Lectures

How to Make Sense of “Traditional (Chinese) Medicine” In a Time of Covid-19: Cold War Origin Stories and the WHO’s Role in Making Space for Polyglot Therapeutics

This article is part of the series:

Note: I wrote this for anyone trying to “teach the virus,” something I will soon be doing myself. The question in the title is meant to signal that this is an open-ended dialogue. Most of the sources are in English and are easily available, meaning that students can use them as evidence, read other scholarship, and develop their own (counter) arguments. I would only add that this article focuses on state policies rather than therapeutic practices. I hope others will join in and round out the picture in the spirit of intellectual exchange.

A seemingly small side-story to the coronavirus pandemic received some media coverage in the U.S. over the last few weeks, though most people probably missed it.[1] It has to do with the way Xi Jinping’s government has supported and even pushed “traditional medicines” in its response to Covid-19. Given the urgency of the moment and the need for accurate information about the disease – including worldwide struggles with an “infodemic” that has accompanied the pandemic[2] – it would be easy to assume that any focus on “traditional medicine” is a distraction at best and a danger at worst. In fact, this is the underlying message of two articles published by CNN and Breitbart news, with the respective headlines, “Beijing Is Promoting Traditional Medicine as a ‘Chinese Solution’ to Coronavirus: Not Everyone is on Board,” and “China Pressures Africa to Embrace ‘Traditional Medicine’ Coronavirus Cures.”[3] As might be expected, these articles pit “science-based medical communities,” characterized as trading in real diagnoses and effective treatments, against China’s state-based initiatives on “traditional medicines,” which are described as having scant evidence or scientific-backing to support them. The Breitbart article goes even further, suggesting without any irony that China’s Communist Party is simply working to enrich itself and its state pharmaceutical companies by peddling ineffective products overseas as part of its propaganda machine. 

It’s hardly a surprise to find journalists covering these subjects in scripted and polarized ways: conventional medicine is characterized as good, i.e. necessary, essential, and the only thing that will and can save us (even if opinions may be divided on strategy), while traditional medicine is characterized as suspect, i.e. snake oil, pseudoscience, and a possible danger to us all (even if it’s still widely used). Breitbart’s coverage seems to be part of a wider conservative effort in the U.S. to shift the focus and the blame to China, so that the country’s politics and its people simultaneously come under extra scrutiny: conservatives’ talking points now refer to China’s oppressive political tactics (which they allege led to delays in epidemiological reporting and control measures) and dangerous foodways (which they say allow zoonotics to emerge and wildlife to be culled to extinction). These issues are not made up out of thin air, but they are taken out of context and used to fan xenophobic alarm and jingoistic sensibilities.[4] Focusing on China’s use of “traditional medicines” is one more way to call into question the country’s standing on the world stage, including its rationality. It also happens to be an effective way to pivot people (read voters) – who have little background knowledge of viruses, pandemics, global health, medical cultures, or history – away from the fact that the US executive branch has actively obstructed a coordinated federal response to the pandemic. This deception game of pivot-deflect, of course, runs both ways as Chinese media outlets and spokespeople have called into question the Chinese origin of the virus and worked to rewrite parts of the pandemic’s history, while also tamping down on public debate and dissent. 

This article is an effort to cut through some of the obfuscations and misdirections swirling around these subjects. To put my cards on the table: criticism of official or state-driven reactions to Covid-19 strike me as both warranted and essential at this stage. This is a pandemic that will literally rise and fall as a consequence of intra- and inter-state coordination. Peoples’ lives and livelihoods are at stake. Pandemics test systems of governance, especially their infrastructures. Responses to them risk all kinds of socioeconomic and political consequences everywhere. For these reasons, social critics – working in the public interest – should do what they can to “bust myths” about what works and what doesn’t, even when so much is still unknown and uncertain. That said, trying to decide in a time of crisis just what is and is not a “myth” involves its own high stakes drama. It also underscores some of the philosophical and geopolitical limits of calls to “believe science” or “trust experts.” These kinds of positions, understandable and urgent as they may seem, can also sideline and simplify ongoing contests in nearly every country (and “global” institution) on Earth over whose science, whose medicine, and whose expertise will even count. Such matters are neither easy nor straightforward. Ignoring them does not make them go away. 

Enter Stage Left: A Global (State) Actor Called “Traditional Medicine”

Just how this pandemic will end is still unclear, but of several things we can be certain: state-based interest in “traditional medicine” is here to stay and has insinuated itself into health policies and programs around the world, across all political jurisdictions. The World Health Organization has been and remains central to this process. This is one reason why it warrants more attention. Much like disease categories, lexicons of “traditional medicine” should be seen as containers for related, rather than identical, phenomena. Wherever the phrase is used and however it is applied, it does crucial boundary work across many divides. Though it is often written about in the singular, it has functioned as a label useful for parsing anything that has existed outside dominant or powerfully ascendant state-sanctioned approaches to medicine and health. The concept, in other words, contains multitudes. It has also functioned as a proxy for different power struggles, socioeconomic priorities, and questions about reality. This is why it tends to prompt debates over monolithic and monolingual views of the world. It also serves to challenge monocausal diagnoses and magic bullet solutions.[5]

The People’s Republic of China has indeed embraced “traditional Chinese medicines” (TCM) in its Covid-19 trials, protocols, and public relations. Its advisory teams working with Iran, Italy, Pakistan, Serbia, Venezuela, Hungary, Nigeria, and Uzbekistan, among other countries, have all made it a point to advocate that health care professionals consider using its treatment guidelines, including TCM, in their responses.[6] Chinese health officials have also briefed at least 24 African countries on their approaches and conducted a series of training programs.[7] These efforts fit within the PRC’s latest “Belts and Roads Initiative” and fall squarely into genres of medical diplomacy and medical humanitarianism that are ongoing. The CNN and Breitbart reports picked up on these dynamics, suggesting they may be insidious; the Chinese state mentions them in press releases, implying they are benevolent.[8] In truth, they are part of long-standing patterns of medical geopolitics in which the goal of saving lives and protecting people’s health becomes wrapped up in other kinds of ambitions, whether to colonize lands, save souls, or advance certain systems of production and governance. No part of the world has been left untouched by the epidemiological aftermath of empire-building and economic production: the globalization of disease and the history of pandemics are rooted in these forces. Likewise, no part of the world has been left untouched by the “colonizing” logics of medicine.[9] The Covid-19 pandemic needs to be situated within these wider histories.

To understand the roots of China’s advocacy for “traditional medicine” requires going deeper into the past and expanding beyond any single country, even one as powerful as China. What the few journalists who have reported on these topics miss – and misunderstand – are the imperial and Cold War origins of the global (and state-based) turn to “traditional medicine.” These dynamics endure. For better or worse, we still live in a world shot through with ideas and policies established during the Cold War era (circa 1950 to 1990). The fact that these pathways and precedents remain relatively invisible in conversations about Covid-19 means that when discussions of “traditional medicine” do become more important – and they will– they are likely to be described in sensationalist and misleading ways. They are also likely to reproduce similar scripts and hot takes that push people’s (panic) buttons. Such unease seems to accompany the concept almost everywhere it goes. 

SARS as Precedent and Catalyst for China and the WHO: Enter Coronaviruses

Indeed, I suspect that many of the epidemiologists, public health officials, and front-line professionals strategizing about Covid-19 containment – across Europe and North America and also within the World Health Organization (WHO) – have found themselves uncomfortable, perhaps even alarmed, to see “traditional medicine” receive such a prominent place in the official Chinese responses. As late as March 7th, some of these tensions were apparent to observers reading the Chinese, English, and French versions of the WHO’s online advice.[10] In a series of bullet points addressing measures that “ARE NOT effective against Covid-19,” the English and French versions included four bullet points: “smoking, taking traditional herbal remedies, wearing multiple masks, [and] taking multiple self-medication such as antibiotics.” In the Chinese version only three bullet points were listed, with the note about traditional remedies omitted. By March 8th, the English language advice was changed (though not the French) to be identical to the Chinese. And on March 9th, the advice was changed again, in all languages, to note that no medicine “could cure or prevent COVID-19” but that both “western and traditional medicines” were undergoing “ongoing clinical trials.” (Box 1.1 and 1.2) 

Box 1.1– Source: Screen shots from WHO website, 7thMarch 2020, “Q&Aon Coronavirus”
Box 1.2– Source: Screen shots from WHO website, 9thMarch 2020, “Q&A on Coronavirus”; https://www.who.int/news-room/q-a-detail/q-a-coronaviruses. Because these are still current, they remain online.

Those handling the WHO’s messaging might have added that these trials had begun during the original Severe Acute Respiratory Syndrome (SARS) outbreak in 2002-03, resulting in a WHO-sponsored report on the use and effects of “integrated Traditional Chinese and Western treatments.”[11] In spite of the many state-based requirements to support TCM in China – begun in 1954 with proclamations from Mao Zedong himself and codified more thoroughly in the 1982 constitution – China’s official and national embrace of these techniques during the SARS outbreak was not a foregone conclusion. In the early months of 2003, several “Chinese Medicine” hospitals in Beijing and Hubei Province were actually closed and patients exhibiting SARS symptoms were treated only in the “western hospitals.” As Eric Karchmer has argued, this was because many policy-makers in China had by then come to see TCM as “efficacious” (if they accepted it at all, that is) mostly for chronic, rather than acute illnesses. It was a “slow medicine” par excellence, while “Western” medicine was seen as fast-acting and thus most appropriate in “emergency” situations.[12] This view was itself a byproduct of PRC state priorities, which gave legal precedence to biomedical approaches (and institutions) over Chinese approaches and TM practitioners.[13] By contrast, during much of the Republican period (1911-1949), even with growing acceptance of germ theories of disease, most experts in Chinese medicine would have applied their skills to any case they felt equipped to handle, including cases of acute care, in part because they operated outside the bounds of most state regulations.[14] This remained true even after the Manchurian plague outbreak of 1911, which was an enormous test of such healers’ expertise, and state efforts to outlaw such practitioners in the late 1920s, which backfired and generated a direct and organized response.[15]

What SARS did – vividly as it turned out – was remind biomedically trained experts within China that their counterparts in TCM might know and do things that had important real-world effects. In other words, their work just might save lives, even in an emergency. They learned this lesson in real time, as the epidemic unfolded, and as fatality rates began to roll in from different places, including Guangdong Province where the outbreak began and where, by chance, “Chinese medicine” was “thought to be more popular . . . than anywhere else in China.”[16] This is why, between January and March of 2003, the Guangdong Hospital for Traditional Medicine developed its own protocols for diagnosis and treatment, integrating “Western” and “Chinese” practitioners from the start (all of whom, it should be noted, would have trained across both fields). This included placing SARS within “Chinese medicine diagnostics,” labeling it a“category of Warm Pestilential Disease (Wen Yi Bing) which primarily, though not exclusively, affected the lung.”[17] Of the 103 patients they treated during this time, all were listed as severe and 77 became acute, yet only 7 of these cases proved fatal, for a mortality rate of 6.79% (with no health care professionals contracting the disease).[18] The known mortality rate by late March for Beijing, the area hardest hit, was around 10% and about 16% of health care professionals were contracting SARS.[19] These differentials, alongside reports coming in from other areas, were enough to prompt a full-blown national response. On April 11th, the State Administration for Traditional Chinese Medicine established a “technical scheme . . . to prevent and treat SARS with TCM.”[20] And on May 8th, Premier Wen Jiabao publicly announced that “Chinese medicine should play a full role in the prevention and treatment of SARS.”[21] By the end of the outbreak in late July, nearly 100 TCM hospitals had been enlisted in treatment measures across the country and roughly 60% of China’s 5,327 confirmed cases (and many also in Hong Kong) were treated with combined therapies. 

It was one thing, however, for leaders in the PRC to decide that TCM had something useful to offer, but quite another to convince the outside world – or even everyone in the biomedical community within China – that combined therapies made any difference. The director of the WHO’s Traditional Medicine program, Xiaorui Zhang, believed her program could help with this question, so she decided to sponsor an expert meeting in Beijing (with funding from Japan’s Nippon Foundation) to analyze the role played by “traditional remedies.”[22] Because so many factors were in play in each city and province and with every SARS patient, the WHO’s expert report ultimately took a cautious tone, offering conservative assessments across the board. In their review of the thirteen “clinical trials” undertaken during the outbreak – 10 across mainland China and 3 in Hong Kong – they found that the different treatments seemed to be “safe” and that they might even have “potential clinical benefits.” Yet they also felt obliged to point out that the evidence was “insufficient” and “inconclusive” because pandemic conditions ensured that there were few “random controls.”[23] With this framing in place, they then proceeded to present case evidence that also seemed to show several specific benefits of “integrated treatments,” especially in terms of SARS patients’ fatigue levels, oxygen intake, lung recovery, liver and renal function, and speed of convalescence. In turn, they reported on certain “serious” side-effects from “high doses” of specific “Western” antivirals and glucocorticoids (or corticosteroids). One of the trials referred to corticosteroids as a “double-edged sword” because, while they could help with acute symptoms, they could also suppress a patient’s immune response, known as “double immunosuppression.” [24]

WHO’s Medicine is Most Effective? Benefits and Dangers of Different “Cures”

One rationale the Chinese government gave for experimenting with combined herbal therapies during SARS was that it allowed them to explore ways to avoid or lessen the toxic effects of existing “Western” pharmaceuticals, by using them in lower doses or not at all. This may seem a dubious, even dangerous, goal because to investigate these questions convincingly, especially during a pandemic, required that they make ethically charged choices about patient care. So many drugs are now so integral to different treatment protocols (and diagnostic and prescribing practices) that they are considered fundamental to “health.”[25] Withholding or avoiding certain drugs may seem a death sentence in its own right given the faith physicians and health care professionals base in them . . . and the mountains of evidence that appear to back up that faith. Corticosteroids, for instance, have been a treatment of choice for various lung diseases and breathing complications (including asthma) for decades. (Most inhalers contain corticosteroids.) They were used actively during the SARS epidemic, again during the Middle Eastern Respiratory Syndrome (MERS) outbreak, and, are still being used actively with Covid-19 patients in many countries throughout the world, including China. 

As of January 28th, 2020, however, the WHO advised against their use, precisely because they are now considered to cause more harm than good. Several clinical investigators from the University of Edinburgh, one of whom serves on the WHO’s panel for Covid-19 clinical management, reported these dangers in the Lancet: “Patients who were given corticosteroids were more likely to require mechanical ventilation, vasopressors, and renal replacement therapy.”[26] Given the number of people worldwide who are facing acute symptoms and are (or will be) in need of acute care, this is significant news. It is also crucial for those people around the world who may learn during this outbreak that their frequent use of corticosteroid-based treatments may make them more vulnerable to “acute respiratory” pandemics of the sort epidemiologists have been warning the world about for decades.[27] While the WHO’s latest guidelines on how to treat Covid-19 patients say nothing about using Chinese phytotherapies (at least not yet), they do highlight the same concerns that drove Chinese investigators to take up these questions in the first place.[28] The Lancet article even cites among its evidence reports from Chinese research published in 2004 on the side effects of corticosteroids in treating acute SARS patients. 

Why does this matter? For one thing, because profitable pharmaceuticals can shift over time from being considered “effective” to being labeled “dangerous” and these dangers can be extreme. This point goes beyond the idea that any cure can also be a poison by reminding us, first, that most pharmaceuticals have come into existence following an industrial logic: scale-up production in order to scale-up consumption; and second, that these same drugs often gain approval by using models for toxicity and side effects that deliberately simplify real-world variables and downplay the fact that humans cohabit the planet with ever-evolving parasites and live in ever-more toxic environments. Fast-moving pathogens like coronaviruses can therefore act as tracers, highlighting how certain drugs, developed for “chronic” ailments, potentially create new vulnerabilities when used in cases of acute care. For another thing, the last three decades have witnessed a sea-shift in botanical drug-development strategies that begin, not with laboratory tests, but in situ where people actually consume such treatments.[29] It has become increasingly acceptable for investigators to establish research protocols with the goal of reverse engineering a multi-compound plant therapy. They do this by studying what it is “patients” actually take for different ailments and how “healers” prepare their therapies. These methods rest on the understanding that sometimes “whole plants” or their different component parts (leaves, seeds, stems) interact in solutions in ways that laboratory-based studies and randomized control trials can miss. (In recognition of some of these shifts, the US-FDA established draft “guidance for industry” on “botanical drug studies” in 2000 and formal guidelines in 2004.[30]) This is bioprospecting with a couple twists: the precedents that investigators single out to justify these strategies were developed over the last several decades in India, China, and Mali (to name just a handful of countries) and their stated goal is to keep costs low, avoiding both the expense and the profit associated with “blockbuster drugs.”[31] The idea of minimizing profits is anathema to models of health care that are literally for-profit.

To bring this back to the WHO’s online messaging, it should now be less surprising that during this fast-moving pandemic, there were discrepancies in the way staff handled the issue of “traditional herbal remedies,” including the matter of their efficacy and usefulness. The WHO staff seem to have run up against some of the fault lines and growing pains of the organization’s own far-reaching bureaucracy. When that apparatus includes not just its director-general, executive board, headquarters staff, annual assembly, and emergency panels, but also the work of its six regional offices and intercontinental networks, staying on the same page – and deciding just what that is – can be a challenge. To put things in perspective, the WHO employs about 7,000 staff worldwide. (For comparison, the CDC reports that it employs more than 15,000.) It has always built into its operations a fair amount of accountability to its member states and regional offices, even when US and European actors (states, foundations, universities, research institutes, nonprofits) have still exercised disproportionate influence. In this moment, this accountability and the precedents it has set matter because it means the WHO is one of the few legitimately global organizations that is trying to juggle the priorities and interests of all states, including their people.

The irony here is that the WHO’s staff did manage to figure out fairly quickly how to communicate to everyday people what “ARE NOT effective” remedies, and accurately chose to report that clinical trials were investigating “Western and traditional medicines.” (Box 1.2) It will likely take much longer for the advice on corticosteroids to become a settled matter, in part because some clinicians are now suggesting that patients need higher rather than no doses of corticosteroids if and when their immune systems go into overdrive (also known as a cytokine storm).[32] Those health care professionals actively working with Covid-19 patients are having to do their best while also navigating a sea of competing and contradictory guidelines and protocols, none of which are binding, except perhaps those established at the hospital level. [33]

Box 1.3 WHO-EMRO’s Tweet withadvice against using corticosteroids.

Just where this leaves “traditional medicine” in terms of infectious disease treatments in general and Covid-19 in particular, remains an open question. But already there is modest evidence of a multinational turn to such therapies on the frontlines of the pandemic.[34] Because many of these plant mixtures have been identified in regions outside the “West,” or by marginal groups within these areas, it also means that their genealogies are imbricated in many other cultures of care with histories and conceptual frameworks of their own. Put differently, they tend to be associated with semiotics that are not limited to or easily constrained by official state positions.[35] So how do we explain these developments; what are their significance; and why do they matter? To answer these questions we must go back in time.

Traditional Medicine, Global (Health) Governance, and Cold War Antecedents

The WHO’s member states have been working to address “traditional medicine” at the global level in its annual world health assemblies since 1969, only after dozens of newly independent African states had joined the organization and put the first resolution on the subject forward for debate. Originally submitted by delegates from Guinea and the Republic of Congo, the resolution stemmed from a critique that too little of the WHO’s operating budget was devoted to the needs of member states from Africa and that too little was known about “the differences in the development of therapeutic practices in the countries of the world.”[36] This work coincided with a period when the People’s Republic of China played little official part in the UN or its specialized agencies, which helps to explain why, when the WHO took up these questions more fully in the 1970s, it ultimately used a set of definitions for “traditional medicine” and “traditional healer” developed during two pan-African meetings in 1976 in Brazzaville (Republic of Congo) and Kampala (Uganda). (Box 1.4) Some of this language is used in WHO documents to this day and has crossed over into other organizations with different kinds of jurisdiction, including the World Trade Organization (WTO).

Box 1.4 – Sources: African Traditional Medicine (Brazzaville: WHO-AFRO, 1976), pp. 3-4; and O. Ampofo and F. Johnson-Romauld, Traditional Medicine and Its Role in the Development of Health Services in Africa (Brazzaville: WHO-AFRO, 1976), pp. 37-39.

These early initiatives in the WHO owed much of their inspiration to work by the Organization of African Unity, which from 1965 onwards, added a program on “African traditional medicine and pharmacopeia” to its slate of pan-African activities.[37] It was the OAU’s leaders – also in 1969 during a ten-day gathering of hundreds of government representatives in Algiers – who first connected the continent’s cultural heritage to its medical heritage and called for its “cultural property” to have state protections as “intellectual property.”[38] Within just a few years, these projects were underway in almost every African country.[39] They had also been hardwired into the constitutions of at least two other pan-African organizations, the Conseil Africain et Malgache pour l’Enseignement Supérieur (CAMES, Burkino Faso, 1968) and the African Intellectual Property Organization (ARIPO, Central African Republic, 1977). While CAMES focused on research and higher education, in an effort to “recover authentic traditions and the original spirit of African civilization,” ARIPO focused on finding legal means to protect the continent’s “traditional medicine and psychotherapy . . . handed down from generation to generation.”[40] Most African leaders in this era tended to see these goals as fully compatible with building stronger health care systems overall: even at the Algiers meeting in 1969, the organizers touted that participants could avail themselves of the best medical care Algeria had to offer should anyone become unwell.[41]   

Work within the OAU, of course, had other roots and antecedents. Before either the OAU or the WHO had turned its energies to “traditional medicine,” UNESCO’s social science department in Paris and the pan-imperial organization, the Scientific Council for Africa South of the Sahara in Bukavu (Belgian Congo), had already taken up these questions by the mid-1950s, just as Mao Zedong issued his first declaration (in July 1954) on the need to combine “Western and Traditional medicine” as part of PRC state policy.[42] In other words, developments in China, and Asia more generally, were coterminous with developments across Africa. They were also, at times, mutually reinforcing. For UNESCO, a turning point came in 1960, when the newly admitted African delegates succeeded in getting the biannual Conference in Paris to hold a special set of six break-out meetings on the needs and priorities of member states from “Tropical Africa.” They ultimately identified two areas in which they sought support: “the study and preservation of cultures” and the need “for African authors and artists to enjoy protections of their creative works.” As the delegation from Congo-Brazzaville put it, this would help new states “contribute effectively to the cultural activity of the modern world.”[43] In 1963, UNESCO followed this up with two pan-African conferences: one was in Kampala and explored how “cultural commissions” could develop national and pan-African activities; another was in Brazzaville and explored a model copyright law and the language that could be included to protect forms of “African culture,” including “oral works.” Both meetings helped to reinforce rhetoric about “traditional” cultural heritage and both also raised important questions about (group) authorship and (collective) ownership, because delegates agreed that it was “the people [who were] creators of almost all the works” and so it should be these same people who deserved “proprietary rights.”[44] At least a few diplomats extended these ideas to “medical heritage,” seeing African therapeutics as falling within similar creative, oral, and collective undertakings. 

The work of anthropologists – often outsiders, but sometimes insiders – became integral to these conversations too because they helped diplomats (and many others) define the contours of different medical cultures, including who and what would be included. In 1953, for instance, the African Regional Office of the WHO hired a French anthropologist to undertake “a study of indigenous pharmacopeia and African practitioners’ activities in relation to African social-religious conceptions of disease.” As the report in 1954 made clear, “It was felt that the knowledge of such matters is necessary in order to be more efficient when implementing WHO projects and programmes.”[45] This research actually hewed closely to the kinds of studies British and French administrators had been sponsoring across their colonial territories from the early years of the twentieth century (and even earlier in South and East Asia). As more and more countries gained political independence, however, the relationship became uneasy. On the one hand, anthropologists began to distance themselves from instrumental uses of their work, preferring to focus on cultural analyses of people’s therapeutic and medical practices rather than anything having to do with state capacity-building. On the other hand, as more African leaders assumed the helm of state bureaucracies, they were increasingly critical of outsiders’ ethnographies because they seemed to turn people into exotic objects of study. For these men (and they were invariably men), sociocultural research needed to dovetail with state-building goals; paradoxically this drove them to “rehabilitate” parts of their “medical heritage” that were rooted more in colonial rather than precolonial patterns. 

During these early conversations about “traditional medicine,” concerns about property and state-building became connected in crucial ways. By the late nineteen-sixties, OAU officials were advocating that member states put “traditional medicine” in the public domain and define it as a public good.[46] These goals of course were inherently fraught because they gave states more power to act as gatekeepers and umpires for “traditional healers,” most of whom referred to themselves by different terms entirely. Yet officials’ aspirations also reinforced an ethos, at least for a time, that peoples’ “knowledge and know-how” was the preserve of governments rather than private capital.[47] When staff in the WHO finally launched the global program to develop “traditional medicine” between 1975 and 1978, they took a similar stance, seeing their work as part of a wider effort to bolster public health and primary care. In other words, they tended to envisage a broad cross-section of practitioners and practices being relevant to state health services. In 1976, African member states and staff in the African Regional Office took these points even further, explicitly characterizing their efforts as a way to “decolonize the minds” of medical professionals and government officials and connect ideas about “rights to health” with efforts to bolster states’ sovereignty. (See Box 1.4) Their rationale was clear: no one could exercise a right to health when their country was colonized or occupied; every country trying to handle the active military conflicts and cold war hostilities could profitably take advantage of, and even build upon, their own home-grown medical cultures. These were survival strategies on several fronts: states as a buffer to neocolonial and economic incursions; “local” healers as a means to bolster frontline care; and endogenous “cures” as a way to substitute for more expensive imports.

Box 1.5 – Excerpts of Speeches to African Regional Office (AFRO) Member States’ Annual Assemblies 

Interestingly, at the crucial WHO meeting in New Delhi, India in October, 1976, where many of the more important decisions were made to incorporate “traditional medicine” into the WHO’s global mission, only five of the six regional offices were invited. The European office (based in Denmark) was left out, while the staff who attended from the WHO headquarters were from China (the assistant director-general, Ch’en Wen-Chieh) and Ghana (the secretary of the working group on traditional medicine, Robert Bannerman). In fact, all the delegates but two came from outside Europe and North America and even these delegates worked in Mexico and the Philippines.[48] This composition was deliberate: the meeting was designed to serve the needs and interests of countries in “the developing world.” While delegates debated how best to cooperate with popular healers, they all agreed that “collaboration” could reveal approaches to human health that were both less expensive than biomedical systems, especially in terms of drugs and custodial care, and also more culturally appropriate. The African Regional representatives also insisted that governments work “to adopt and apply rules for the practice of traditional medicine . . . and [insure] that true healers . . . be enlisted and granted legal recognition.”[49] Much of this work was already underway in many countries, but the WHO’s international backing gave it the imprimatur of credibility and legitimacy. It also reinforced the idea that it should become an object of study in its own right.

Box 1.6 – WHO Résumé of Research Areas in Traditional Medicine, 1978

At the heart of the new research agenda was “traditional practitioners” themselves.

As we now know, this generation’s ambitions rarely panned out as they wished or expected; they were also rife with contradictions, including authoritarian impulses that they originally sought to combat. Even so, they did manage to set some important precedents, carving out a space for talk about “traditional medicine” and also “traditional” and “indigenous knowledge” within many UN institutions and countries around the world. In the intervening decades, the WHO has sponsored and supported several different programs relating to traditional medicine worldwide. And since 1973, the People’s Republic of China has played an important role in all of these activities. Yet it was hardly the sole, or even the most important, actor given the UN’s one-country, one-vote system. Pan-African diplomacy and lobbying often functioned as a tipping point in policy discussions because African representatives tended to coordinate as a bloc (and the largest bloc at that). In truth, as the Cold War came to a formal end in 1991 with the collapse of the Soviet Union, these programs had become a genuinely global and transnational phenomenon, as anyone studying the different versions of the WHO’s strategy documents and global surveys knows.[50]

III. Artemisinin, the 2015 Nobel Prize in Medicine, and the 11thEdition of the ICD

This global character of debates over “traditional medicine” helps to explain the story of artemisinin, an anti-malarial drug borne in the crucible of Cold War geopolitics, and ultimately responsible for a Chinese scientist being awarded in 2015 the country’s first Nobel Prize in Medicine. It also helps to explain the WHO’s underlying rationale for adding a chapter on “traditional medicine” to the 11th edition of the International Classification of Diseases in 2019. As Marta Hanson has pointed out, the Nobel announcement prompted immediate debate over what the prize meant for “Traditional Chinese Medicine.”[51] The question arose because the prize recipient, Youyou Tu, had first learned of the anti-febrile properties of the anti-malaria drug she chose to analyze from a seventeen-hundred year-old medical text. The Nobel Committee openly acknowledged the role “ancient literature” played in “guid[ing] her in her quest to extract the active component from Artemesia annua.” As Tu herself noted, she would never have thought to try soaking qing hao or sweet wormwood [Artemesia annua] in a cold rather than heated medium to obtain an effective drug had she not paid close attention to the details of Ge Hong’s fourth-century compendium of therapies.[52] While many observers within China and most commentators in scientific journals stressed the unconventional aspects of Tu’s achievements, choosing to frame it as a landmark moment for “Chinese medicine,” the Nobel panelists were quick to clarify that they “were not giving the prize to traditional medicine, the award was only for scientific work that had been inspired by it.”[53] In fact, they seemed most interested in rewarding scientists – including the two other recipients that year who had developed a new drug to treat roundworm parasites – whose research led to inexpensive treatments that improved the lives of poorer people in developing countries.[54]

Tu’s research had arisen from a multi-sited collaborative project, launched by Mao Zedong himself in May 1967 and known as “Project 523” for the month and day of its launch. Mao wanted the People’s Republic of China to stand by its embattled allies in North Vietnam and hoped his covert research network would help identify treatments for malaria, a disease then decimating the region’s troops. Scholars estimate that Project 523 ultimately “involved over 500 scientists from 60 research units and extended from 1967 to 1980.”[55] Tu – and her many collaborators – ultimately crafted artemisinin by isolating and extracting its active ingredients and by using laboratory methods (to test its effectiveness) that fell squarely within the norms of clinical medicine. In her published work, Tu also avoided discussing parts of Ge Hong’s text that invoked different notions of the human body, the idea of qi for instance, and diagnoses of its ailments. For these reasons, medical historian Paul Unschuld ultimately declared that Tu’s Nobel “was not a win for ancient Chinese medicine.”[56] Yet the Nobel’s open discussion did mark an historic shift, prompting Hanson to insist on characterizing Tu’s work as a form of “medical bilingualism,” not just because Tu could communicate across medical cultures, but also because she had spent her entire career working in institutions in China dedicated to supporting and refining “traditional Chinese medicine.”[57]

Left out of many of the stories about Tu’s Nobel, however, was the role played by the WHO and by pharmaceutical companies in the drug’s transnational evolution and circulations. It seems highly improbable that artemisinin would have received the international attention it did, including recognition from the Nobel jurists as a “life-saving drug,” without several other transformative steps: additional investigators, such as Zhou Yiqing, taking up the question of artemisinin resistance (as malaria parasites adapted to its use); his subsequent work to register and patent the drug in China and forge connections to the Swiss pharmaceutical company, Novartis; the WHO’s endorsement of a version of the drug; and African health officials’ decision to use it on a massive scale. In other words, the research and testing landscapes and the political economy of production and use all affected artemisinin’s fortunes. One of the ironies of artemisinin’s history is that it was never used in either North or South Vietnam during the war, but was introduced there only in 1987 by an Anglo-American research physician, Keith Arnold, who had studied chloroquine resistance in South Vietnam in 1969-1970 as part of the U.S. Army’s research on anti-malarials.[58]

Questions of credit circulate around all kinds of scientific awards given the mammoth infrastructure and social networks that tend to be required for any innovation. Just as important, however, are matters of jurisdiction and definitions of property (state or otherwise). This was something leaders within the Organization of African Unity grasped early on as they worked to modify model laws on copyright, patents, and innovation in the 1960s and ‘70s. The PRC was a relative late-comer to conversations about intellectual property in large part because its sovereign scope and state controls gave it sufficient jurisdiction over “domestic” innovations, making questions about patent rights a lower priority.[59] That changed in the nineteen-eighties as the formal strictures surrounding the Cold War were coming to an end and Chinese officials began to pay closer attention to export trade. As Yiqing reported when looking back on the steps he took to ensure that combined artemisinin-based therapies could travel across borders: “No Chinese pharmaceutical company was capable of introducing this medicine to the rest of the world. So I went to the Ministry of Science and Technology, which introduced me to China International Trust and Investment Corporation (CITIC), the only Chinese state enterprise at the time that was authorized to deal with foreign investors. With the State’s approval and CTITC’s help, we were introduced to Novartis [circa 1990-91] . . . In 1994, Novartis received worldwide licensing rights for Coartem [the trademarked name for the combined therapy] outside China and in 1998 also gained regulatory approval for the drug, which became China’s first internationally patented pharmaceutical product.”[60]

The year 1998 also happened to be when the WHO held its first in a series of “informal consultations” exploring whether and how to use artemisinin in countries with endemic malaria as a “combined therapy” for the disease’s control. With a vaccine a long way off, because the protozoa’s rapidly changing protein coat makes it a difficult target, prevention and treatment were the next best measures. By the WHO’s third consultation in April, 2001, its experts finally agreed that artemisinin-combined therapies (ACT) were among the best options, especially “for use in Africa.” Later that year, leaders in Novartis and officials in the WHO signed a ten-year “memorandum of understanding” that Novartis would provide “at no profit” Coartem to any country with endemic malaria that needed it.[61] It still took several more years for the company to scale up production and for African governments to develop their own guidelines for its use. By 2008, 46 African countries had approved ACT as their “first line therapy” and 41 of these had already begun to implement this goal, meaning people across the continent who lived in areas with endemic malaria, were taking it actively (if unevenly since distribution within countries could still be challenging).[62] And it turns out, it worked, reducing people’s parasite loads and helping relieve them of their symptoms. 

Given this history, it is worth recalling here three things: first, the ease with which “Chinese herbals” have been – and still are – characterized as just so much “snake oil”; second, the extent to which a geographical qualifier, such as “China,” tells only a fraction of the story (and one implicitly inflected with ethno-national angles); and third, the degree to which so-called “traditional medicine” pursuits have been imbricated with state actors, biomedical specialists, and global institutions all along. This last point would hardly surprise medical diplomats working in the WHO. Just in the last twelve months, in fact, “traditional medicine” has been on the minds of all the WHO’s member states because last May, 2019, the World Health Assembly made the unprecedented move to approve a supplementary chapter on “Traditional Medicine Conditions” for the 11th edition of the International Classification of Diseases and Related Health Problems (ICD). (The new edition is meant to go into effect on January 1, 2022.) The ICD has been managed under the auspices of the WHO since its founding in 1946 and, by the 1980s, had become the gold standard for disease categories and the basis for medical insurance coding in most countries around the world.[63] After the WHO published its first global traditional medicine strategy in 2002, both staff and diplomats began to shift their attention from developing “norms and standards” for “safety, efficacy, quality, and research” to standards of classification itself.[64] By 2012, they made this explicit in the next strategic traditional medicine plan, reporting that the WHO would now “promote the international standardization and classification of TC&M” and ensure that it was included in the International Classification of Diseases (ICD).[65]

The ICD’s new chapter on traditional medicine is meant to serve as a global placeholder – “all countries should tailor the eleventh revision to their own context”[66] – so that any state, regional office, or subset of states can develop agreed upon (and translatable) nomenclature and definitions that they can then use for “optional dual-coding of traditional medicine diagnoses and patterns.”[67] Thus far the only region that has prepared a list of “diseases and problems” is the Western Pacific office, which includes most of the members states in East and Southeast Asia.[68] This too helps to explain why the ICD text currently gives as examples categories developed from “ancient Chinese medicine and commonly used in China, Japan, Korea, and elsewhere around the world.”[69] Gestures to antiquity aside, these are decidedly new ways of organizing this kind of knowledge.

Yet even when the ICD chapter on traditional medicine was going through the final approval stage, there was clearly some disagreement and skepticism among the WHO’s member states and staff about its scope, function, and usefulness. As the WHO vice president for data and analytics, Samira Asma (from the United States) insisted during the discussion, “The inclusion of the chapter on traditional medicine conditions should not be understood as an endorsement of any specific therapeutic approaches but rather as a means of filling an existing data gap.”[70] The director-general from Ethiopia, Tedros Ghebreyesus, had made a similar point in his written brief to delegates: “These categories . . . do not refer to – or endorse – any form of treatment . . . The inclusion of a supplementary chapter on traditional medicine in ICD will, for the first time, enable the counting of traditional medicine services and encounters; the measurement of their form, frequency, effectiveness, safety, quality, outcomes, cost; comparison with mainstream medicine; and research, due to standardized terms and definitions nationally and internationally.”[71] A handful of European delegates echoed these points, with the US representative cautioning that “the WHO should develop careful messaging strategies . . . in order to avoid confusion in the absence of clinical evidence.” In reply, the Japanese delegate noted that the system itself would actually “improve research and clinical practice based on standardized terms and definitions,” a view endorsed by all the delegates from Africa as well as several more from Asia and the Eastern Mediterranean (which accommodates much of the Middle East).[72] Both critics and advocates of the chapter seemed to see the push for metrics as the thin edge of the wedge: open the ICD to diagnostic categories from “traditional medicine” and it just might release the floodgates to legitimize things that currently operate outside the official margins.[73] In terms of long-term effects, the jury is still out. Yet it must be said that those margins are already blurry everywhere, as even a glance at the US National Institutes of Health research center on “complementary and alternative medicine” reveals.[74] More to the point, since the 1970s, the WHO has helped member states pursue their own programs on “traditional medicine,” creating feedback loops that have allowed different “stake-holders” to press their own conceptual frameworks within their own countries.  

Prologue – Covid-19 Diagnostic and Treatment Guidelines in China and the Place of TCM

The Covid-19 pandemic came right on the heels of the final ICD vote. The timing alone raises interesting questions about the status of TCM treatments and their place within China’s wider protocols. Interpreted from one angle, the answers may seem anticlimactic, but seen from another vantage point, they are a revelation. To begin with the mundane, both TCM practitioners and their therapies have actually played circumscribed roles in China within a much larger strategy that blends biomedicine, primary care, and public health approaches. For those who have designed the diagnostic and treatment protocols, TCM is integral to pandemic management, but still subordinate when it comes to handling the most acute bodily dangers of Covid-19. This point comes across clearly in the report the WHO issued at the end of February 2020 when describing the extent of “emergency research programs” that the country had developed since reporting the virus to the WHO at the end of December 2019, including investigations into “virus genomics, antivirals, traditional Chinese medicines, clinical trials, vaccines, diagnostics and animal models.”[75] Several different (and carefully identified) TCM therapies, some of which are also undergoing clinical trials in the United States under FDA guidelines, are being used, first as prophylaxis, then to treat mild, moderate, and severe cases, and finally as part of the rehabilitation phase.[76] The 7th version of China’s protocols identified at least eleven treatments that are prescribed during these different stages of Covid-19. Some of these have already been “patented” (by the state) and are manufactured in capsule or granular form, while others are specific herbal formulae, requiring fresh daily preparation. These formulae, though drawing upon specific texts for their inspiration, have been refined and developed largely during the last two decades as a result of trials exploring their effects on respiratory and viral illnesses.[77]

For anyone tracking the physiological fallout from the pandemic, it remains unclear just how much lasting damage Covid-19 does, especially to the lungs of people who have experienced more serious symptoms and survived. Research around TCM use (as around so many other drugs and treatments) is therefore focusing especially on their antiviral, antifibrotic, and antibiotic properties i.e. whether consuming them staves off or slows down onset of an acute stage of the disease; whether they slow down or ameliorate fibrosis of the lungs, once acute; and whether they ward off secondary (bacterial) infections. TCM principles also focus on avoidance strategies – “Prevention before illness is better than treatment after getting diseased” – including lessening “adverse reactions” from other drugs and hastening rehabilitation. Such treatments are thus of a piece with other kinds of recommendations including the advice – in one of the rapid response guidelines published on February 6th by doctors at Zhongnan Hospital at Wuhan University – that all patients be screened for “nutritional risk” and be encouraged “to eat protein-rich foods (such as eggs, fish, lean meat, dairy products) and carbohydrate containing diets” and be taught “psychological techniques like mindfulness-based stress reduction . . . to relieve . . . anxiety and panic by building up their optimistic confidence in overcoming the disease.”[78]

Sometimes in medical literature these kinds of interventions are called “adjuvant” or “add-on” therapies, but these terms cannot do justice to the many reasons the PRC – and so many other countries around the world – have thrown their support behind “traditional medicine” programs. This is where the revelations come in. Efforts to study coronaviruses within China over the last two decades have been premised on the idea that they come in many human and animal forms and that much about them remains unknown. Assuming it will be possible to develop a vaccine for Covid-19, which is the shared goal among all countries (whatever their heads of state may say), many health care officials within China still recognize that having emergency plans in place – preparedness, so to speak – to mitigate the effects of novel strains (before there is a vaccine) cannot hurt. TCM is part of that larger mitigation plan. If this sounds squarely biomedical, it’s because it is. But it’s also much more besides. It’s the “much more” side of things – and the ease with which it appears and disappears – that is so fascinating . . . and threatening. 

Philosophically, state-based programs around traditional medicine have been grounded in the idea that they strengthen “home-grown” medical cultures, even when their roots are far-reaching and their boundaries amorphous. Geopolitically, they often embrace a kind of cultural patriotism and quest for sovereign rights that pushes back against past political harms (and future threats), often at the hands of outsiders. Economically, they are rooted in the view that costs and profits should be held in check, even if the reality is usually more complicated. Scientifically, they espouse a trust in forms of practice and experience – other kinds of know-how – that challenge more dominant techniques of scientific proof and persuasion. And conceptually, they open the door to diagnoses and descriptions that oscillate between worlds of meaning and unsettle sharp boundaries around what is real and unreal, true and false, effective and ineffective. One could call this a Janus-faced dynamic, but it seems more apt to label it a form of polyglot therapeutics.[79] The truth of the matter is that “traditional medicine” sparks the most controversy when its advocates insist on the idea that people can occupy different “conceptual realities” and bodily “modes of existence” at one and the same time.[80] Ironically, this is exactly what so many people – including scientific experts – do all the time. 


Helen Tilley is an Associate Professor of History at Northwestern University. Her work examines medical, environmental, and human sciences in colonial and post-colonial Africa, emphasizing intersections with environmental history, development studies, legal history, and global history. Her book, Africa as a Living Laboratory: Empire, Development, and the Problem of Scientific Knowledge (Chicago, 2011) explores the dynamic interplay between scientific research and imperialism in British Africa between 1870 and 1950. She has also written articles and book chapters on the history of ecology, eugenics, agriculture, and epidemiology in tropical Africa, and is co-editor with Robert Gordon of Ordering Africa: Anthropology, European Imperialism and the Politics of Knowledge (Manchester, 2007) and with Michael Gordin and Gyan Prakash of Utopia-Dystopia: Historical Conditions of Possibility (Princeton, 2010). Her current project focuses on the history of African decolonization, global governance, and the ethnoscientific projects that accompanied state building in the colonial and Cold War era. 


Acknowledgements: My thanks to Melissa Macauley, Peter Carroll, Marta Hanson, and Eugene Raikhel for their helpful comments. Anyone interested in delving more deeply into the SARS epidemic and “traditional Chinese medicine” – including media reactions, therapeutic practices, and scientific (mis)translations – is encouraged to read Marta Hanson’s “Conceptual Blind Spots, Media Blindfolds: the Case of SARS and Traditional Chinese medicine,” in Health and Hygiene in Chinese East Asia: Publics and Policies in the Long Twentieth Century, ed. Angela Ki-Che Leung and Charlotte Furth (Chapel Hill: Duke University Press, 2010), pp. 228-254. Also see Lanternv. XVII (March 2020) on Covid-19 for “practitioners of Chinese medicine” with a guest editorial from Volker Scheid: https://www.thelantern.com.au/product/volume-xvii-issue-2/. For background analysis, I’m grateful to Yung-Chi Cheng, professor of pharmacology and chair, Consortium for the Globalization of Chinese Medicine, Yale University, who helped me locate version #7 of China’s diagnostic and treatment protocols (issued March 3, 2020); and Mimi Choi (MD), who attended the 2003 WHO meeting in Beijing on integrated treatments for SARS and shared her recollections. Some of the material here comes from a book I’m writing on the imperial and Cold War histories of “traditional medicine” and from insights I’ve gleaned from editing a special journal issue, Therapeutic Properties: Global Medical Cultures, Knowledge, and Law (Osirisv. 36, forthcoming, 2021). I alone bear responsibility for whatever flat-footed analysis and inaccuracies remain.

Notes

[1] Journalists began covering the issue much earlier; included here are several in English: [Jan 28, 2020] https://www.theglobeandmail.com/world/article-as-coronavirus-death-toll-rises-china-combines-western-and/; [Jan 30, 2020] http://www.koreabiomed.com/news/articleView.html?idxno=7309; [Jan 29, 2020] https://pib.gov.in/PressReleasePage.aspx?PRID=1600895; [Jan 31, 2020] https://www.iflscience.com/health-and-medicine/indian-government-advises-homeopathy-for-coronavirus-prevention-as-countrys-first-case-confirmed/; [Feb 5, 2020] https://www.nytimes.com/2020/02/05/world/asia/coronavirus-traditional-chinese-medicine.html; [Feb 3, 2020] https://foreignpolicy.com/2020/02/03/tcm-shuanghuanglian-pseudoscience-chinese-media-is-selling-snake-oil-to-fight-the-wuhan-virus/; [Feb 3, 2020] https://www.japantimes.co.jp/news/2020/02/03/asia-pacific/science-health-asia-pacific/herbal-remedies-coronavirus-traditional-chinese-medicine/#.XniG7C2cb_Q; [Feb 2, 2020] https://www.washingtonpost.com/world/asia_pacific/kimchi-cow-poop-and-other-spurious-coronavirus-remedies/2020/02/02/34c54b5a-43fe-11ea-99c7-1dfd4241a2fe_story.html; [Feb 11, 2020] https://www.dw.com/en/coronavirus-can-traditional-chinese-medicine-help-fight-the-disease/a-52337292; [Feb 15, 2020] https://www.bloomberg.com/news/articles/2020-02-15/china-tries-3-000-year-old-tcm-technique-on-coronavirus-patients; [Feb 15, 2020] https://www.nature.com/articles/d41586-020-00444-3; [Feb 17, 2020] https://www.scmp.com/news/china/society/article/3051009/coronavirus-do-herbal-remedies-work-and-could-they-help-stricken; [Feb 26, 2020] https://fox5sandiego.com/news/chinese-officials-using-traditional-medicine-in-fight-against-coronavirus/; [Feb 29, 2020] https://newsus.cgtn.com/news/2020-02-29/Traditional-Medicine-helping-in-COVID-19-fight-OsENfPF5ss/index.html.

[2] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30461-X/fulltext.

[3] https://edition.cnn.com/2020/03/14/asia/coronavirus-traditional-chinese-medicine-intl-hnk/index.htmlhttps://www.breitbart.com/africa/2020/03/19/china-pressures-africa-to-embrace-traditional-medicine-coronavirus-cures/.

[4] https://theconversation.com/why-shutting-down-chinese-wet-markets-could-be-a-terrible-mistake-130625.

[5] I am hardly alone in taking up these questions: scholars who have influenced my thinking include Steve Feierman, Nancy Hunt, Stacey Langwick, Murray Last, Projit Mukharji, Marta Hanson, Vincanne Adams, Laurence Monnais, Ruth Rogaski, Abena Osseo-Asare, and Hannah Louise-Clark. 

[6] http://en.nhc.gov.cn/2020-04/03/c_78744.htm[Italy, Serbia, Pakistan, Venezuela]; http://en.nhc.gov.cn/2020-04/02/c_78677.htm[Hungary]; example of a Chinese traditional doctor resident in Portugal (and married to a nurse): http://en.nhc.gov.cn/2020-04/05/c_78808.htm

[7] This took the form of a 3.5 hour videoconference on which several hundred people took part; http://en.nhc.gov.cn/2020-04/04/c_78787.htm; http://en.nhc.gov.cn/2020-04/03/c_78731.htm.

[8] http://www.xinhuanet.com/english/2020-03/17/c_138887940.htmhttp://www.xinhuanet.com/english/2020-03/17/c_138887920.htm; Li Yu, “Administration of Traditional Chinese Medicine: Traditional Chinese Medicine Lianhua Qingwen Plays an Important Role in Fighting Against COVID-19.” MENA English (Middle East and North Africa Financial Network). This is an official press release that has been picked up and printed as reporting.

[9] Again, so many scholars and social critics have made these kinds of points before me: Alfred Crosby, Frantz Fanon, Che Guevara, William McNeill, Philip Curtin, Emmanuel Le Roy Ladurie, Ivan Illich, Meredith Turshen, David Arnold, Nancy Stepan, Megan Vaughan, Randall Packard, Philippa Levine, Anne-Emanuelle Birn, Alison Bashford, John McNeill, Warwick Anderson, and Mark Harrison.

[10] Some of these reactions were discussed on Twitter; I first saw the screen shots of the WHO advice pages on Tony Lin’s feed (@tony_zy), prompting me to track the changes myself. See Box 1.1 and 1.2.

[11] https://apps.who.int/medicinedocs/pdf/s6170e/s6170e.pdf. For a terrific analysis that goes much deeper into the diagnostic category wenbingand the conceptual and therapeutic histories in play, see Marta Hanson, “Conceptual Blind Spots, Media Blindfolds: the Case of SARS and Traditional Chinese medicine,” in Health and Hygiene in Chinese East Asia: Publics and Policies in the Long Twentieth Century, ed. Angela Ki-Che Leung and Charlotte Furth (Chapel Hill: Duke University Press, 2010), pp. 228-254.

[12] Eric Karchmer, “Slow Medicine: How Chinese Medicine Became Efficacious Only for Chronic Conditions,” in Howard H. Chiang, ed., Worlds of Chinese Medicine: Historical Epistemology and Transnational Cultural Politics (Manchester: Manchester University Press, 2015), pp. 188-216. 

[13] I base this claim not just on legislation and regulations around medical education and licensing, but also on those laws and rules addressing infectious disease control, sanitary measures, reproduction, and even birth and death registrations. For some of these points, see Volker Scheid, Chinese Medicine in Contemporary China: Plurality and Synthesis (Durham: Duke University Press, 2002), chapter 3 “Hegemonic Pluralism: Chinese Medicine in a Socialist State.”

[14] Bridie Andrews, “The Republic of China,” in TJ Hinrichs and Linda Barnes, eds., Chinese Medicine and Healing: An Illustrated History (Cambridge: Harvard University Press, 2013), pp. 209-227.

[15] Sean Hsiang-Lin Lei, Neither Donkey Nor Horse: Medicine in the Struggle Over China’s Modernity (Chicago: University of Chicago Press, 2014).

[16] Karchmer, “Slow Medicine,” p. 210.

[17] Lin Lin et al, “Treating severe acute respiratory syndrome with integrated Chinese and Western medicine–a report on 103 hospitalised cases at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, China,” The Journal of Chinese Medicinen. 73 (June, 2003), pp. 5-10. Interestingly, these diagnostic classifications do not appear in the WHO report, though one of the Hong Kong reports cites this version and uses “wenbing” as well. For a historical biography of wenbing, see Marta Hanson, Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China (New York: Routledge, 2011). There is some ambiguity here over terminology since wenyican translate as “pestilence” and wenbing as “warmth disorder.” See Scheid, “A Matter of Life and Death: Engagements with the Covid-19 Pandemic,” The Lanternv. XVII (2020), p. 6.

[18] https://apps.who.int/medicinedocs/pdf/s6170e/s6170e.pdf, pp. 65-82.

[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092360/, p. 25 (for health care professionals).

[20] https://apps.who.int/medicinedocs/pdf/s6170e/s6170e.pdf, p. 17.

[21] Quoted in Karchmer, “Slow Medicine,” p. 211.

[22] Private correspondence from Dr. Xiaorui Zhang, 8 April, 2020. Zhang directed the traditional medicine office at the WHO from 1992 to 2010. My thanks to Mimi Choi (MD, UCLA), an intern for Zhang in the summer of 2003 and participant in the fall 2003 SARS meeting (who helped with the English-language translations and reports), for sharing memories of the event and filling in some of the timeline. Later in October, the WHO Director-General convened a more comprehensive scientific research team in Geneva to assess the entire outbreak and develop preparedness protocols and set new research priorities. https://www.who.int/csr/sars/archive/research/en/. This is covered in more detail in Marta Hanson’s chapter.

[23] [SARS] https://apps.who.int/medicinedocs/pdf/s6170e/s6170e.pdf. [Covid-19] https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19—final-report-1100hr-28feb2020-11mar-update.pdf?sfvrsn=1a13fda0_2&download=true. On the issue of random controls and traditional medicine in Tibet see Vincanne Adams, “Randomized Controlled Crime: Postcolonial Sciences in Alternative Medicine Research,” Social Studies of Sciencev. 32 (2002), pp. 659-690.

[24] The Guangdong TCM trial noted, in passing, that “Those patients who had not been treated with glucocorticoids all recovered and were subsequently discharged.” (p. 78)

[25] This is the “drugs for life” and “pharmageddon” phenomena that Joe Dumit and David Healey, among others, have analyzed. David Healey, Pharmageddon(Berkeley: University of California Press, 2013); and Joseph Dumit, Drugs for Life: How Pharmaceutical Companies Define Our Health (Durham: Duke University Press, 2012).

[26] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30317-2/fulltext. They continue, “In a meta-analysis of corticosteroid use in patients with SARS, only four studies provided conclusive data, all indicating harm.” For the latest WHO clinician guidelines (13 March), see https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.

[27] https://academic.oup.com/jcem/article/105/5/dgaa148/5814115. “[I]t seems logical, if not essential, that we identify all patients taking corticosteroids for whatever reason as high risk. We know from the published reports to date that these patients will be overrepresented in those at greatest risk of dying from COVID-19—the elderly and those with co-morbidities that include diabetes, hypertension, and chronic inflammatory disease.”

[28] The word phytotherapy means plant-based medicines and sometimes conveys that they have undergone testing. 

[29] https://www.scientificamerican.com/article/drug-developers-take-a-second-look-at-herbal-medicines/.

[30] https://permanent.access.gpo.gov/lps120654/4592fnl.pdf.

[31] One organization stewarding some of this work is the Oxford-based Global Initiatives for Traditional Systems of Health (GIFTS). 

[32] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30628-0/fulltext.

[33] Carol Heimer and Jaimie Morse, “Colonizing the Clinic: The Adventures of Law in HIV Treatment and Research,” in H. Klug & S.E. Merry, eds., The New Legal Realism, Volume II: Studying Law Globally (Cambridge University Press, 2016), pp. 69-95. For two such guidelines in the U.S. see https://covidprotocols.org; and https://www.sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf?lang=en-US.

[34] I mean this in terms of government responses, rather than spontaneous popular reactions, though both are present and often connected. India, Ethiopia, and Bolivia are just a few of the countries with governments taking this turn.

[35] For an analysis of “retro-botanizing” in colonial India, see Projit Mukharji, “Vishalyakarani as Eupatorium ayapana: Retro-botanizing, Embedded Traditions, and Multiple Historicities of Plants in Colonial Bengal, 1890–1940,” Journal of Asian Studies v. 73 (2014), pp. 65-87.

[36] The quotation appears in both the original draft and final resolution; for the official record of debate, see Twenty-Second Health Assembly n. 177 (1969), pp. 297, 336-337, 345-348. The following paragraphs condense a rich and complex history; they also gloss over both individual and institutional conflicts and important tensions. Finally, they leave out most participants’ names in favor of focusing on their institutional or national affiliation. 

[37] The OAU’s headquarters was in Addis Ababa, Ethiopia, but its office for science policy (the Scientific and Technical Research Commission, STRC) was in Lagos, Nigeria, where pan-African coordination on African pharmacopeia and traditional medicine was coordinated. 

[38] OAU, La Culture Africaine: le Symposium D’Alger, 21 Juillet – 1er Août 1969(Algiers: OAU and Societé National d’Edition et de Diffusion, 1969); and First Pan-African Cultural Festival Bulletinn. 1-6. Algiers: OAU/Societé National d’Edition et de Diffusion. This meeting followed on the heels of an OAU sponsored conference on traditional medicine and pharmacopeia held in Dakar, Senegal in 1968.

[39] Many of these efforts began years, even decades earlier; I am leaving to one side these longer histories.

[40] ARIPO’s founding document is known as the “Bangui Agreement” or “Bangui Agreement Relating to the Creation of an African Intellectual Property Organization,” March 2, 1977, Bangui, Central African Republic; see articles 5, 44, 46, and 70; for CAMES’ founding resolution, see Chikouna Cissé, Le CAMES 1968-2018: Un Demi-Siècle au Service de l’Enseignement Supérieur et de la Recherche en Afrique (Quebec: Edition Sciences et Bien Commun, 2018), appendix, pp. 215-217.

[41] Pan-African Cultural Festival Bulletin n.1 (March, 1969), pp. 24-25, 28; Pan-African Cultural Festival Bulletin n. 5 (July, 1969), p. 32.

[42] The Organization of African Unity folded the Scientific Council for Africa South of Sahara and its inter-governmental counterpart, the Commission for Technical Cooperation for Africa, into its own operations.

[43] Quotations from UNESCO General Conference and Congo-Brazzaville resolution, 11/C/DR/156, 19 November 1960, Unesco Archives, Paris, France.

[44] Variants of this point were included in the draft copyright law that came out of a second meeting in 1964; see “Committee of African Experts to Study a Draft Model Copyright, 30 November to 4 December, 1964 – Records,” Copyright v. 18 (1965), pp. 10-44, on p. 38. 

[45] Regional Office for Africa, Second Quarterly Report(Brazzaville: AFRO, 1953), p. 3; Regional Office for Africa, Third and Fourth Quarterly Reports(Brazzaville: AFRO, 1953), p. 3; Regional Office for Africa, Report for First Quarter – 1954(Brazzaville: AFRO, 1954). The anthropologist was Jean-Paul Lebeauf, who had been a student of Marcel Griaule, Marcel Mauss, and Paul Rivet.

[46] For different perspectives on publics see Ruth Prince and Rebecca Marsland, eds., Making and Unmaking Public Health in Africa(Ohio University Press, 2013); and Stacey Langwick, “Partial Publics: The Political Promise of Traditional Medicine in Africa,” Current Anthropology v. 56 (2015), pp. 493-514.

[47] The phrase comes from the Pan-African Cultural Manifesto of 1969; it seems to take its inspiration from changes to patent laws – and to a model law on innovations – for African countries in the mid-1960s. See Model Law for Developing Countries on Inventions(Geneva: BIRPI, 1965), Part II.

[48] They were Boris Velimirovic (Pan-American Health Organization) and George Emory (Western Pacific Office).

[49] AFRO, “Present Situation and Perspectives for a Programme of Development of Traditional Medicine in Africa,” p. 6, in WHO, Inter-Regional Consultation on Promotion and Development of Traditional Medicine, Delhi; WHO Archives, Geneva, Switzerland.

[50] Between 2002 and the present, two global strategy reports have been issued (2002 and 2013) and three global surveys have been published (2005, 2012, and 2019); in addition, there have been several supplementary studies. For the 2019 survey, see https://apps.who.int/iris/bitstream/handle/10665/312342/9789241515436-eng.pdf?sequence=1&isAllowed=y; and for the 2005 and 2014 strategies, see, https://apps.who.int/iris/bitstream/handle/10665/67163/WHO_EDM_TRM_2002.1_eng.pdf?sequence=1&isAllowed=y; https://apps.who.int/iris/bitstream/handle/10665/92455/9789241506090_eng.pdf?sequence=1&isAllowed=y.

[51] Marta Hanson, “Is the 2015 Nobel Prize a turning point for traditional Chinese Medicine?” The Conversation, October 5, 2015 (Translated into French and Korean). http://theconversation.com/is-the-2015-nobel-prize-a-turning-point-for-traditional-chinese-medicine-48643; Ian Johnson, “Nobel Renews Debate on Chinese Medicine,” New York Times, 11 Oct 2015.

[52] Nobel Prize in Medicine Press Release, accessed on 24 June 2016; Phil McKenna, “Malaria’s Nemesis,” New Scientistv. 212 (2011), pp. 46-47; and Elisabeth Hsu, “Reflections on the ‘Discovery’ of the Anti-Malarial Qinghao,” British Journal of Clinical Pharmacology v. 61 (2006), pp. 666-670. For context, also see Robert Ford Campany, To Live As Long as Heaven and Earth: A Translation and Study of Ge Hong’s Traditions of Divine Transcendence (Berkeley: University of California Press, 2002).

[53] For a summary of reactions within China, see Zhang Yan, “China Finally Wins a Science Nobel, Yet Critics Remain Unsatisfied,” 23 October 2015; http://www.caixinglobal.com/2015-10-23/101012110.html, accessed 2 April 2017; Nobel panelist quoted in P. Ram Manohar, “Nobel Prize, Traditional Chinese Medicine, and Lessons for Ayurveda,” Ancient Science of Life v. 35 (2015), pp. 67-69, on 67.

[54] Hanson, “Is the 2015 Nobel Prize a turning point for traditional Chinese Medicine?” The Conversation, October 5, 2015.

[55] Dana Dalrymple, “Artemisia annua, Artemisinin, ACTs and Malaria Control in Africa: The Interplay of Tradition, Science and Public Policy,” p. 22. This is the penultimate version of the study before it was published in 2012. Covid-19 has prevented me from accessing the published version. My thanks to Dana Dalrymple for originally sending me this version in 2011.

[56] Paul Unschuld, “Tu’s Nobel Prize Not a Win for Ancient Chinese Medicine,” 7 Dec 2015, http://www.caixinglobal.com/2015-12-07/101046137.html, accessed on 2 April 2017; also see Paul Unschuld, Traditional Chinese Medicine: Heritage and Adaptation (New York: Columbia University Press, 2017), pp. 148-151.

[57] Hanson, “What the 2015 Nobel Prizes Mean For Traditional Chinese Medicine,” Fortune Magazine, 6 Oct 2015.

[58] Dalrymple, “Artemisia annua, Artemisinin, ACTs and Malaria Control in Africa,” p. 27.

[59] Bryan Bachner, Intellectual Property Rights and China: the Modernization of Traditional Knowledge (Utrecht: Eleven International Publishing, 2009). The Chinese Patent Bureau was established in 1980 and became the State Intellectual Property Office in 1998; the first comprehensive national patent law was passed in 1984. This is not to discount the earlier precedents during the late Qing and Republican eras (in legislation on technologies and bilateral agreements with the US, which recognized patent laws), but to stress the shift after 1949.

[60] Quoted in Dalrymple, “Artemisia annua, Artemisinin, ACTs and Malaria Control in Africa,” pp. 25-26.

[61] https://www.who.int/malaria/areas/treatment/MoU_termination_report_may2011.pdf?ua=1.

[62] Dalrymple,“Artemisia annua, Artemisinin, ACTs and Malaria Control in Africa,” p. 21.

[63] Geoffrey Boker and Susan Leigh Starr, Sorting Things Out: Classification and Its Consequences (Cambridge: MIT Press, 1999). A student at Johns Hopkins University has done a fascinating study of the East Asian and Western Pacific sides of the ICD’s history, including the role of Kampo practitioners in Japan; Thomas Le, “Collaborations and Kampo Classifications: The Campaign into the ICD-11 from 2005-2018.”

[64] https://www.who.int/medicines/publications/traditionalpolicy/en/.

[65] https://www.who.int/publications-detail/who-traditional-medicine-strategy-2014-2023, pp. 51, 55.

[66] https://apps.who.int/iris/bitstream/handle/10665/330560/A72_REC3-en.pdf?sequence=1&isAllowed=y, p. 258.

[67] https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_29-en.pdf, p. 8.

[68] https://apps.who.int/iris/bitstream/handle/10665/206952/9789290612487_eng.pdf?sequence=1&isAllowed=y

[69] ICD 11thedition, Chapter 26. Approved in May 2019; https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f718687701

[70] https://apps.who.int/iris/bitstream/handle/10665/330560/A72_REC3-en.pdf?sequence=1&isAllowed=y, p. 261.

[71] https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_29-en.pdf, p. 8

[72] Representatives who spoke to praise the addition of the chapter were from Eswatini (formerly Swaziland), China, Republic of Korea, Japan, Togo, Ghana, India, Zambia, Indonesia, Maldives, Turkey, and Sri Lanka. During a separate discussion of the traditional medicine program (WHA67.18 resolution, 2014) several other countries endorsed this work: Malaysia, Botswana, Bahamas, Burkina Faso, and Bahrain. In addition to the US, delegates from Belgium and the Netherlands expressed concern that “evidence-based medicine” take priority.

[73] This was the position adopted by two European associations of physicians; also see Vincanne Adams, Metrics: What Counts in Global Health(Durham: Duke University Press, 2016).

[74] Charles Rosenburg, “Alternative to What? Complementary to Whom? On the Scientific Project in Medicine,” in Rosenburg, Our Present Complaint: American Medicine, Then and Now (Baltimore: Johns Hopkins University Press, 2007) pp. 113-138. My thanks to Marta Hanson for sharing this chapter with me.

[75] https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19—final-report-1100hr-28feb2020-11mar-update.pdf?sfvrsn=1a13fda0_2&download=true, p. 34.

[76] I have not done a careful search for all FDA approved clinical trials, but see (for Lianhua Qingwen) https://clinicaltrials.gov/ct2/show/NCT02867358; https://www.ncbi.nlm.nih.gov/pubmed/29071849.

[77] “Diagnosis and Treatment Protocol for Covid-19, Trial Version 7” [March 3, 2020]: https://mp.weixin.qq.com/s/XvfY0tZikA65KQnnPPiUnAhttp://en.nhc.gov.cn/2020-03/29/c_78469.htm.

[78] https://mmrjournal.biomedcentral.com/articles/10.1186/s40779-020-0233-6, pp. 14-15 and 20-21. Another manual issued in mid-March makes similar points about nutritional and psychological support, see: Handbook of Covid 19 Prevention and Treatment: https://www.alibabacloud.com/zh/universal-service/pdf_reader?pdf=Handbook_of_COVID_19_Prevention_en_Mobile.pdf.

[79] I discuss polyglot therapeutics in more detail in my introduction to the Osiris volume (forthcoming).

[80] I take these phrases from Sheldon Pollock, “Indian Knowledge Systems On the Eve of Colonialism,” Intellectual History Newsletter v. 22 (2000), pp. 1-16; I also have in mind Stacey Langwick, “Articulate(d) Bodies: Traditional Medicine in a Tanzanian Hospital,”American Ethnologist v. 35 (2008), pp. 428-439.


3 Responses to How to Make Sense of “Traditional (Chinese) Medicine” In a Time of Covid-19: Cold War Origin Stories and the WHO’s Role in Making Space for Polyglot Therapeutics

  1. Goodness. If this is “history” I wish Dr Tilley had taught the subject when I when I was a nipper at high school in the 60s UK – I may have avoided the fate of a biomedical career…this piece is a tour de force of genuine “interdisciplinarity” without the seams showing – which is how it should be (but rarely is) Reframing the whole artemisinin/QingHaosu story is really apt among many other facets of an excellent piece. Thanks for this, will be sharing widely, including to a few Chinese medicine practitioners/educators.

  2. I have practiced Traditional Chinese Medicine and acupuncture for 36 years, recently retiring from office practice but maintaining limited practice and interest in Chinese herbal medicine. Since soon after the onset of Covid 19, the US TCM practitioner community has been able to see protocols used in China for treating it, varying somewhat between regions and different hospitals. Many of us are hoping that rigorous trials will help answer the questions of effectiveness. Interestingly, the different aspects of Covid illness, such as the thrombosis problems, are ‘categorizable’ within the TCM diagnostic framework. As with everything TCM there is disagreement, with various people citing different historical antecedents. Yet as referenced in the article, there is also a lore that claims positive effect in epidemics of the past. Personally, I am a proponent of Integrative Medicine, which can utilize the best of both systems. I have seen that be effective in my own practice, and research is supporting that in oncology now. In terms of pneumonia and other lung conditions, Chinese herbs can have excellent effects at improving dyspnea and reducing phlegm production, something which antibiotics or antivirals may not help with directly. But as the author points out, separating medical effects from politics is no easy task!

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