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Can TCM be Global, by Paul Unschuld

Meine Damen und Herren,

Ladies and Gentlemen,

Acupuncture has a long history of about 2000 years in China and knowledge of acupuncture has been disseminated in Europe already for 500 years.

So, when the organizers of this congress asked me to deliver a plenary lecture on the question “Can TCM be global?,” at first glance I thought: it is global already!

Also, for decades I have hesitated to touch the Ling shu. I am interested in the history of ideas, not in the history of clinical applications of those ideas. And I was misled by secondary literature to assume that the Ling shu is the classic of acupuncture and nothing more.

But then, a few years ago, I thought I cannot end my career without having read the Ling shu, and I soon realized: this is the most fascinating ancient Chinese medical text I have ever read. I decided to prepare a first translation following rigid European standards of philology and historiography.

So, the Ling shu is available now in English and in German, and I should like to share with you my delight at having access to this text. You may be wondering why I care to talk, for a few minutes, about the Ling shu when I am supposed to discuss the issue of whether TCM can become global.

My answer is: Reading the Ling shu carefully inevitably leads to the impression that the contents of this text most likely resulted from global exchange. We have numerous manuscripts from Chinese tombs dating from the late Zhou and early Han period. There are no hints whatsoever about the remarkable medical contents of the Ling shu. Neither are there are hints at any historical developments that eventually might have motivated the mature contents documented in the Ling shu. The Ling shu quotes numerous texts as part of a tradition highlighted in the Ling shu, but these text have never been seen in Chinese tombs, and their contents differ from manuscripts found in Chinese tombs.

The Ling shu is a fascinating text. It contains so many exact morphological details – where were these details discovered? The Ling shu offers psychological insights into patient-physician relationships that require years, if not decades or longer periods of patient-physician interactions – where did these interactions take place? So far, there is no evidence that they happened in China.

Look at the names of acupuncture insertion holes. When the Ling shu was written, China was a highly developed civilization with an advanced literary culture. The names given to the needle insertion holes do not reveal a system — as one might expect. Of course, seen individually, quite a few of the terms are meaningful. But as a whole, they are not meaningful. Thus far, no one has been able to explain them as a systematic terminology. My assumption is: these could be transliterations, using Chinese phonemes to transliterate terms originating from a non-Han-Chinese language.

One might assume that some type of foreign knowledge was brought to China and was integrated into the two competing genuinely Chinese doctrines of systematic correspondences, known as the yinyang and five phases doctrines.

Most of the concepts were nicely adapted to and further developed on the basis of Chinese yinyang and five phases doctrines. But others escaped such adaptation and remained contradictory forever. This applies, for instance, to the concepts of five long-term and six short-term repositories, and to the concept of a “Triple Burner.” The latter appears to have never been really accepted or fully understood, and there are further such hints, which we do not need to discuss today.

This new medicine, expounded in the so called classics of the Yellow Thearch,  often wrongly called “Yellow Emperor” in the West, did not fall on receptive grounds in China. And there may have been several reasons for this. Look at the derogatory treatment of the Yellow Thearch in the Ling shu dialogs. For the most part he is depicted as an ignoramus, requesting to be taught by some hitherto unknown experts, and sometimes he is ridiculed as a weakling who feels nauseous when he climbs up in a high building.

The Ling shu, the Su wen and the Nan jing survived in a very fragile state over the first 1000 years of their existence. They were lost and had to be retrieved from Korea. By the 8th/9th century they existed only in fragments, until a physician named Wang Bing collected and annotated these fragments, leaving a rather non-homogenous and often corrupt text to future readers. Few physicians used these ancient classics to further develop their basic concepts, unlike genuine Chinese pharmaceutical therapy that thrived and was continuously further developed .

Yang Shangshan, a Tang author, combined the most essential elements of the Su wen and the Ling shu in his Huang Di nei jing tai su. Without success. If it were not for fragmentary copies that survived in Japanese temple libraries where they were rediscovered in the 19th century, the Tai su would have remained unknown to us. It was entirely lost and forgotten in China.

The contents of the Ling shu and the other ancient texts were widely acknowledged as “Chinese Medicine” only in the aftermath of Song Neoconfucianism. This was the beginning of a most fruitful discussion of how to understand disease and health in theoretical terms, and what were the best strategies and approaches to prevent, cure or at least mitigate disease.

From the late Song dynasty onward a fascinating wealth of medical literature was published, in addition to an already rich pharmaceutical literature. Much earlier than the European renaissance, intellectuals and philosophers in China demanded the use of “reason” to examine the world, distrust of tradition and knowledge based on facts.

A most outstanding landmark combining both medical and pharmaceutical knowledge is the encyclopedia Ben cao gang mu of 1593, whose author or editor, Li Shizhen, is honored in China this year because it is the year of his 500th birthday.

No comparable survey of the medical potential of herbal, mineral, animal and man-made substances existed anywhere in the world at the time. Today, as Prof. Zheng Jinsheng has labeled it, it mainly serves as a museum where you find all manner of things, some still useful, others obsolete.

This encyclopedia, the Ben cao gang mu, is one of the hallmarks of Chinese historical medicine that found its way to Europe early and immediately met an enthusiastic reception. This was at a time when a global expansion and dissemination of knowledge, including medical knowledge, resurged anew. Such a global expansion and dissemination took place between the ancient cultures of Mesopotamia, the Indian continent and China toward the Far East and enriched the Greek world in the West. Tang China had welcomed visitors from all over the civilized world; Nestorians and many others met in Chinese cities. But it was only beginning with the 16th, 17th century that the curtain rose world-wide opening a new era of globalization.

Acupuncture was welcomed in Europe since the 17th century on a broad scale. So much so, that a German medical writer in the early 19th century spoke of an “acupuncture-mania.”

But this enthusiasm did not last forever. In the 19th and early 20th century, modern medicine, stimulated by Rudolf Virchow’s doctrine of cellular pathology, driven by advances in anesthesia and surgery, and flanked by the revolutionary and immediately successful institution of public health, gained a self-consciousness and a positive image it had never enjoyed before. Chinese medicine seemed to be no match.

And this atmosphere was not restricted to Europe. Even before the arrival of Western medicine, some Chinese physician-writers were unhappy with the state of Chinese medicine. They complained about too much theory, and they questioned the ethics of their physician colleagues. You may take the 18th century scholar-writer Xu Dachun as a witness.

The direct military and technological confrontation of the Chinese world view of a relationist science, evident in the yinyang and Five Phases theories, and the European analytical science, evident in chemistry and physics, biochemistry and biophysics, proved disastrous not only for Chinese sovereignty and the integrity of its territory, but it also proved disastrous for the image of Chinese medicine, in the Western world and also in China. A lengthy series of traumas, from the first Opium War initiated by the British in 1839 to the invasion of China and massacres committed by its neighbor Japan, required a reevaluation of all sectors of traditional Chinese culture and civilization.

Reformers and revolutionaries alike raised their voice in the early 20th century and offered suggestions as to how China might regain its legitimate place among nations. There was not one of them who did not seek to abolish Chinese Medicine. Young people in China today no longer know of the harsh judgments published by Chen Duxiu, the co-founder and first secretary general of the CCP; by Lu Xun, the most eminent novelist, by Ba Jin and many others. They all agreed: for China to regain its strength it was necessary to adopt modern science, modern technology and modern medicine.

It is often criticized in Western TCM circles how the People’s Republic of China has handled its enormous and most impressive heritage of medical ideas and practices. Those who criticize the domination of modern Western medicine in China are unaware of the severe traumas inflicted upon China in the 19th and first half of the 20th century.

In my book The Fall and Rise of China, I have focused on these traumas, and on the unique way – yes, unique in world history – how China cured itself  and rose to be a respected nation again.

I wrote The Fall and Rise of China. Healing the Trauma of History simply to demonstrate, how the tradition of Chinese Medicine has helped China to rise again and achieve its current status – admired by its own people and feared by neighbors and even distant, highly industrialized nations, for its regained political, economical and military strength.

Chinese politics have followed the same ideals demanded by Chinese Medicine. A close connection has existed in China for two thousand years between political wisdom and therapeutic wisdom. This close connection is most obvious in the common usage of the term zhi for “ruling” and for “curing.” To foreign intruders coming into your country as into your body, the same applies: Never blame the invader, blame yourself for having let the invader enter your territory or your body.

In politics this means asking: why were they able to steal our territory and to infringe upon our sovereignty? If they can do such horrible things to us, and since we are unable to defend ourselves, they must have a knowledge and a technology superior to our traditional knowledge and technology. Let us acquire these things, and once we have acquired them, we shall never be victimized again.

This is the secret behind the rise of China and this is why I wrote the book The Fall and Rise of China. It was to show how deeply ingrained Chinese medicine is in Chinese culture. Without an understanding of these intimate relationships, neither general Chinese politics of the past 100 years and today, nor China’s politics towards its traditional medicine can be understood. And, of course, this is also most relevant when we return in a minute to the question “Can TCM be global?”

China has paid a high price to regain its strength and reputation. For almost 100 years its leadership felt obliged to neglect China’s own cultural heritage, including its own medical heritage, and to adopt Western medicine in the same way as Western science and technology.

Look at China now in 2018. In many respects it has surpassed the West. It is more efficient in digitalization, its surgeons and physicians master the most difficult challenges, its trains run faster than those in Europe, and in global politics China plays an increasingly important role.

Thus, the time has now come for China to look back at its own traditions and to resuscitate those aspects of its traditions it can be proud of – and Chinese Medicine is one of those aspects. The vitriolic criticisms by Chen Duxiu, Lu Xun and others are forgotten. A new law, enacted only a few years ago, names Chinese Medicine as equivalent to Western Medicine.

When in the 1950s a first French delegation went to China to inquire about the status of Chinese Medicine in the recently founded People’s Republic, the Chinese hosts were surprised: why would Europeans be interested in a doomed tradition? As late as 1954, Mao Zedong was forced to react to requests aiming at eliminating Chinese medicine from the official health care delivery system in China. Mao Zedong’s wise reaction to these requests has been quoted again and again: Chinese Medicine is a treasure trove. Its treasures are to be unearthed.

The atmosphere has changed. Chinese Medicine, called “TCM” outside of China, is actively promoted by Chinese government agencies for world wide dissemination.

Here now I may repeat the initial question I was asked to discuss: Can TCM be global?

Again, my response might have consisted of only a short answer, namely: TCM is global already!

After all, in 2018 it is practiced all over the world. Not only are Chinese TCM healers found in cities and small towns. Indigenous, local practitioners who have acquired TCM and acupuncture competence in China or in other East Asian countries, or increasingly by local transmitters in their own countries.  They too have contributed to a global dissemination of TCM.

Literature on TCM is available now in the languages of most larger countries. The classical writings of Chinese Medicine have been translated into leading Western languages and hence are accessible worldwide, either conventionally printed on paper or on-line.

To conclude, with all this in mind one might be tempted to say: TCM has become global.

But is this really so? Perhaps before we decide to answer the question whether TCM can be global we should ask ourselves what we mean by a medicine being global. Is it enough to say it is globally available?

Let us look, for comparison, at the one health care and medical system that we might all agree on when it comes to its being global or not, and that is: biomedicine.

Biomedicine has its roots in Europe. Beginning with the 19th century it began to spread worldwide. Europeans took it with them, to all continents, and quickly enough its advantages over local traditions were acknowledged. Non-Europeans strove to study it, in Europe and the USA, and wherever Europeans and Americans had decided to set up medical schools. Non-Europeans later founded medical schools in their own countries and wrote texts in their own languages. So far so good.

Actually, this is where TCM stands today.  On the one hand, there is China – the motherland of TCM. It has its own history of Chinese Medicine, and it has its own agenda of working hard to see TCM spread world-wide. In addition, there are countless non-Chinese, non-Asian individuals in Europe, in the USA, on other non-Asian continents, who believe that they have acquired profound insights into TCM, who have studied and experimented with TCM and who have added new approaches and interpretations to TCM.

Biomedicine became global when it left its cultural affinity to Europe and opened itself to contributions by healers, physicians and scientists from a non-European cultural background. Biomedicine is not only practiced in virtually all corners of our globe. It also accepts and benefits from contributions by persons and institutions all over the globe.

Biomedicine is global because it is based on a science of chemistry and physics and their biological counterparts, biochemistry and biophysics. It uses for diagnosis and treatments a technology that is also based on chemistry and physics. That is, biomedicine is nourished by a science and by a technology that are applied world-wide and that develop further every day, every moment because of contributions from all countries, from all civilizations, from all cultures.

Here we have to ask ourselves: will TCM ever be able to reach this level of globalization? Or, to be more specific: are those in charge of TCM, notably in China, interested at all in acquiring for TCM such a level of globalization?

Let us look at names. Biomedicine is called “Western medicine” only in China in contrast to “Chinese medicine.” Outside of China, the term “Western medicine” has been obsolete for a long time. It may refer to the geographical and cultural origins of biomedicine, but it does not reflect its current reality.

The designation “Chinese Medicine” is different. It signifies not only the geographical and cultural origins of TCM. It also signifies an implicit claim. Chinese Medicine is Chinese and it shall be recognized as such forever. Chinese medicine has spread to Korea and Japan, and while its characteristics in Korea and Japan are still closely related to their Chinese origins, it is without doubt that over the centuries Korean and Japanese physicians and writers have contributed to further developments, modifications and adaptations of Chinese medicine in their own countries.

In the WHO deliberations on a standardized English terminology for traditional medicines, it was suggested to speak of East Asian medicine or Oriental Medicine instead of Chinese Medicine. The Chinese participants in these deliberations categorically rejected such a more encompassing designation as hiding the origins of Chinese Medicine in Chinese culture.

The fact is, for the Chinese side to this day, the global spread of TCM is a one-way-street. Chinese Medicine is an export article.

The contributions of non-Chinese practitioners and writers to a further enhancement of TCM may have been increasingly acknowledged by some individual Chinese TCM promoters, but they are not acknowledged by the motherland of Chinese Medicine – that is, by those Chinese authorities who consider themselves to be guardians of a national character of Chinese medicine.

Consider the China Academy of Chinese Medical Sciences in Beijing. It may be said to be the center of the protection and propagation of TCM. It has a remarkable library. There is no comparable institution elsewhere. And yet, this library refuses to acquire books written on TCM in foreign languages.

The Bencao gangmu may is the most impressive encyclopedia of pre-modern Chinese pharmacotherapy. Chinese experts, some of them members of the China Academy of Chinese Medical Science, have published in co-authorship with European and American authors three Dictionary volumes on, first, Historical Chinese Illness Terminology in the BCGM, second, all the place names found alluded to in the BCGM, and, third, all the book titles and names of persons quoted in the BCGM.

Without these dictionary volumes, scholarly academic or scientific access to the BCGM is simply impossible. But these dictionary volumes were published by University of California Press in the USA. Hence the library of the China Academy of Chinese Medical Sciences will not acquire them.

Can TCM be global? With its current one-way-export-article attitude TCM may have reached global welcome and successful application, but it fails to be truly global.

Maybe the question “Can TCM be global?” needs to be rephrased to “can the one-way-export-article TCM be successful on a global market?” The fact is, the global market is increasingly filled with competing TCM products. This is knowledge, these are approaches and applications that share the name TCM but have developed increasingly independently of TCM stimuli received from China.  

Also, further questions are raised whether the narrow confines of TCM specified by the TCM authorities in China do justice to the vast and heterogeneous heritage of pre-modern, historical Chinese medicine. TCM is only a meager digest of this vast and heterogeneous heritage. It was constructed by committees beginning in the 1950s and 1960s. They were required to select those elements deemed to fit into a modern health care delivery system based on modern science and technology – the foundation of a China aiming at regaining strength as a globally influential power.

Much of what has developed outside of China under the name of TCM, notably in Europe and the USA, during the past three to four decades, was and still is influenced by the myths generated and spread in the 1970s and early 1980s by the first bestselling authors on TCM in Western languages.

These were authors who went to China without knowledge of Chinese language, without knowledge of Chinese medical history and without personal experience in Chinese clinical reality. When they went to China, they did not meet specialists of Chinese medicine because it would have been virtually impossible to find such specialists who also might have been able to communicate their knowledge in a European language.

Westerners in search of Chinese medicine were informed by officially selected Chinese spokespersons who themselves knew little if anything of the complexities of historical Chinese medicine. If Western visitors were able to meet specialists of Chinese medicine, they mostly were told only what the responsible authorities of the People’s Republic of China had deemed as meaningful in a Chinese medicine meant to survive in a modern China and to spread abroad.

Western audiences were influenced in the 1970s by increasing doubts in the benefits of Western science, technology and medicine. Books on Chinese medicine and other media reports found a receptive readership. This was a readership that was unaware that they were given not an original Chinese Medicine but a digest.

And this digest was further alienated from the historical origins of Chinese Medicine by fantasies and misinterpretations introduced by Western transmitters in their books and media reports.

Here we are confronted with another facet of the issue “can TCM be global?” To what degree are the basic theoretical foundations of TCM as expounded in contemporary Western publications “traditional Chinese”? Anybody who speaks of the wu zang liu fu as the “five solid and six hollow organs” abuses the original Chinese understanding. Anybody who continues to translate the illness terms yong and ju as “welling and flat abscesses” betrays the original understanding. Anybody who continues to interpret the Chinese notion of qi as an energetic concept contributes to an alienation of Western TCM from historical Chinese Medicine.

This is not only the fault of Westerners unable to penetrate the true meaning of historical Chinese medical concepts and their terminology. Let us look at the Ben cao gang mu again, that most fascinating encyclopedia of Chinese pharmaceutics and health care. Compiled in the 16th century it quotes the best of medical and pharmaceutical literary sources of the previous two millennia. Two decades ago, the Foreign Language Press in Beijing offered an English version, translated by Luo Xiwen.

Luo Xiwen’s English version is faulty and problematic for many reasons. But in view of the issue we are concerned with here, its most blatant fault is its unconditional attempt at pressing historical Chinese illness ideas into the straitjacket of modern biomedical terminology. Reading this English version of the Ben cao gang mu does not provide access to historical Chinese medicine and pharmaceutics. Rather, it provides access to a hybrid construct that is neither traditional Chinese nor modern Western medicine.

Many of the fantasies and misinterpretations introduced by the bestsellers in the 1970s and 1980s have survived to this day, withstanding sufficient information to the contrary. They appeared and continue to appear plausible because they reflect emotions and aspirations of a public in the industrialized Western nations that was unsettled in the 1970s and 1980s by the energy crisis and a beginning awareness of environmental pollution resulting from a careless handling of chemistry and technology. A creative interpretation of “qi” as energy, and far-reaching mistranslations of further core terms in acupuncture theory are the most obvious examples of such idiosyncrasies.

That is, the one-way-export-article TCM sent out from China competes with a broad selection of non-Chinese TCM interpretations. They range, nowadays, from attempts at providing Chinese pharmacotherapy and needle therapy with a modern biomedical legitimation, to attempts at resurrecting the authority of the two millennia old classics of the Yellow Thearch, the Ling shu, the Su wen and the Nan jing, now available in philologically and historiographically sound English translations by Western scholars.

No neutral authority exists that could select from this heterogeneous array of TCM products those elements that might be suitable for building a single edifice of TCM that acknowledges both its historical origins in China and worldwide contributions by non-Chinese healers and scientists.  The library of the China Academy of Chinese Medical Sciences would certainly be overtaxed by such a task. After all, who in that library masters foreign languages to select from English, German, French, Spanish, Italian and other literature those contributions that are serious and noteworthy?

When Japan in the course of the Meiji reforms in the 1860s decided to adopt modern Western medicine, this meant adopting modern German medicine. The Japanese invited excellent German representatives of this medicine to teach them the new medicine, and they adopted with this medicine German medical terminology. For one hundred years, until it was replaced by English, German medical terminology was part and parcel of medical university training in Japan. Japanese medical scientists read German publications and used German themselves to publish their contributions.

How many Westerners who believe in the value of TCM have adopted sufficient Chinese language competence to fully understand historical Chinese medical terminology? How many of these Westerns have acquired sufficient Chinese language competence to inform Chinese audiences of their own contributions to a further development of traditional Chinese medicine?

The fact is, the emergence of a unified global system of TCM is rather unlikely. Westerners from the USA and Europe to Australia and New Zealand have developed and continue to develop countless individual adaptations of TCM to their own world views and mentalities. Chinese propagators, too, have often left the historical foundations and unique characteristics of Chinese medicine and have adapted their heritage to modern forms of marketing and life style. Successful practitioners of TCM in China with a hundred or up to two hundred patients a day have greatly distanced themselves from all the arguments of a holistic, individual health care that made TCM so attractive to many Westerners in the 1970 and 1980s, in contrast to a perceived reality of biomedicine. The request by the new TCM law of the People’s Republic of China to open TCM facilities to financial investors will demand as much efficiency and profit-oriented thinking from these facilities as is customary in commercialized Western medicine.

Years ago, I have asked myself  “what is medicine?” and I have published my answer to this question in a book of that title: What is Medicine? My answer was – and still is – based on the fact that medicine for as long as we can trace its history has always been carried further, in its theoretical handling of health and disease, by stimuli exerted by more encompassing notions of order and disorder. This has been true, as history shows, for European medicine, now called “biomedicine,” and also for Chinese medicine.

There is hardly a nation today that might consider a safe and successful future without modern science, modern technology and hence biomedicine. But modern science, modern technology and hence biomedicine also raise many questions and uncertainties. Such questions and uncertainties in turn justify the quest for alternatives and better ways.

Such a quest is evident in the increasing interest in TCM and its predecessor, historical Chinese medicine. Many doctors and non-medical practitioners outside of China are encouraged by their successful use of TCM and historical Chinese medicine in their belief that they are on the right track.

A congress, such as the one you have gathered at here in Munich, will be most important to discuss the many TCM products and ideas on the market now. It is for such congresses to pave the way for a development of TCM that reaches beyond a competition between a one-way-export-article sent out by China and countless TCM products generated and marketed elsewhere.

By Paul Unschuld