A dialogue on traditional medicine: east meets west.

Roth, Adam ; Zhang, Hongxia

Roth: Several articles published recently in the New York Times refer to the rise of "personalized" and "precision" medicine in the US (Editorial Board, 2015; Kolata, 2015; Mukherjee, 2016). I find this fascinating since both Eastern and Western medicine were founded on a personalized approach to healing, a philosophy of medicine that accounted for the unique constellation of forces that defined the body in a state of health or disease (Roth, 2011a). Today, personalized medicine is seen as a novel enterprise in the West, since medical practitioners and treatments historically, in the Modern era, focus more on populations than individuals. For example, medicines are often prescribed based on clinical studies of groups, and little attention is paid by Western physicians to the ways in which certain medicine may react in particular bodies. Holistic treatments, in other words, are what has been missing.

Zhang: It is a good idea to begin our dialogue from the point of view of "personalized" medicine. "Personalization" is a relevant and interesting entry point to our discussion. In fact, there has been a heated debate for many years in China on the standardization versus individualization of Traditional Chinese Medicine (TCM). (Cui, et al., 2005, 2006).

Individualized medicine, from the perspective of TCM, focuses on the human being rather than the illness itself when one is sick. TCM rejects the one-size-fits-all method by emphasizing multiple treatments for the same disease, determined on the basis of an individual patient. A good TCM doctor, therefore, will diagnose through symptoms, onset, disease location, bodily reactions, and the different stages of the disease and how it originated (Sun & Zhen, 2012). TCM also stresses the effects of environmental changes on health and disease. Just as this editorial indicates that "personalized medicine" provides a new way of looking at diseases, TCM uses a holistic understanding of health as a dynamic balance inside the body and as a unity between the internal body and the natural world. For instance, a person's perception of the season can have an effect on their lifestyle. According to Huangdi Neijing (Yellow Emperor's Canon of Medicine) (Li, 2005), a TCM classic, the four seasons are featured by spring-birth, summer-growth, autumn-reaping, and winter-storing, which means the energy begins to grow in Spring, enhances fast in Summer, reaches its peak in Autumn, and decreases in Winter. Therefore, people should follow nature by getting up early and going to bed late in spring and summer, because one can greatly absorb the vital energy (qi) in the two seasons; getting up early and going to bed early in autumn in order to keep the energy balanced; and getting up late and going to bed early in winter to save the energy. The theory has influenced the lifestyle of Chinese people for many generations.

Correspondingly, Chinese TCM practitioners believe people should nurture yang in the spring and summer, and nourish yin in the autumn and winter. (1) As such, one should not take tonics in the summer, because the pores in the body are liable to be open then and will prevent the smooth circulation of qi and blood, in turn leading to difficulty in absorbing and storing nutrients. Thus, winter is the best time to take tonics.

Roth: Indeed, any new trend in the U.S. to personalize and individualize medicine is a point of connection to TCM. Ironically, as we have discussed, Western medicine stems from the medicine of the Hippocratics in ancient Greece, which paid great attention to such things as environmental factors, seasons, weather, geography, diets and food, psychological disposition, and other variables at both the micro and macro level (Roth, 2008, 2011b). Contemporary Western medicine has dissolved many of these axiomatic principles of individualized care in favor of one-size-fits-all treatments, medicines, regimens, and diets. But the Greeks knew what is good for one person is not necessarily good for another. In fact, the Hippocratic Corpus of medical texts makes this explicit. But as medicine moved away from the apprenticeship model of training doctors and more toward the mass education of physicians, effectively we also lost a lot in the process, including the astute diagnostic power of physicians to understand the unique health concerns of patients. Surprisingly, biomedical science may allow us to reinvent personalized medicine at the level of genomes. Recent studies indicate medical science may once again be moving (back) to the individualized care of patients (Kolata, 2015; Mukherjee, 2016).

Zhang: In "The Ballad of East and West", Rudyard Kipling wrote, "Oh, East is East and West is West, and never the Twain shall meet...." (cited from Song, 2004). Indeed, West and East seem to have met a long time ago with the connection between TCM and TWM dating back to the time of Hippocrates. I am sure Hippocrates would be surprised to find his bosom friend in the ancient China of 2000 years ago.

Since the time of Hippocrates, physicians have recognized the relationship between human health and environmental factors. For instance, as you mentioned, the Hippocratic work On Breaths (Peri Physon) attributes all sufferings and diseases to the natural element of "wind". Coincidentally, at approximately the same time during the period of the Yellow Emperor about 2000 years ago, the Chinese people viewed the concept of "wind" as a main cause of disease. Huangdi Neijing, the earliest and greatest classic in TCM composed by various medical experts in Chinese history, recognizes the five basic elements, namely, wood, fire, earth, metal, and water, that encompass all the phenomena of nature. These five elements stand for the tangible activities of yin and yang as manifested in the cyclic changes of nature which regulate life on earth. Huangdi Neijing develops therapeutic principles based on syndrome differentiation, seasonal changes, geographical localities, and individual constitution. In comparison, Hippocratic medicine stipulates the theory of Four Humors and stresses that equilibrium in the proportion of four bodily humors keeps a person healthy. Both ancient Western and Eastern practitioners believe in the natural ability of the human body to cope with disease. From the perspective of TCM, health is a state of balance between yin and yang. The balance between yin and yang contributes to human health, while excessiveness in either side inevitably will lead to sickness of people. Hence, the role of a medical doctor is to strengthen the balance of and to reduce the excessiveness to either side of yin and yang for patients, so that health can be maintained.

Roth: Both the Hippocratic Corpus and Huangdi Neijing represent perceptions of health in the original development of Western and Eastern healing. Both reveal a dynamic balance between the inside and outside, reflecting a simple, holistic view of conforming to nature. Although TWM and TCM have a lot in common in ancient times, TWM has been almost entirely replaced by the modern biomedical model in the West. TCM, on the contrary, has survived and maintained for almost five thousand years. How do you think social and cultural developments in the East and West have affected the practice of medicine over time?

Zhang: The ancient Greek history of navigation and ocean exploration strongly influenced the Western spirit of adventure and its stress on tools and instruments in confronting and conquering nature. As a result, Western medicine, along with other arts, enjoy the freedom to seek solutions to medico-therapeutic problems without ideological restraints. By comparison, China has a long history of a farming economy that depends on nature and climate. There was an old Chinese proverb that says, "Live on the face of the Heaven," which reflects Chinese belief in subordinating to nature. China's development of an agrarian society over the course of its history has played a key role in promoting the growth of its large population. It also continues to sustain its traditional values. For example, the Taoist notion of following the nature's way is closely related, as in other naturalistic movements, to the development of Chinese medicine in modern society (Sivin, 1995).

However, West and East met again in the 1970s when the biopsychosocial model of health and illness began to arouse attention and recognition in modern medicine (Wang, 2008). The whole world seems to take a new look on the cause of illness and the relationship between nature and human health. People realized that although contemporary Western medicine, founded on a biomedical model, can trace the disease to cell and molecular levels, it neglects the relationship between the internal and external environment (Tang, 2004). According to TCM, the human body is treated as an organic whole, in which the constituent parts are inseparable in structure, interdependent in physiology, and mutually influential in pathology. Since the human body is regarded as an organic whole, treatment of a local disease has to take the state of the whole body into consideration. We can find many therapeutic principles of TCM reflecting a belief in holism. For instance, "treating the feet for curing the disease located on the head" indicates that the disease rooted in the head could be cured by the treatment of the feet. In contrast, Western medicine teaches physicians to treat the head directly if the head is the location of the problem.

Roth: You are correct that Western medicine has moved far away from its origins in ancient Greece, and our philosophy of medicine has adapted to a modern era and to the biomedical model. Still, the traces of our past are not extinguished, and some principles of TWM, like keen perception, astute diagnostic skill, and inference based on clinical experience, live on and continue to influence medical practices. Furthermore, Western medicine is experiencing a renaissance of sorts in once again valuing a holistic approach to healing. In fact, Western medicine is also adopting many of the principles found in TCM, and even coopting TCM as an "alternative" or "complementary" approach to healing (Whorton, 2004).

Yes, that's right, TCM may not be seen as mainstream in Western medicine, but it has certainly earned its place as a supplement to biomedical medicine. Some top U.S. hospitals are embracing Chinese herbs and other alternative practices of healing. Even elite hospitals like the Mayo Clinic, University of California San Francisco, and Duke University Medical Center are offering traditional Chinese healing practices. Alternative and complementary healing has become a multi-billion-dollar industry, ranging from herbal supplements to acupuncture, energy work, and other curative procedures. Why is this? One reason is people are not always ready to succumb to invasive treatments and seek out more mild regimens that may produce positive results. Another reason is that we recognize the limits of the biomedical model; it cannot cure every illness or even begin to understand others. As such, we understand the relative value of knowledge and appreciate principles developed over time in other cultures (Starosta & Chen, 2009). Yes, TCM has some credibility in the West.

Zhang: This is an encouraging trend. The integration of Western and Eastern approaches to healing will broaden our view of medicine and offer more choices and therapies. Western medicine and TCM provide two different ways of healing. TCM stresses balance and harmony between the two opposite forces of yin and yang. Take Chinese kongfu (martial arts) as an example. A taiji master can use the soft force to overcome the impact of the hard blow, as indicated by the saying "si liang bo qian jin" (Art is good for strength) (Yang, 1998). On the contrary, Western medicine uses allopathy, like a boxing player who focuses her/his strength in confronting and defeating the rival. Western medicine is obviously good at treating medical emergencies and performing surgery, while Chinese medicine is advantageous in treating chronic diseases and maintaining proper health. Moreover, TCM has a great tradition in the practice of yangshen (life maintenance). A golden rule for yangshen in TCM is to prevent disease before it emerges, which is congruent with the new trend in people's seeking for a natural way of life. Thus, a good TCM doctor is always judged on the basis of whether she or he can prevent disease before it is formed. TCM obviously has great potential to contribute to public health in the West.

Roth: Lifestyle, diet, exercise regimens, and other approaches to healthy living are all the rage in the West, especially in the United States. The ancient Greeks, however, knew well that a healthy lifestyle consisted of a balance in the body and mind. We are reminding ourselves of that today. But, for the ancient Greeks, they believed in a very different makeup of the body than we do today. Back then, the body in health was considered the harmonious balance of four humors, blood, phlegm, yellow bile, and black bile. Any imbalance of these humors, any excess or deficiency, could cause problems in temperament and health, and medicine was seen as a way to realign and balance the humors (Lloyd & Sivin, 2002; Longrigg, 1991). Since they believed every human body was uniquely composed, medicine had to be individualized and specific to each patient, each season, and each environment.

Surprisingly, this philosophy of the body and approach to healing characterized Western medicine well into the 19th century, only to be overthrown when modern medical research emerged as the prevailing science of the times. Hippocratic medicine, however, that version that grew out of ancient Greece, was always in competition with other approaches to healing, religious ones, in particular. The medical marketplace in ancient Greece was competitive and populated by a wide variety of healers, from midwives and root cutters, to temple healers and shamans (Nutton, 1994). Today, it is clear in the West we have a biomedical model of medicine, but we certainly continue to entertain alternative sources of healing. How about in China? Is the medical marketplace competitive?

Zhang: Before the missionaries first arrived in China in 1564, TCM was the dominant healing system. Unlike Western medicine, TCM is closely related to Chinese culture and characterized by a well-developed and closed social system, though it absorbed other sources of healing in different stages of history. Before Western medicine prevailed, there were no modern hospitals in China. Some TCM practitioners had clinics in a community or in their own houses, some went to the patient's home for treatment, and others were scattered in villages and towns with street-corner practices. Since the door of China was opened after the Opium War (the first Opium War erupted when Britain invaded China during 1840-1842, and the second Opium War started in 1856), modernity has begun to emerge in China. The introduction of Western medicine into China led to the establishment of modern hospitals and health and educational systems. It also resulted in the loss of medical market share for TCM. Heated debates on whether TCM should be abandoned in China began to appear in the 1920s. The debate centers on whether TCM is a scientific practice because TCM is an experience-based form of medicine, which is quite different from the modern medicine developed in the West.

TCM had gone through three times of crisis in the modern history of China, which could help us realize the impacts of science and technology on TCM. The first controversy on a national scale over whether traditional Chinese medicine should be abolished took place in 1912, and the second was after the foundation of the People's Republic of China, and the third happened in 2006 (Han, 2012; Ma, 2010; Zhao, 2012). Fortunately, TCM has survived in its competition with Western medicine, though it has certainly lost some of its stature. Although Western medicine dominates China today, a strong trend is pushing it to be integrated with TCM (Ma, 2010; Wang, Li, & Chen, 2005; Zhao, 2012). Scholars argue that the integration of the two medical systems can be a way for both Eastern and Western approaches to prosper and complement each other in their mission of relieving human suffering.

Roth: To what extent or for what purposes will Chinese people still see TCM doctors? And will they see them in lieu of Western-style doctors, or in consultation with them? For instance, if a person is diagnosed with a cancer and undergoing chemotherapy and other aggressive treatments, might they also see a TCM doctor for complementary healing? Or are the two treated exclusively, Western medicine for one kind of disease and TCM for others?

In the United States, it goes both ways. Often, TCM is consulted when Western medicine lacks clear answers, particularly around chronic diseases (like you mentioned TCM is good at treating) such as fibromyalgia. A friend of mine used acupuncture, for instance, to treat (successfully!) infertility, for which she had sought modern treatments unsuccessfully. Unfortunately, the business world and health care systems in the West have been slow to catch on to these benefits, and are often unlikely to fund them either. Therefore, alternative and complementary therapies can be very expensive and are often not covered, or at least fully covered, by insurance companies.

Zhang: Sure, a Chinese patient diagnosed with a cancer and undergoing chemotherapy will see a TCM doctor for complementary healing.

Western medicine and TCM provide two different ways to fight against cancer. From the perspective of Western medicine, surgery is the best way to remove the tumor, discard the bad part of an organ, or keep the good intact. That's called allopathy. But according to TCM theory, it is not always necessary to remove a tumor (Tang, 2004). The human body is like a tree, even if the tree has a tumor on its branch, it can survive and live well if the body balance of the tree can be maintained. So, there is no need to cut off the branch. Instead, what should be done is to regain the balance by stimulating the body's healing ability. Moreover, most TCM doctors will not recommend an operation and other aggressive treatments for elderly patients, because these treatments may destroy the system of the body and cause much suffering in the process.

As you mentioned, TCM is successful in handling chronic diseases, such as infertility. Yes, it's true. TCM therapies aim to stimulate the healing ability of the human body to improve the whole inner system of bodily functioning. Many young Chinese couples who have infertility problems often choose a TCM doctor for treatment. TCM treatments have proven to be more effective and caused fewer side effects than other more invasive therapies. Chinese people attribute the success of TCM to the experiences TCM practitioners have passed down from generation to generation. Although modern science cannot explain some mechanisms and the theoretical foundation of TCM, it is undeniable that TCM makes great contributions toward maintaining human health for thousands of years. Thus, TCM is not regarded as a complementary healing regime in China. For Chinese people, TCM is more of a mainstream or primary practice, although it is still operating alongside modern scientific approaches and therapies.

In addition, since the establishment of the People's Republic of China, Mao Zedong has encouraged the Chinese medical society to develop a new health system that consists of three branches of medicine, including Western Medicine, Traditional Chinese Medicine, and Integrative Medicine (Wang, Li, & Chen, 2005). Today, President Xi Jinping has suggested on different occasions to promote the education and practice of TCM in China and overseas (Wang, 2016; Zhang, 2016). Although TCM is facing many challenges from modern medicine, it continues to show a strong vitality and social need. TCM is not only a medical system; it is an indispensable part of Chinese culture and daily life. Does Western medicine also give Western people similar life guidance?

Roth: That's an interesting question, and one I think about often throughout our dialogue. I also think about the incredible history of medicine in America, its progress, triumphs, and setbacks. I do not want to go into too much detail about the current administration of the healthcare system in America, which is incredibly complex, but I do want to say a few things about what we have variously considered alternative medicine in America, mainly in the 19th century.

The American model of medicine that most Americans are familiar with today emerged at the turn of the 20th century (Whorton, 2004). The 19th century was an incredibly competitive medical marketplace populated by a wide variety of healers and a proliferation of medical colleges that trained doctors in a variety of approaches. In fact, in the spirit of Jacksonian democracy, we actually abolished all licensing credentials for doctors in all states in the country that had them in an attempt to honor the spirit of American free labor, as we did not want to constrain anyone from freely practicing their art and trade. So, in the 19th century, something very interesting happens. Every state that had licensing laws on the books to credential physicians, repealed them. As such, we had a medical free-for-all on our hands, which led to a proliferation of quacks and charlatans and the need, at the turn of the century, thanks in large part to the publication in 1910 of the Flexner Report, under the aegis of the Carnegie Foundation, to shut down diploma-mill medical colleges and institute curricular standards for medical education in America. This was the real birth of modern medicine for us (Beck, 2004; Cooke, Irby, Sullivan, & Ludmerer, 2006).

What many Americans do not always realize, is that as a result of these purges of the medical system, we were left with two, sometimes very different, mainstream models for medicine and approaches to healing, and we still have these in place today! Indeed, we have doctors of osteopathic medicine (DO's) and regular medical doctors (MD's). They attend different medical schools but often fill the same residency and internship programs once they graduate to continue their training in hospital settings. In many ways, these two types of doctors are indistinguishable, although it is much less common for a DO to go into specialties like surgery, as they usually become family physicians, or focus on internal medicine. In part, this is due to the stigma some MD's still place on DO's. The public, however, for the most part, is unable to distinguish between them. Those who can, however, know that DO's are more focused on natural and less aggressive approaches to healing, many will incorporate and encourage natural and alternative practices, including supplements and massage, and manual manipulation of the body (such as in chiropractic medicine, another form of healing that survived the purges of medical schools at the early turn of the century), which is a central part of an osteopathic philosophy of a healthy functioning body. So, medicine in the United States is more complicated than some might expect. It is easy to group it all into Western medicine, but we have several types of medicine and various philosophies of healing operating together all at the same time!

I am interested in asking you another, albeit tangential, question that has been on my mind. In the United States, medical dramas on television are quite common. They idealize medicine and the role of doctors in society, and they represent and reinforce the dominant form of healing in the West (Rojas, 2014). Is TCM represented in Chinese media and cinema? If so, what does it represent to the Chinese people? Does it reflect well actual practices?

Zhang: Thanks for informing me more about the history of American medicine. In response to your question, interestingly, American medical TV dramas are also very popular in China. Shows like ER, Doctor House, and Grey's Anatomy all give Chinese audiences a positive impression of the medical system and the status of medical doctors in the US.

The first medical drama in China, Healing Hands, was aired on television from 1998-2005. It reveals the real life of medical workers, especially in emergency rooms. TCM always plays an indispensable part in those medical dramas, such as in A Legend of Magic Doctor Xi Laile, King of Pharmacists in Qing Dynasty, A Great Chinese Medical Master, Doctor Heroes, and All That is Bitter is Sweet. For instance, programs have shown how TCM made great contributions toward the national war against SARS in Hong Kong, China in 2003, which was also vividly depicted in Healing Hands. There was a boom of medical dramas on television in China around 2010 when the relationship between doctors and patients became strained. Thus, the conflict between doctors and patients has become a main theme in those medical dramas. Doctors are no longer portrayed as angels with brave and benevolent hearts. They sometimes are fragile and weak when facing death and are trapped in terms of trust in the complex relationship between doctors and patients.

Although Chinese media gives Western medicine an edge over TCM especially in the efficacy of healing, TCM continues to play a significant role in Chinese health maintenance. In Chinese media, TCM is portrayed as reinforcing a healthy lifestyle and offering effective preventative treatments. TCM is always viewed as a good way for doctor-patient communication by its "harmonious" principle in dealing with sickness, as well as its unique techniques in four ways of diagnosis involving watching, listening, asking, and pulse reading (Tang, 2004). Moreover, TCM is also considered as being affordable and close to the life of ordinary people.

Roth: That's fascinating. I am not the most avid television viewer, but I suspect some TCM practices may have been featured in medical dramas in the US too. This would be an interesting study for us to pursue, i.e., representations of TCM and TWM in Western and Eastern medical dramas and how perceptions of medicine and the roles of physicians in society differ based on the particular audiences surveyed.

Thank you for teaching me a great deal about TCM and how it is perceived, practiced, and studied in China. Certainly, TCM has an incredibly long history of success, and it is thoroughly ingrained into the fabric of Chinese society. As we began this dialogue looking into the similarities and differences between Eastern and Western approaches to healing, I am left with a great respect for the time-tested techniques and diagnostic methods of TCM practitioners, as well as with a belief that in joining together, TCM and modern bio-medical science and contemporary approaches to healing will help us arrive at the most effective approaches to alleviating human suffering and allowing human life to flourish. After all, no matter the approach, the objective is usually the same.

Zhang: It would be very interesting to pursue a project that studies the representation of TCM in Western medical dramas and how Western viewers perceive TCM theories and practices. If you've been watching the 2016 Rio Olympic Games on TV, you will notice an interesting phenomenon that draws a great interest in the media in China and the US. The famous American swimmer, Michael Phelps, has deep-purple circles on his back and shoulders. These deep-purple circles are produced by a traditional Chinese medical healing practice, i.e., cupping (Mazziotta, 2016). Physiologically, the cupping therapy draws blood to the affected area so that the pain and soreness can be reduced, which in turn will speed up the recovery process. In addition to Phelps, athletes from different countries were also trying the therapy. As an American reporter mentioned, "cupping is having a moment at the Rio Olympics!" (Reynolds & Crouse, 2016). This acceptance of Eastern healing techniques is also due to sports and Hollywood stars like Jennifer Aniston, who has been a fan of cupping for years. It is nice to see that TCM practices seem to reach a wider audience in the West.

I entirely agree with you that TCM and TWM have different approaches but with the same objective. They had much in common in their origin. They moved in different directions throughout their long history, but can still enrich each other in this new age of human society. In this new century marked by globalization and cultural diversity (Chen, 2012), I hope TCM can enjoy the achievements of modern medical technologies and make an effort to move forward by integrating with Western medicine. As Manfred Porkert pointed out, TCM is a mature science which can produce authentic and effective doctors of Chinese medicine if it is well developed and managed (see Zheng, 2016). The point manifests an optimistic future for the interaction between TCM and Western medicine through mutual learning and respect. It also reflects that the dialogue of medical practices between East and West should be an indispensable part of intercultural communication in this globalizing human society. In the case of Michael Phelps, as you can see, social media is helping us bridge the divide and produce mutual understanding.

Roth: Thank you. That's a great point to end with. In our next dialogue, let's explore how medical information is transmitted through social media in the US versus in China, as well as how medical information and the role of doctors in society are represented on television and in other forms of media in both countries. This has been an incredibly fulfilling dialogue from which I have learned a great deal.

Note.

(1.) Yin and yang refer to the two opposite, but interdependent and mutually transformative forces of the universe (Chen, 2009). Yang refers to the positive force that features the flourishing, bright, upward, and wax side of the myriad, while yin refers to the negative force that indicates the oppressing, dark, downward, and wane side of the myriad.

Correspondence to:

Adam David Roth, Ph.D.

University of Rhode Island

Harrington School of Media and Communication

10 Lippitt Road, Davis Hall

Kingston, RI 02881, USA

Email: adamroth@uri.edu

Hongxia Zhang

School of Humanities and Social Science

Zhejiang Chinese Medical University (ZCMU)

548, Binwen Road, Binjiang District, Hangzhou City

Zhejiang Province, 310053, P. R. China

Email: evezhanghx@sina.com

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09/29/2016

Adam Roth, University of Rhode Island, USA

Hongxia Zhang, Zhejiang Chinese Medical University, China