothing but medicine writ large” (Tan, 2008: 13). The same Rudolf Virchow, according to Michael Shiyung Liu (2009) championed social medicine, in claiming “that medicine is about treating sick people not diseases and that the government had to treat individuals as social beings as well as diseased bodies” (Liu 2009: 22). Interactive anthropological theoretical perspectives are used in understanding Japanese collective attitudes and activities towards health and illness—phenomenology, social-interactionism, political economy, and cultural ecology. Using the phenomenological or interpretivist framework means seeking to translate the complexities of a past culture using a contemporary interpretation. This framework is explained better using Clifford Geertz’ “thick descriptions” methodology as it capitalises on interpreting meanings through experiences, obtained from written and oral narratives. Michael L. Tan (2008) explains the social interactionist perspective as looking at “the way people interact to shape and reshape notions of health and illness” (Ibid.: Tan 11–12). Further, understanding meanings and experiences is not enough if not read within the context from which these were taken from. The third perspective, political economy looks at the larger interaction of political and economic policies and activities that directly affected the people’s lives as constituents. The fourth perspective that would ultimately cover the people’s resort to herbal remedies where there are no allopathic conveniences is cultural ecology. Under this perspective, there is a need to look at the way people “use culture to respond to the challenges posed by the natural environment” as well as utilising the “natural environment for… materia medica, from medicinal plants to the explanations themselves” (Ibid.: 15–16). It is within the continuum of evolving medical traditions that age-old practices have perpetually been tied with western medical science to fit into the people’s concept of health and illness.

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Prevalent Views on the Japanese Healthcare System Throughout Japan’s history, various medical systems have been incorporated into what developed as a medical culture that essentially integrates Chinese, western, and indigenous or local health practices. After centuries of Chinese medical tradition, more than a century of state-sanctioned western medicine, the Japanese have developed their brand of “indigenised” medical culture. The concept of health comes from a cultural framework in which people transcend their view of their physical bodies, into layers of social and ecological terrains of interactivity. Under this concept, “popular perceptions”, often taken for granted, deserve a closer analysis and examination. As applied into medicine, Japanese popular perspectives on health take on a framework that reveals a cruciate of historical and anthropological paradigm. From a medical-anthropological study, it manifests common trends leading to stronger culture-based norms and patterns. The ultimate interaction between the realms of medical science, that which is normally found within the natural sciences, and that of an anthropology that looks into people’s behaviour towards medicine is highlighted as the basis of the framework for this research. The main objective of this research is to look into how the Japanese view their health. The parameters delineating this perspective involve the very medical systems in which the Japanese work with. In the case of Japan, official medical policy revolves around the regulation, promulgation, and education in essentially western medicine. The whole Japanese medical system is in fact almost monopolised by a state-sponsored medical culture that promotes the practice and patronage of western medicine. The practice and regulation of Chinese medicine was formalised in the 1930 s as a specialisation, rather than as a competing medical system. Contemporary Japanese medical system, as promoted by a state health bureaucracy, is accessible through a national health insurance system. This health insurance system though has varying degrees of accessibility depending on age and economic status. For the most part though, people who avail the national health insurance system also subscribe to private health insurance.2 Unfortunately, availability of medical services in Japan is neither free nor completely universal. Though it has always been the

2 Respondent B, Interview on 21 August 2012; Respondent D, Interviewed on 17 December 2012.

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ultimate goal to offer free universal healthcare programme in Japan, economic realities have so far eluded this dream. There are various forms of medical insurance in Japan, spearheaded by a mandatory standardised national health insurance system available in varying degrees by Japanese citizens according to level of income or employment. For the most part though, depending on qualification, a Japanese citizen availing of the national health insurance system still pays a percentage of the total accrued medical bill.3 Some Japanese do avail of private health insurance schemes in addition to the national health insurance system.4 Students are required to avail of a student insurance system through parents and guardians.5 Immigrant labourers and foreign students residing in Japan however have varying ways of obtaining medical insurance depending on their employers or schools of affiliation.6 For the most part, the Japanese view this as a rigorously-structured system, which in most instances the attending physician is expected to be not only authoritative in his or her profession, but also objectively indifferent to each patient handled.7 In a society that expects strict and perfectionist professionalism, this general view of the medical profession is to be expected. However, such a structured, objective, and often impersonal view of the medical profession creates the image of the apathetic, almost robotic physician.8 It may be argued that there are medical professionals who have developed close affinity with their patients, as in the case among family physicians.9 They are exceptions rather than the rule among medical professionals.10 The demand for professional objectivity in western medicine is reflective of a global expectation of this medical system. Rational science has often demanded impersonal objectivity in dealing with medical subjects— the body as an emotion-less variable. This seeming universal norm is however stronger when it comes to professional discipline, rigour, and 3 Respondent F, Interviewed on 28 November 2012. 4 Respondent D, Interviewed on 17 December 2012. 5 Ibid.: Respondent F 6 Respondent C, Interviewed on 28 November 2012. 7 Respondent E, Interviewed on 23 August 2012. 8 Ibid.: Respondent B 9 Respondent L, Interviewed on 17 December 2012. 10 Ibid.

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character among the Japanese. In effect, it is not surprising that many Japanese patients develop an antagonistic attitude when it comes to dealing with western-style healthcare providers, physicians in particular. The demand is somewhat different for nurses and caregivers, who are more appreciated than their physician or surgeon colleagues.11 The effect of this rather negative view of western medical professionals in Japan is that there are patients, especially those coming from a younger age bracket, who would prefer to seek alternative medical remedies than the highly structured medical care offered in clinics and hospitals.12 This does not however mean immediate preference to western medicine’s recognised competitor, Chinese or kampo medicine. There are patients who would prefer to purchase over-the-counter medicines directly in pharmacies rather than seek medical attention from a licensed physician in a nearby clinic or hospital.13 Many patients would by-pass the physician and go directly to the pharmacy. There of course exists the danger of undiagnosed serious illness, but many people would rather take the risk.14 A widespread feeling of discomfort owing to lack to emotional connection has often times developed between patients and doctors. Worse, there are also those who suspect collusion between physicians and drug companies—a widespread allegation of “over-medication” on suspicion that physicians often prescribed unnecessary drugs or dosages which would favour drug manufacturers and retailers.15 The phenomenal widespread suspicion of physicians’ collusion with drug companies is not based on reliable evidence, and it deserves a more extensive and closer study on its own. However, the existence of suspicion or rumour adds to the negative image of the physician as a credible medical professional. The existence of rumours or negative publicity against medical professionals stems from a collective public anxiety against a monolithic institution. Powerful institutions are often subject to public attack, reinforced by an already antagonistic, if not apathetic public

11 Respondent G and Respondent A, Interviewed on 25 November 2012. 12 Ibid.: Respondent F. 13 Ibid.: Respondent E. 14 Ibid: Respondent F. 15 Ibid.: Respondent B.

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opinion. In Japanese medical profession, widespread suspicion of corruption is connected to western medical science direct affiliation to the state and corporate enterprise. The fact that as of the late 1950s and early 1960s, Japanese health insurance is assured and carried out by the state creates this unmistakable lumping of the medical profession along with the negative connotations surrounding the state, the government, and bureaucracy. For the Japanese, state sponsorship of health care adds to the conscious antagonism reinforced by the impersonal doctor, creating the perception of a cold science. Despite widespread health insurance in Japan, many Japanese are not comfortable with the existing western medical structure.

Hospital Stigma: The Unwritten Subtext The hospital setting is normally recognised as a professional venue for patients to go to in times of medical emergencies when one cannot simply be treated at home or in small clinics. This is a universal understanding of hospital spaces, which is of course equated with western medicine and the professions behind it. Hospitals have been in existence in Japan as soon as western medicine was introduced during the Meiji era. Sometimes, hospitals in Japan are attached to Christian missionary institutions, universities, or both. Japanese hospitals in general are understood as institutions covered by the national health insurance system. The general view also is that hospital spaces are places of sophisticated modern medical facilities operated by highly-skilled medical professionals. The survey conducted in fact indicates a high level of trust placed on western medical institutions. However, it is surprising that there exists a rather negative view towards hospitals among the Japanese. Beforehand, it is quite understandable that perceptions of hospitals are negative due to the popular view on the concentration of potentiallycontaminating bacteria and viruses among confined patients. In Japan however, this is not the reason why many Japanese, specifically youngergeneration Japanese indicate that hospitals are the last place they would want to be in during times of medical crises.16 It seems that the age bracket of patients attended to in Japanese hospitals gravitate towards

16 Respondent G, A, and K were interviewed on 25 November 2012, and Respondent I was interviewed on 14 December 2012.

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the elderly.17 Although the Japanese deny profusely that their aberrance towards hospitals is because of the potential stigma of being a place for old people, the collective unconscious is quite certain.18 The unwritten subtext accorded is that: “only old people go to hospitals”. For a modern Japanese society painstakingly presenting itself as a robust healthy people with very long lifespans, instances of medical concerns are considered weakness that must never be publicly acknowledged. Younger Japanese tend to control illness through personal rituals confined in private homes.19 Resorting to seeking professional medical help are secondary, or to be done only when one can no longer control the symptoms or if the illness is in fact worse than originally imagined.20 These cultural subtexts are of course not consciously admitted or publicly acknowledged. In Japanese medical culture, instances of illnesses are considered as signs of unproductive weaknesses, thus embarrassment. It is even unique to the Japanese for an employee who has fallen ill and taken leave from work to come back with gifts for colleagues. According to one interviewee, this was a form of “apology for the damage done by his absence from work”.21 This clearly strengthens the original argument that illness in Japan is an unpopular part of social life. Illnesses affect normal social activities and disrupt daily routines, which in turn create an unwanted disruption in the collective management of professional or employment activities. Thus, in addition to the unacknowledged stigma of hospitals as a place for old people, hospital confinements are also cause for alarming embarrassment for absence from the workplace. Despite this collective subtext however, foreigners researching on Japanese medical culture should not dismiss Japanese society as inconsiderately inhumane and apathetic to the plight of the sick. The selfconscious embarrassment caused by illnesses to a person is counterbalanced however by a robust culture of sympathy evidenced by an array of erstwhile gatekeepers of health via a network of family and friends from work and/or school.22 To clarify: a patient suffering from an illness is 17 Ibid. 18 Ibid.: Respondent F. 19 Ibid. 20 Ibid: Respondent G. 21 Ibid.: Respondent L. 22 Ibid: Respondent B.

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embarrassed by his or her absence, but the patient’s social network are compelled to sympathise with their family, friend, or colleague who has fallen ill.

Kampo Medicine (漢 方): Tradition Versus Modernity Chinese medicine has been in existence in Japan for many centuries before the introduction of western medicine as filtered from the Dutch in the early nineteenth century, and the imposition of German-style state medicine after the Meiji Restoration. Japan’s kampo or Chinese medicine has had a strong root in Japanese society since the turn of the tenth century (Hiroshi, 2009:211). It is thus not impossible to imagine the ramification that it would be viewed as a competing medical paradigm at the height of westernisation in late nineteenth-century Japan. The proponents of Japanese state medicine however enacted a policy of accommodation to rather than rejection of Chinese medicine. Michael Shiyung Liu (2009) stated that when the Japanese introduced state medicine in Japan, there was a strong tendency to support German medicine (Liu 2009: 33). However, unavoidable historical presence of Chinese medicine could not be eliminated. To remedy a potential clash of medical systems, the Japanese in 1870 regulated Chinese medicine as a specialty (Ibid.). In this regard, though the recognition of the efficacy of Chinese medicine is therefore recognised, this historical development deserves further study on its own. Kampo medicine is the Japanese version of Chinese medicine that has evolved towards modern times. It must be distinguished from traditional Chinese medicine or TCM, which is more popularly practiced in mainland China and Taiwan. Today, there are a number of distinguishing features between kampo and TCM. There are a number of distinguishing differences between kampo and TCM. For one, kampo herbal products are strictly regulated by the Japanese government. These are handled by western-trained medical professionals. Another is in acupuncture. Kampo acupuncture needles are smaller compared to the TCM equivalent. In accupunctures procedures too, kampo needle insertion is not as deep compared to that in TCM. There are also other differences. Kampo is manufactured and licensed in Japan today are insured for the Japanese public under the national health insurance system, but not all aspects of kampo medicine though (Hosokawa 2011). Acupuncture

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medicine and selected herbs are covered by public and private insurance schemes. As expected, a global pattern of scepticism also exists in Japan for state agents or policy-makers to give premium, let alone recognition, to a discipline that directly competes with an essentially state-sponsored western medical science. With this attitude, it is not surprising that official state agencies involved in health policies are generally uncomfortable in extending recognition to Chinese medicine. An age-old medical system that competes with state-sponsored western medicine could only compete and manifest its legitimacy as a “science” by allowing western scientific paradigms to be applied to it. For this, laboratory research, clinical trials, and academic regulations are also applied. Since the 1870s, Chinese medicine had to be rationalised as compliant with existing yet evolving demands for a western-style of scientific criteria for widespread acceptance. Systems of control in terms of standards and regulation are also accepted and promulgated in order for Chinese medicine to be recognised as a legitimate medical field. The stigma of kampo as a relic of an archaic past is still remaining as proponent of western modernity and objective rationality in contemporary Japan. An active campaign through political and economic structures which drives the promotion of western medicine adversely cringes on the cultural patronage of Chinese medicine in post-war Japanese society. Aside from state patronage, western medicine does enjoy the economic sponsorship of multinational pharmaceutical corporations23 . Combined, western medicine has enjoyed these favourable sponsorships, which aid in promoting the concept that western medical science is equated with modernity, and thus rational reliability, if not objective accuracy. However, despite all the apparent advantages that western medicine possesses, there remains an almost equal patronage among the Japanese in favour of Chinese medicine. The survey conducted indicates that 10 out the 22 respondents favour the use of kampo medicine. The respondents who admitted usage of kampo medicine are also aware of kampo’s unique identity. For this, the same survey indicates that the pitfalls of western science are the attracting points for kampo medicine. Despite the apparent monolithic omnipotence of western science, there remain significant problems, issues, and concepts that elude scientific explanations or medical solutions. This is where kampo medicine presents its appeal to

23 Ibid: Respondent B

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the same Japanese society. It is not about historical and cultural presence in Japan, as it is about kampo’s capability to address what allopathy or western medicine cannot do.24 What is important, for this research is the affinity and accessibility of the Japanese to Chinese medicine. Kampo’s apparent difference with western medicine should not be taken as rigid competition by both camps. In reality, the Japanese’ patronages for Chinese medicine, more often than not, runs complementary to western medicine rather than as rigid preference for either systems. Most Japanese use a combination of western and Chinese medicines in varying degrees depending on the patients’ needs. Many Japanese also use other forms of medical systems which equally run complementary to western medicine.25 However, for the most part, Chinese medicine enjoys a noticeable percentage of patronage among the Japanese, as represented in the 2013 survey. The most “scientific” aspect, to borrow the terms, in Chinese medicine is the herbal medicines employed. Japan’s Ministry of Health, Labour, and Welfare regulates kampo pharmacopeia in terms of use, dosage, and contraindications.26 This form of standardisation serves to promote Chinese medicine rather than limit its acceptability to the general public. In terms of marketing, official regulation creates the consciousness of some kind of official state recognition. Decades-old government recognition boosts the contestable issue of efficacy in favour of Chinese medicine. Due to strict regulations and standards, kampo medicine is clearly packaged and labelled, to legally differentiate it from western drugs and other forms of medicines.27 There are a variety of forms of kampo in Japan. Contemporary kampo medicine exists in the form of liquids or powders distinctly packaged and marketed in pharmacies specifically retailing Chinese medicines. This legal regulation equally serves in promoting the notion that a particular kampo product has passed strict standards regulation, therefore, should be both safe and effective. Not all Chinese medicines, in a general sense, are legally allowed to be sold in the

24 Respondent J, interviewed on 23 November 2012. 25 Ibid. 26 Japanese Pharmacopeia (16th ed), Retrieved from the Ministry of Health, Labour, and Welfare, Tokyo (2011). 27 Ibid.: Respondent J.

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markets. First, the definition “kampo” extends only to Chinese medicines grown, tested, and processed in Japan or by Japanese companies (Dharmananda 2013). The license does not extend to TCM herbal medicines imported from China or other countries. Further, only kampo manufactured, processed, tested, and regulated in Japan pass the qualification to be recognised as “medicines”. The rest must be clearly labelled as “food supplements”.28 Compared to most countries that have competing medical systems, Chinese medicine in Japan enjoys a favourable position in the Japanese market as legally-recognised medicine, even enjoying the benefits of health insurance. For this, kampo enjoys significant patronage, surprisingly from younger members of the Japanese population. Though it may be perceived that kampo medicine would be patronised by older Japanese, most older and middle-aged Japanese, there seems to be stronger patronage among younger Japanese. It is significant to note that for several decades, the Japanese education system strengthened the favourable position of rationalistic western science, inclusive of course of medical science. The existence of medical universities reinforced the concept of a regularised medical education, along with the very teaching of lay health practices in schools and popular media reinforced the western medicine’s monopolistic hold among the Japanese for much of the postwar decades. It is only in recent years that a global phenomenon of challenging the canonised orthodoxy of western medicine also came in vogue in Japan. In a place where a traditional form of medicine has been in existence for centuries, this should not come as a surprise. At the turn of the twentieth century, a global phenomenon of questioning the objectivity and accuracy of western science has simultaneously arisen in among many fields in the humanities and social sciences. As a result, the very monopolistic orthodoxy of western science has been shattered. Contemporary Japan is no exception. Younger Japanese today are brought up in an atmosphere when alternatives to western science are accepted. Though the phenomenal patronage of alternative medical systems among younger-generation Japanese deserves an in-depth study by itself, it is important for the purposes of this research to point out this overwhelming preference. In relation to negative publicity thrown against

28 Ibid.: Respondent B

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practitioners and ministers of western medical science, it is not difficult to understand these developments in the Japanese medical landscape. Many Japanese are after holistic health, meaning looking at bodily malaise as part of a more general physiological-pathological framework, rather than as piece-meal problem-solution oversimplification.29 There are popular perceptions among the Japanese that indeed western medicine works, but its efficacy is only as far as symptoms are concerned. Corollary to this, many Japanese tend to regard Chinese medicine as provident of long term, if not complete solution to physical pathology.30 The fact that Chinese medicine’s acupuncture component provides for a radically different cosmological concept of the human body, separates itself from western medical-scientific paradigms. For many, the difference offers the possibility of addressing ailments or syndromes that western medicine cannot answer satisfactorily.31 The example of pain management has often been offered as an example of the limits of western medical science. However, the list is in fact long. The limits of western medical science are sometimes a painful human reality in dealing with the “incurable” as late-stage cancer, autoimmune disease, and more recently, radiation poisoning.32 The survey conducted also indicates that 16 out of 22 interview respondents use kampo medicine, though in varying degrees. For some Japanese, the perception that while western medicine addresses the symptoms and that Chinese medicine addresses the whole disease deserves attention. Western medicine is perceived as more of a “mechanical” science where specific diseases or ailments in one part of the body are treated separately. The popular concept in western medicine as purely a physical science goes against the Japanese cosmology of “anima” in all of creation. An alternative philosophy to that offered by western science is in fact presented by millennia-old Chinese medical philosophy. For most Japanese, Chinese medical philosophy, one that cannot be accommodated by western medical science, seems to provide a much better and more acceptable cosmology akin to Japanese cultural psyche.

29 Ibid.: Respondent J. 30 Ibid.: Respondent F. 31 Ibid.: Respondent J. 32 Ibid.

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The Futei Shuuso (不定 愁訴) Enigma Although the Japanese medical phenomenon known as futei shuuso syndrome deserves a whole study on its own, the importance of how the Japanese look at it is important for the purposes of this research. Futei shuuso has been described as a state in which the person supposedly suffering from it is “neither sick nor well”.33 Originally, this condition has been attributed to menopausal and post-menopausal women.34 However, recent statements by selected Japanese individuals reveal that such a condition extends even to younger women and some cases involving men.35 Futei shuuso may qualify as a culture-bound illness as reference to its phenomenology cannot be found anywhere else in the world. It is safe to conclude that it is unique to Japanese society. The very manifestation of this syndrome includes extreme depression, menstrual cramps, loss of appetite, loss of weight, and general loss of interest.36 Although an observer unfamiliar to this syndrome may dismiss sufferers as possibly manifesting clear signs of psychological disorder, futei shuuso also manifests patho-physiological affectations. For women sufferers, chronic headaches, body pains, and erratic fevers have been reported. However, western medical practitioners could only address treatment for symptoms. Futei shuuso syndrome is clearly an illness that can never be accepted using the western framework for identifying diseases through pathological infection, physiological breakdown, or neurological disorder. The Japanese themselves do not look at this syndrome as a normal stage in life parallel to western concepts of “mid-life crisis” or “pre-menopausal stress”, since not everyone has suffered from it.37 Unfortunately, the “epidemiology” of futei shuuso has become very difficult to define given the multitude of symptoms supposedly reported by patient-sufferers. What was originally acknowledged by the Japanese as purely a women’s syndrome now includes men reported to have suffered from this particular syndrome.38 After suffering from an undeterminable

33 Ibid.: Respondent E. 34 Ibid. 35 Ibid: Respondent J. 36 Ibid: Respondent L. 37 Ibid.: Respondent J. 38 Ibid.: Respondent E.

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period of time, which can take several months to a few years, patients who recovered are reported to have returned to their daily routines as if they have never suffered from the socially-debilitating effects of futei shuuso.39 Although it is possible that there are other syndromes unique to the Japanese, the significance of the phenomenology of futei shuuso in medical anthropology elucidates the desire of the Japanese to present a culture-bound uniqueness. It remains to be seen if a medical-historical research will be made to prove that this syndrome has been in existence centuries before. However, the singular significance of futei shuuso is the syndrome’s ability to unite all popular medical activities to address it. From its unique Japanese recognition affecting all possible networks of health gatekeepers, to the very cultural and political-economic affectation that this illness creates, futei shuuso covers much that the Japanese need in creating a modern contemporary medical tradition. For this research though, it is sufficient to present this syndrome as part of a plethora of medical knowledge unique to the Japanese.

The Role of Religion In any given society, religion has traditionally and historically played an active role in the medical culture. The cosmological attributes of Japanese historical religions as Buddhism did play an active role in the development of kampo as medical system as manifested in both indigenously Japanese traditions as well as Chinese books. Buddhism, including all the known sects within Japan, is ground wells of traditional Japanese philosophical and cosmological understanding of human physiology and pathology as condensed in modern-day kampo medicine. Hiroshi (2009) has conducted an extensive study on the role of Buddhist priests in the “medical silk road” in which Chinese-Buddhist medical texts, along with Chinese pharmacopeia, were progressively imported into Japan during the Song Dynasty period. These of course were followed by Buddhist medical-scientific influences in succeeding periods. Given Japan’s active subscription to Buddhism, all the way to the nineteenth and twentieth centuries, it is safe to infer on Buddhism’s active and sustaining role in the practice and development of Chinese medicine in Japan throughout the centuries. Furthermore, Buddhism as an institution has successfully

39 Ibid.: Respondent L.

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managed to sponsor the cultivation and promotion of Chinese medical knowledge through extensive historical manuscripts imported through and from China. In contemporary times however, modern Chinese or kampo medicine is no longer popularly attributed to Buddhism, as it has become secularised. While it is difficult, to say the least, to determine the presence or absence of popular religious piety among the Japanese will require largescale and long-term study; piece-meal evidences do point to traditional religious-medical matrices. For one, at least one Buddhist deity is revered in the Daibutsu Temple in Nara by those with bodily malaise. The idea is that a pilgrim is required to touch the deity’s body part corresponding to one’s ailing body part. With corresponding prayers and rituals, the pilgrim, with faith, expects miraculous recovery. This tradition may not be unique to the Japanese. The crux for this research is merely to illustrate the traditional continuum that Japan’s traditional religion plays in Japanese life. Christianity on the other hand is a beacon of western medicine and western-style modernity in Japan. Christianity has had a historically unique role in the development of modern Japanese medical culture. In the nineteenth and twentieth centuries, Christianity became known more for establishing modern western medical facilities all over Japan. For American missionaries at the turn of the nineteenth century, the necessity for establishing schools and hospitals in East Asia ran with the “social gospel” framework (James et al. 1981: 51). After 1945, the continuation of western missionary-sponsored universities and hospitals went in line with a politicised American-mandated anti-Marxism within the Cold War framework (Moore 2011: 127). At the same time, western-based hospitals or medical institutions and universities founded on American and European Christian models worked well with post-war Japanese state-sponsored framework of scientific modernisation and standardisation along western lines. Thus, while traditional Japanese religions provide for personal and cultural medical traditions, Christianity provides for western medical modernism in Japan. This dichotomy however is lost in today’s highly-secularised contemporary Japanese society. Whereas contemporary Japanese consciousness as regards religiosity deserves an extensive study by itself, the nuances on medical beliefs and practices are filtered through secular popular practices. It is thus safe to say that though religion plays

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a role in Japanese medical philosophy, it is not consciously manifested in day-to-day activities and discourses related to health.

Phenomenology of Popular Health Practices Whereas there seems to be a rigid distinction between western and Chinese medicine, most Japanese practice a combination of these plus a plethora of practices unrelated to either systems. To complicate matters, there are other medical traditions that have recently been introduced and popularised in Japan. Sei tai (整体) is one example of health disciplines that introduces an alternative medical philosophy—one that draws strong credible following among the Japanese. The Japanese practice more or less a combination of existing medical traditions, depending on the reliability and credibility of those that are identified as gatekeepers of health. When the Japanese gets sick, availing the physician’s services is not normally the first act in the medical process. All of the interviewees attested to this fact. Whereas there is a tendency among middle-aged Japanese to proceed through this process, younger Japanese prefer to go to a more personalised process not involving established medical systems western or Chinese. The most common practice for simple common illnesses, which may even be mistaken as almost instinctive, is to rest and keep the body warm. This is of course true for personally-manageable discomforts as fevers, headaches, and colds. For these, it seems to be common knowledge that the body needs to be rested and warmed for healing and recovery to take place. Some Japanese even avoid bathing or showering—in varying degrees, throughout the duration of an illness. While some prefer to wash selected parts of the body, others prefer to avoid it altogether.40 The second step is the taking of medicines, western or Chinese. For simple illnesses, both western and Chinese may be purchased in pharmacies in anticipation of future maladies.41 For many Japanese, the immediate availability of medicines for fevers or colds is much better than going to a doctor for appropriate diagnosis and prescription.42 Kampo medicine at this point is not preferred due to the fact that it has to

40 Ibid.: Respondent J and D. 41 Ibid.: Respondent J, K and D. 42 Ibid.; Respondent F.

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be taken over a prolonged period of time, e.g. for a month.43 Western medicines however need not be consumed for a longer period of time than when the illness is believed to have been cured already.44 It is only at a certain point when it has been determined that the illness is worse or more complicated than simple headaches or fevers that Japanese patients proceed to avail of professional help. For the most part, medical decisions are dependent on the patient’s health gatekeeper. In most cases, family members and friends act in this role as advisers and mentors on health matters. Long-term gatekeepers are of course teachers and the physicians themselves. In this, the role of family and friends as support cannot be underestimated in the medical or healing process. As a necessary support group, they assist and lead ailing members. In the long-term however, they serve as educative guides in serving as examples for future members of the family or kinship group to follow. The attitude of family members or friends does affect the decision-making trends that individuals follow as regards health. This of course includes longterm health-maintaining lifestyle choices that extend to food, nutrition, and exercise. As regards established medical traditions as western and kampo however, the influence of family members and friends does not necessarily affect directly one’s decisions in times of illnesses. There are times when personal biases and inclinations come into play—which may be contradictory to actions prescribed by family or friends. Another factor that must be taken into consideration is the role of popular media in developing personal decisions and trends as regards health maintenance.

Promoting the Image of the Healthy Japanese Popular health practices of course include disease prevention activities and lifestyle choices. The Japanese are popular for being a healthy people. The Japanese also boast the longest average lifespan in the world. Extensive empirical studies have been conducted on the types of food, dietary choices, and lifestyle patterns that the Japanese are into. This research filters through these in looking into the direct relationship between these healthy lifestyle choices and activities and continued health maintenance.

43 Ibid. 44 Ibid.

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Activities and choices leading to the avoidance of disease may be classified into nutrition and exercise. Are the Japanese conscious about health maintenance when they are involved in diet and exercise? The very act of involving one’s self into a regimen or even just the semblance of a healthy regimen reinforces the idea of subscribing to health maintenance. For the Japanese, it may not seem apparently to be personal initiatives for them to be involved in health maintenance activities. However, extensive analysis point to the entirety of the Japanese education curriculum as contributing to lifelong consciousness of a predisposition towards healthy lifestyle choices and activities.45 Early on, through education, students are ingrained with valuing healthy lives through sports and nutrition education.46 Teachers thus serve as longterm gatekeepers of health—fully or partially influencing their students’ future health choices. The fact that most Japanese in one form of sports or exercise—even the simplest walking proves that indeed there is consciousness and predilection for everything healthy.47 From an early age, Japanese students are involved in baseball, football, swimming, and wrestling, among many other contact sports. Extensive public and private institutions and facilities all over Japan provide the necessary structures to support regular physical exercise.48 For older individuals, facilities for physical exercise are in abundance in public parks and similar areas. Competitive sports need not be the only source of physical exercise. Widespread cultural practice of walking dogs also forces Japanese dog owners to move around on a regular daily basis. The global perception of suicide-prone highly-stressed Japanese employees however overshadows and obscures the presence of health-conscious Japanese. The fact still remains that lifespan in Japan is still the longest on average, in world record. The second determining factor is dietary choices. Whereas the Japanese record longer old-age or rather healthy ageing among elderly Japanese, there are also alarming reports of “unhealthy Japanese” among younger generations. Many of the Japanese recognise this and place the blame

45 Ibid.: Respondent B. 46 Ibid. 47 Ibid. 48 Ibid.: Respondent F.

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on the recent abundance of western fast food chains.49 It is common knowledge that fast food chains offer a wide variety of food choices which are bereft of necessary nutrients, and are instead high in carbohydrates and cholesterols. It is thus safe to say that alongside the challenge of stressful life among the Japanese, there are facilities and initiatives within Japan that work to promote better healthy lifestyles. Such is especially promoted among the youth who face the challenge of balancing the rigours of academic life and the enthusiasm for competitive sports. The question is maintaining the clichéd work-life balance among middle and older generation Japanese. So far, with healthy Japanese dietary regimens and active lifestyles, Japanese individuals’ capability to fight off diseases is almost assured.50 The bigger question or threat however is the continued possibility of threats from disease outbreaks, which are beyond the control of normal safeguards. With the March 2011 triple tragedy, Japanese standards for health maintenance were challenged with the immediate danger of nuclear radiation and the long-term threat of radiation-related diseases which may come from plants, animals, and the environment especially in the areas in and around Fukushima.

Conclusions Japanese medical culture is necessarily unique and complicated compared to western social norms and practices. Whereas there are indigenously Japanese medical traditions and practices, state-sponsored western medical institutions create the unavoidable whirlpool that integrates traditional Japanese philosophical understanding of human health and illness and modern western medical science. First, there is a balanced interplay of perspectives among various Japanese on the reception of western medicine and kampo medicine. A significant voice among the Japanese favours support for state-sponsored western medicine. Among them however are mostly middle-aged or older Japanese. On the other hand, historically-rooted Chinese medicine has, over the past few decades, made a comeback with a vengeance.

49 Ibid.: Respondent B. 50 Ibid.: Respondent E.

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Its resurging popularity among younger Japanese indicates western medicine’s limitations as a paramount monolithic medical system in Japan. Second, along the lines of modernisation, kampo medicine has so far followed the western strategy of presenting itself as “scientific” in accordance with state-required rules such as standardisation and professionalisation. An equal segment among younger Japanese voice support for Chinese medicine. Their reasons do vary, and do not simply depend on scientific rationality or clinical efficacy. Third, Japanese medical practices and perspectives are varied. Though there are uniquely Japanese culture-bound illnesses such as futei shuuso, Japanese medical traditions are interplayed with traditional and modern religious frameworks in both political-economic as well as social-cultural array of normative traditions and well-entrenched practices. Family support as bolstered by networks of friends and colleagues fundamentally assist in the creation of practices and perspectives which create normative views on health and illnesses among the Japanese. Finally, Japanese perspectives on health are governed by a much larger cultural framework prevalent in an urban culture that puts premium on a uniquely Japanese work ethic that demands uncompromising robustness. For this, ill health is consciously considered undesirable and must be prevented, if not compensated for, culturally speaking. The “preventive” measure is for the Japanese to create a healthy environment for younger Japanese generations as manifested in active involvement in sports activities and highly-physical pursuits encouraged in educational institutions. The image of the healthy Japanese is being placed as a necessary counterbalance against the undesirable contra-position between western and kampo medical systems in Japan. Such movement is not however unique in Japan as there exists current global trends on health measures through nutrition and healthy lifestyles aimed at preventing illnesses. There also exists a global reality in which every social and cultural community debates on traditional practices and western science. Although it is not unique for the Japanese to find a cultural integration of western systems and local traditions, larger-scale framework of individual connection to a much larger working society comes into play. One cannot dismiss the unique culture in their society that the Japanese presents to the rest of the world.

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References Dharmananda, Subhuti (2013), “Kampo Medicine: The Practice of Chinese Herbal Medicine in Japan” (http://www.itmonline.org/arts/kampo.htm) (Institute for Traditional Medicine) Retrieved on 08 April. Dyck, Erika and Fletcher, Christopher (2011), “Introduction: Healthscapes: Health and Place among the Disciplines,” In Dyck, Erika and Fletcher, Christopher (eds), Locating Health: Historical and Anthropological Investigations of Place and Health, p. 3. London: Pickering & Chatto Limited. Hiroshi, Kosoto (2009), “Volumes of Knowledge: Observations on Song-Period Printed Medical Texts,” In Andrew E. Goble, Kenneth R. Robinson, and Haruko Wakabayashi (eds), Tools of Culture: Japan’s Cultural, Intellectual, Medical, and Technological Contacts in East Asia, 1000s–1500s, pp. 46–66. Andrew E. Goble, (trans). Michigan: Association for Asian Studies. Moore, Ray A. (2011), Soldier of God: MacArthur’s Attempt to Christianize Japan, p. 127. Maine: Merwin Asia. Ritsuo Hosokawa, Ritsuo (2011), “The Ministry of Health, Labour, and Welfare Ministerial Notification No. 65.” 24 March. Landy, David (1977), Culture, Disease and Healing, p. 170. New York: MacMillan. Liu, Michael Shiyung (2009), Prescribing Colonization: The Role of Medical Practices and Polices in Japan-Ruled Taiwan, 1895–1945, p. 22. Michigan: Association for Asian Studies. Tan, Michael L. (2008), Revisiting Usog, Pasma, Kulam (Student Edition), p. 13. Quezon City: The University of the Philippines Press. James, C. Thomas, Jr., Peter W. Stanley, and John Curtis Perry (1981), Sentimental Imperialists: The American Experience in East Asia, p. 51. New York: Harper and Row.

Index

A Accessible, 67, 122, 130, 134, 144, 195 Acupuncture, 24, 26, 27, 29, 32, 38–40, 42, 54, 88, 96, 99, 121, 122, 125, 132, 149, 151, 200, 204 Alternative, 40, 66, 143, 149, 197, 203, 208 American, 16, 105, 165, 167–169, 172, 175–178, 180–182, 192, 207 Analysis, 11, 41, 43–46, 119, 157, 188, 193, 195, 210 Anthropological, 194, 195 Apathetic, 196, 197, 199 Apprenticeship, 3, 4, 6, 10–12, 17, 30, 31, 34, 121, 149, 157

B Bachelor, 29, 32, 53, 118, 126, 128, 150, 152–154

Beauty problems, 104, 108, 109 Beijing University of Chinese Medicine, 11, 17, 26–30 Ben Cao Gang Mu, 99, 104, 106, 107, 131 Botanical, 96, 98, 101 British, 66, 85, 120, 133, 140 Buddhism, 2, 61, 67, 188, 206, 207 C Centralized, 16, 64, 166–168, 178, 181, 182 Challenges, 11, 12, 15, 32, 35, 38, 42, 50, 77, 82, 89, 95, 96, 107, 109, 123, 145, 156, 158–160, 191, 193, 194, 211 China, 2–10, 13, 14, 16, 17, 24–28, 31–33, 37, 38, 40, 42–44, 48, 51, 53, 54, 59–64, 66, 67, 69, 70, 75–78, 85, 86, 88–90, 96, 100, 102, 103, 105–107, 109, 110, 117, 121, 127–131, 134, 140, 151, 152, 154, 166,

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 M. N. Islam (ed.), Chinese Medicine and Transnational Transition during the Modern Era, https://doi.org/10.1007/978-981-15-9949-1

215

216

INDEX

170–172, 175, 182, 200, 203, 207 Chinese, 3–5, 15, 17, 33, 40, 47, 52, 54, 60, 62, 64, 65, 67, 76, 77, 85, 86, 99, 105–107, 117, 118, 121, 127–130, 133, 134, 140, 141, 165, 167, 168, 174, 177, 180–182, 188, 191, 195, 206, 208 Chinese Materia Medica, 24, 27–30, 33 Chinese medicinal cosmetics, 95–110 Chinese medicine (CM), 1–17, 24–27, 29–35, 38, 52–55, 61, 78, 85, 86, 88, 89, 95–99, 101–110, 117–131, 133, 134, 140, 168, 177, 180, 182, 188, 195, 200–204, 206, 208, 211, 212 Chinese medicine classics, 95, 96, 101, 106, 107 Chinese medicine theories, 95–98, 101, 107–110 Chinese tourists, 62, 66 Cholera, 13, 15, 16, 75, 76, 78, 80–90, 165–169, 171–182 Classification of Chinese medicinal cosmetics, 95, 96 Climate, 100, 121, 178 Clinic, 11, 31, 37, 52, 53, 61, 66, 79–84, 86, 87, 89, 118, 120, 124–126, 129, 130, 132–134, 140, 141, 144, 148, 153, 189, 197, 198 Clinical, 9, 11, 12, 15, 24, 25, 28–34, 41, 53, 54, 60, 64, 85, 120, 126, 147, 148, 151, 153, 154, 156, 160, 212 clinical trials, 201 Colonial, 16, 76, 118, 120–122, 133, 140, 166–169, 172, 177, 178, 180, 190 Combined Chinese medicine, 6, 9

Commodification, 10, 13, 16, 17, 59–67, 70, 128 Communist China, 8 Community, 52, 55, 62, 68, 81, 85, 87, 120, 140, 141, 147, 174, 212 Complementary medicine, 15, 40, 119, 125, 140, 142, 144, 149 Consultation, 37, 121, 125 Contemporary, 14–16, 40, 109, 122, 132, 134, 188, 189, 194, 195, 202, 203, 206, 207 Contemporary China, 7, 12, 96 Corporate, 198 Cosmetic industry, 104, 105 Cosmetic market, 105–107, 110 Cosmetics, 7, 14, 95–98, 100, 102–105, 107–110 Cosmetics development, 95, 107 Cosmological, 16, 187, 191, 204, 206 Cross-sectional, 159 Cultural, 4, 8, 9, 12, 14, 17, 42, 59–66, 69–71, 105, 140, 151, 188–192, 194, 195, 199, 201, 206, 210, 212 Cultural identity, 60, 61, 67, 140 Cultural influence, 188 Cultural preservation, 13 Customers, 50, 97 D Develop, 5, 6, 9, 13, 17, 96, 97, 110, 146–148, 151, 157, 197 Disease, 1, 2, 5, 7, 16, 17, 29, 37, 39, 41, 55, 68–70, 76–78, 84, 85, 89, 98, 101, 102, 144, 147, 148, 169, 171, 172, 178, 187, 188, 193, 194, 204, 209, 211 Disinfection, 176, 179, 180 Doctors, 8, 24, 42, 44–50, 54, 55, 61, 67, 81, 82, 85, 87, 89, 102, 155, 171, 178, 179, 197

INDEX

Domestic cosmetics, 97, 107 Drug Control Authority (DCA), 143 Dynasty, 1–4, 16, 24, 25, 85, 98, 102–104, 110, 118, 131, 206 E Economic, 4, 8, 25, 60, 70, 78–80, 105, 120, 123, 126, 131, 188, 194, 195, 201 Economic development, 25, 28, 60, 62, 63, 68, 70 Education, 6, 7, 9–11, 15, 23–34, 48, 84, 118–120, 123, 124, 126, 127, 129, 133, 142, 144, 149, 151, 153–156, 160, 176, 180, 192, 195, 203, 210 Environment, 40, 41, 60, 61, 67–71, 99, 100, 109, 151, 158, 211, 212 Environmental factors, 99, 109 Epidemic, 13–15, 76–78, 81–83, 85, 89, 90, 165, 167–169, 171–177, 180–182, 190 Ethnic, 4, 15, 17, 60, 62, 63, 67, 70, 117, 119, 120, 122, 127–130, 133, 134, 142, 150 Ethnic group, 63, 123, 128, 130, 142 Ethnicity, 122, 166 European, 105, 118, 166, 171, 178, 182, 207 F Faculty, 128, 129, 131 Female, 37, 131–133, 144 Filipinos, 15, 16, 166–168, 175, 177, 178, 180–182 Finally, 3, 10, 118, 134, 167, 182, 212 First, 2–4, 16, 17, 25–28, 32, 33, 38, 41, 50, 51, 68, 75, 76, 79, 82, 84, 86, 87, 89, 96, 101, 104,

217

105, 118, 119, 125, 132, 139, 157, 167–169, 175, 190, 203, 208, 211 Food, 7, 85, 158, 174, 178, 179, 209, 211 Foreign cosmetics, 106, 107 Foreigner, 141, 145, 146, 192, 199 Formulas of Chinese Medicine, 29, 30 Framework, 6, 11, 12, 14, 68, 77, 118, 119, 141, 143, 144, 146–148, 191, 192, 194, 195, 204, 205, 207, 212 Functions, 67, 96, 97, 99, 100, 102, 107, 108, 110, 141, 160 Future, 16, 17, 24, 50, 51, 53, 54, 155, 159, 160, 192, 208, 210 G Geographic, 188, 194 Globalization, 7, 10, 14, 17, 63, 124, 125 Global market, 13, 14 Government, 2, 3, 12–14, 16, 24, 26, 42, 48–50, 53, 55, 63, 76–79, 81–84, 88–90, 110, 118–120, 124, 126, 127, 131, 133, 134, 140, 141, 144–146, 149, 157, 159, 167–169, 171–174, 177, 181, 182, 190, 194, 198, 200, 202 H Han, 1, 2, 16, 98, 102, 103 Healing, 1–3, 13, 60, 61, 67–71, 119, 142, 208, 209 Health, 2–5, 7, 10, 15, 31, 38, 40, 42, 54, 61, 67, 68, 79, 82, 83, 89, 105, 119, 125, 126, 132, 133, 141, 142, 144, 160, 175, 178, 181, 182, 187–189, 191–195, 200, 204, 208–212

218

INDEX

Health care, 2–4, 6, 8, 9, 12, 14, 15, 17, 38, 40, 54, 65, 119, 120, 123, 124, 126, 128, 134, 140, 141, 144–149, 155, 156, 159, 160, 167, 178, 181, 188, 190, 196–198 Herbal, 7, 14, 33, 38, 40, 47, 49, 50, 52, 54, 96, 107, 108, 125, 143, 146, 155, 157, 158, 160, 180, 182, 194, 200, 202, 203 Higher, 5, 15, 25, 26, 30, 32, 45, 120, 131, 144, 149, 151, 154–156 Hinduism, 117 Historical, 14, 43, 96, 101, 102, 140, 168, 187, 195, 200, 202, 206, 207 Historical preview, 95, 101 Hospital, 9–13, 17, 30, 37, 38, 40, 42–51, 53–55, 61, 65, 83, 86, 89, 130, 144, 148, 149, 154, 168, 174, 177, 179, 189, 197–199, 207 Huang Di Nei Jing , 1, 2, 98, 99, 101, 104, 131, 132 Human body, 29, 41, 98–101, 178, 204 Humidity, 178 Hybrid Chinese medicine, 9 Hybridity, 6, 10

I Illness, 15, 16, 39, 41, 49, 67–69, 101, 142, 187–189, 191, 192, 194, 197, 199, 205, 206, 208, 209, 211 Immigrants, 140, 175, 182, 196 Imperial, 2, 3, 5, 16, 24, 104, 131, 168, 180–182 Indigenous, 2, 16, 117, 123, 127, 128, 141, 187, 188, 191, 195

Institution, 6, 10, 11, 15, 17, 24–31, 33, 52, 60, 64–66, 118, 122– 124, 126, 130, 149, 151–156, 158, 174, 181, 182, 197, 198, 206, 210, 212 Institutionalization, 10, 13, 14, 78, 89, 90 Insufficiencies, 96 Insurance, 149, 195, 196, 198, 200, 203 Integrated Chinese medicine, 7, 9, 10, 17, 34 Integrated education, 6, 14 Integration, 9–12, 15, 30, 32–34, 38, 40–42, 48, 54, 103, 120, 133, 134, 142, 146, 148, 149, 155, 157, 158, 160, 189, 212 Interdisciplinary, 55 Interview, 43, 46, 119, 134, 192, 204

J Japan, 10, 16, 144, 188–192, 195, 197–203, 206–208, 210–212 Japanese, 16, 105, 187–191, 194–212

K Kampo, 16, 187, 188, 191, 193, 197, 200–204, 206, 207, 209, 212 Knowledge, 3–5, 14, 23, 24, 32, 35, 40, 43, 48–50, 64, 67, 70, 77, 103, 130, 149–151, 154–156, 158, 159, 179, 206–208, 211 Kuala Lumpur, 118, 119, 123, 125, 126, 129, 130, 132, 134

L Laboratory research, 201 Legal, 49, 127, 190, 202 Licensed physician, 197 Lifestyles, 211, 212

INDEX

M Malay, 117, 123, 127, 128, 130, 133, 139, 141, 158 Malay Peninsula, 117, 118, 140 Malaysia, 7, 10, 14, 15, 117–134, 139–149, 152–161 Male, 38, 131, 134 Manila, 166–175, 178–182 Manufactured, 200, 203 Manufacturer, 7, 10, 143, 197 Marxism, 28 Massage, 30, 38, 40, 132, 145, 146, 148, 151, 154 Masters, 25 Materials, 1, 33, 96, 98, 103, 107, 108, 175 Medical anthropology, 192, 206 Medical institutions, 32, 42, 48, 59–61, 70, 168, 198, 207, 211 Medical insurance, 124, 149, 196 Medical practices, 9, 42, 60, 65, 84, 118, 166, 168, 182, 189, 190, 212 Medical schools, 2, 13, 34, 144 Medical systems, 52, 70, 156, 160, 181, 190, 193, 195, 200, 202, 203, 208, 212 Medical traditions, 63, 67, 68, 71, 188–192, 194, 207–209, 211, 212 Medicine Buddha, 68 Methodology, 194 Migration, 4, 76 Military, 176, 178, 180 Mineral, 14, 38, 96, 98, 101, 104, 118, 140 Ministry, 105, 144 Minority, 60, 62, 63, 117, 120 Modern education, 25 Monolithic, 7, 8, 197, 201, 212 Moxibustion, 26–29, 96, 99 Multidisciplinary, 26, 148, 151

219

Municipalities, 166, 167, 171, 173, 174 Muslim, 140, 168, 171, 181

N Nationalism, 6, 167 Nature, 2, 5, 9, 14, 37, 66, 71, 101, 107–110, 126, 133, 178 Necessary, 43, 46, 82, 140, 154, 155, 178, 209–212 Nineteenth, 4, 5, 85, 120, 188, 190, 200, 206, 207 19th century, 140, 166–169, 171, 173, 178, 180–182

O Otherness, 63

P Pandemic, 13, 15, 75–78, 81, 85–90, 165 Pathological, 205 Patients, 9, 10, 13, 38–40, 42, 46, 48, 49, 51, 54, 81, 84–90, 119, 126, 130, 146, 148, 149, 154, 160, 168, 172, 174, 176, 178–180, 182, 196–198, 202, 206, 209 Patriotic, 66 People’s Republic of China, 6, 8, 12, 16, 25, 26, 42, 105 Philippines, 7, 10, 15, 16, 75, 165, 166, 169–173, 178, 179, 182 Philosophy, 2, 16, 40, 142, 204, 208 Physiological, 98–101, 205 Pluralist Chinese medicine, 9 Policies, 12, 48, 52, 63, 64, 78, 119, 122, 154, 155, 159, 165–168, 176, 181, 182, 190, 194, 200, 201

220

INDEX

Political, 2, 4, 6, 8, 10, 14, 16, 17, 48, 60–63, 65, 75, 77, 83, 84, 90, 134, 166, 171, 182, 188, 191, 194, 201 Political economy, 190, 194 Popularity, 16, 85, 159, 190, 212 Postgraduate, 27, 123, 150, 151, 154, 156 Practitioners, 1, 3, 5, 7–9, 14, 28, 31–33, 42, 49, 53, 61, 65, 71, 79–85, 88–90, 120, 121, 129–132, 134, 140–142, 144–148, 154, 156, 158, 179, 204, 205 Predominantly, 16, 34, 67, 130, 132, 134, 187 Prescriptions, 4, 5, 12, 31, 42, 85, 86, 88, 95, 96, 98, 99, 101–104, 109, 110, 208 Prevention, 1, 13, 37, 39, 55, 76–78, 80–83, 87, 89, 90, 147, 176, 179, 180, 209 Private, 12, 13, 42, 118–120, 122–124, 126, 128, 131, 134, 142, 145–149, 153–155, 158, 178, 195, 196, 199, 201, 210 Products, 3, 4, 7, 14, 15, 42, 43, 49, 51, 63, 65, 95, 103, 105–108, 110, 125, 140, 143, 155, 156, 158, 159, 170, 200 Professionalism, 83, 150, 196 Professionalization, 6, 8–10, 14, 142, 144 Program, 8, 11, 12, 24, 26–34, 77, 123, 128, 129, 132, 149–152, 154–157, 196 Prostitution, 174 Public health, 53, 76–78, 119, 126, 145, 146, 165–169, 173, 176, 181

Q Qing, 4, 25, 104 Quality, 15, 32, 33, 35, 50, 65, 107, 142, 144, 149, 155, 159 R Regulation, 8, 14, 24, 52, 82, 84, 89, 108, 110, 141, 142, 144–147, 155, 167, 171, 175, 177, 195, 201, 202 Religion, 2, 61, 63, 68, 119, 206, 207 Religious, 2–4, 59–62, 64, 69–71, 117, 134, 140, 166, 181, 191, 207, 212 Research, 12, 15, 27, 31, 38, 43, 53, 76, 88, 97, 109, 144, 150, 151, 154–160, 168, 187, 189–192, 194, 195, 202, 203, 205–207, 209 Rituals, 66–68, 167, 174, 181, 199, 207 Robotic, 196 Rural areas, 13, 65, 78–80, 90, 189 S Sanitary, 16, 171–174, 177, 182 Sanitary inspector, 168, 175, 176 Scholars, 9, 17, 59, 64, 66, 77, 85, 167, 188 Scientific, 9, 25, 31, 32, 35, 61, 67, 140, 168, 189, 201, 202, 204, 207, 212 Secondly, 3, 5, 7, 8, 10, 43, 48, 99, 109 Segregation, 119, 120, 122, 124, 126, 128, 129, 134, 174, 179 Services, 2, 8, 12, 14–17, 42–44, 46–53, 62, 79, 81, 82, 119, 120, 124–126, 130, 132, 140–144, 146, 147, 149, 159, 167, 168,

INDEX

173, 175, 177, 180, 181, 195, 208 Sex, 15, 119, 120, 122, 131, 134 Skills, 11, 15, 28–30, 33, 48, 50, 149–152, 154–157 Skin care, 102, 103, 108 Social factors, 100 Society, 14, 15, 44, 52, 62, 66, 82, 101, 103, 122, 123, 134, 151, 167, 168, 174, 177, 179, 181, 182, 191, 196, 199–202, 205–207, 212 Socio-economic, 14, 119, 120, 122, 126, 128 Southeast Asia, 4, 189 Spain, 166, 171, 179, 181, 182 Spanish, 165, 167, 168, 172, 178–182 Spanish colonial, 16, 165, 168, 169, 171, 172, 174, 175, 181, 182 Sponsorship, 198, 201 Standardized, 5, 10, 33, 148 Statistics, 119, 126, 128–132, 134, 169 Student, 6, 11, 12, 24, 27, 28, 30–35, 50, 89, 128, 129, 131, 133, 134, 150, 151, 153, 154, 156, 160, 196, 210 Support, 2, 5, 8, 46, 48–51, 53, 131, 134, 140, 142, 146, 148, 149, 154, 156, 157, 159, 193, 209–212 Survey, 119, 143, 144, 189, 192, 193, 198, 201, 202, 204 Syndromes, 12, 31, 54, 204–206 Systems, 24, 40, 41, 43, 50, 52, 77, 110, 141, 142, 154, 157, 189, 201, 202, 208, 212 T Technology, 5, 32, 42, 49, 55, 89, 104, 106, 160, 193 Temperature, 178

221

Theoretical, 2, 9, 11, 31, 70, 98, 102, 110, 154, 194 Thirdly, 8, 49 Tibet, 70 Tibetan, 13, 59–61, 63–71 Tourism, 62, 63, 65, 68, 71, 117 Tourist, 13, 17, 63, 66, 67 Trading, 169–171, 182 Traditional Chinese medicine (TCM), 11, 16, 23, 25–27, 29–34, 37, 38, 40–44, 46–52, 54, 55, 70, 118, 125, 132, 140, 142, 151, 153, 159, 187, 190, 200 Traditional Japanese systems, 16 Traditional medicine, 53, 124, 128, 142–144, 189, 190 Transition, 1, 2, 7, 8, 10, 14, 16, 17, 34, 119, 165, 178 Treasure house, 64 Tuina, 24, 26–30, 38 U Unequal, 65, 120, 122 University, 50, 123, 128, 129, 149, 151, 152, 154, 181 Urban, 2, 64–66, 89, 123, 126, 132, 144, 167, 168, 178, 181, 191, 212 W Welfare, 15, 80, 166, 167, 202 Wellness, 15, 16, 144, 159, 188, 189, 191 Western medicine (WM), 4–12, 15–17, 25, 33–35, 37, 38, 40–46, 48–55, 85–90, 108, 118–120, 122, 124, 126, 129, 130, 140, 142, 155, 156, 158, 168, 177, 181, 182, 188–190, 195–198, 200–204, 207, 209, 211, 212

222

INDEX

Women, 104, 120, 122, 132, 133, 205 X Xiamen University, 123, 124, 128, 131, 132, 134

Y Yin/Yang, 37, 38, 40, 101