ABSTRACT: This supplement to Traditional Medicine in Contemporary China summarizes the author's observations and discussions with physicians while working in a Beijing research institute in 1987. Traditional doctors tend to accept the claims of modern biomedicine and to see the staying power of traditional medicine as dependent on its technologies (acupuncture, etc.) rather than on such less tangible characteristics as its system for understanding the body, health, and illness in a unitary way. Few young physicians are well acquainted with classical doctrines or confident in applying them. Many depend on biomedical diagnoses. At the same time, the industrialization of clinical practice and the breakup of the Cultural Revolution health care delivery system introduce further uncertainties about the future role of Chinese medicine in public health.
I spent the first six months of 1987 in Beijing reading rare historical sources at the Academy of Traditional Chinese Medicine in Beijing. I was given every aid and courtesy by my colleagues in the China Institute for Medical History and Literature, including an office, which made it possible for me to invite graduate students, physicians and scholars to drop in freely for informal conversation. My wife and I lived in the Sino-Japanese Friendship Hospital, the largest general hospital in China, with a large proportion of professional staff members trained in Chinese medicine. We got to know a few of them fairly well. I also gave at the Academy a series of lectures and seminars to which historians, most of them medical practitioners, were invited from all over China.
My observations deepened some concerns expressed in Traditional Medicine in Contemporary China, which I finished writing in 1984. I found among medical policymakers, physicians, and, for that matter, historians, little awareness of medical change as a world-wide phenomenon, or of what tensions between old and new systems had been resolved or had proved intractable in other countries. Social and political issues of Chinese health care are never publicly debated, and are practically unstudied by historians and others. Like all that lies within the province of the Party, such matters are risky except for the few who have the power to decide. These few, on the other hand, can make their decisions without necessarily being fully informed about the problems ordinary people face.
In the West a balanced view of the strengths and weaknesses of biomedicine is becoming the norm. I seldom found traditional physicians well informed. Everyone, laymen included, agreed that Western technologies are powerful, and that chemical drugs are better for acute emergencies than traditional ones, but had more side effects. It was often said that biomedical therapy is better for relieving symptoms, but treatment by a skilled Chinese doctor is more likely to result in a cure. It was rare to find an estimate more penetrating than that. Most of the usual claims by spokesmen for modern medicine were accepted at face value.
This became particularly clear at one of the seminars. I had proposed a topic that everybody was debating at the time, namely "Is Chinese Medicine a Science?" Traditional physicians know that their practice is ostentatiously supported by the government, which has silenced what before the Cultural Revolution was loud and powerful opposition. They are not entirely sure what would happen without such support. They justify this support by finding evidence that Chinese medicine is as good as the imported article. They know that in the eyes of those who determine what resources will be available (for instance, the ratio of students in Chinese-style to those in Western-style medical schools), the criteria are those of modern science--not always well understood, but always hanging over the heads of traditional practitioners.
I began the seminar with two propositions:
The debate was predictably lively. Anyone practising or studying Chinese medicine in China is used to defending the idea that it is a science. The notion that biomedicine itself is not a science left the participants, with the exception of a few perennially skeptical graduate students, stymied. I argued that for most historians and many physicians, medicine is an art of caring for suffering people that extensively uses knowledge from biology, chemistry, physics, etc., and that a physician who approached a patient like a biological scientist approaching an experimental animal could not provide good care. My point did not have much impact. Tossing away the ideal of Science is too dangerous, even for the sake of discussion.
The second point did not fare better. I found erudite scholars asking me, rather than telling me, how Chinese medicine could possibly be used to improve Western medicine. There was little response to my suggestion that conspicuous weaknesses of the latter might be remedied as a result of understanding strengths of the former--for instance, its close fit with the way Chinese patients experience illness, the concern of physicians with the whole somatic and emotional constellation of the patient, and their habit of considering disease as an evolving and ramifying process of which all the significant outcomes must be anticipated in therapy.
Here and elsewhere I was often told that what mattered was not such intangibles but the technology that Chinese medicine commanded-- acupuncture, moxibustion, natural drugs, and so on. Few would agree with me that such techniques are easily appropriated by people who do not consider the rest worth keeping. Few saw that this view of traditional medicine as a mere collection of technical resources would leave no future for its sophisticated functional view of body processes, its subtle diagnostic reasoning, its live interplay of classical doctrine and clinical experience, and so on. I found a great deal of enthusiasm for computer diagnosis, uninformed about the criticisms levelled in the West against that aid to medical industrialization. None of these enthusiasts admitted that there is any significant difference between a reasoned diagnosis based on examination of a whole, living person and a decision tree based on a list of symptoms.
Finally, then, there is the question of whether such differences will continue to be crucial. The doubts I had expressed in the book were reinforced by many conversations. Young doctors told me again and again that they do not really grasp manifestation type determination, and prefer to diagnose by symptoms. Medical school, they said, did not give them a deep enough understanding of yin-yang and the Five Phases to make them confident about using these concepts. They are thus driven to diagnose on the basis of what seem to them more concrete and objective Western criteria. They are aware that it is impossible to work out a traditional course of therapy on the basis of a biomedical diagnosis, but that is the best they can do, and they do it somehow.
This atrophy of traditional doctrine is not their fault. As children they did not learn to think about the world in terms of ancient Chinese philosophy. In school they learned physics, chemistry, and biology instead. By the time a new physician begins practice, chances are that she has never read through the Inner Canon or any other medical book, much less the old philosophic books that were the basis even of elementary education in China before the twentieth century. The young doctors who spoke to me frankly were determined to meet the heavy demands of good practice, but few felt well prepared.
But there is a still larger question, mentioned above, that no one can answer. Many ordinary people educated before 1949 prefer Chinese medicine because they use yin-yang and the Five Phases, not the language of anatomy and physiology, to understand their bodies. What will happen when they are gone? What will Chinese medicine, assuming it survives for another generation, have to say to patients who see their bodies as a collection of physical and chemical processes? My experiences left me still wondering, still with no clue to a final answer.
Finally let me mention some portentous changes in the delivery of health care that were very perceptible in 1987.
The institutions that gave the rural majority inexpensive access to medical treatment during the Cultural Revolution have largely disappeared. The system of Barefoot Doctors in the countryside and Red Medical Workers and others in the cities, peasants and workers with a minimum of training who provided low-level medical care part time, has been quickly disappearing. The new emphasis on individual enterprise has made farming lucrative, doing away with the incentives that attracted farmers to doctoring. At the same time former Barefoot Doctors were being encouraged in 1987 to seek further medical education and even to take up private practice in what used to be collectively owned clinics. At the same time, the system of cooperative medical insurance in rural work units that protected the poorest against medical catastrophes has largely ended as official approval has moved from everyone sharing poverty to individuals getting rich. Those who are not getting rich, for instance those farming poor land, are no longer insulated from medical costs that, although very low compared to those in the United States, are high in proportion to their income. A number of experiments to finance rural health care are under way, but in the present climate they disproportionately benefit wealthy parts of the country. Most city-dwellers work in government enterprises and their medical expenses remain covered by the state.
Social historians of medicine sometimes speak of its industrialization, a process that includes making therapeutic work specialized and routine in character, reorienting it toward profit, regulating the time that the therapist spends with each patient, and so on. My observations and the reports of others suggest that this process is under way, at least to the extent that productivity has become an issue. Chinese physicians working in many large clinics do not tarry with their patients, or explain to them what the problem is and make sure that they understand. This deterioration in the quality of medical encounters, while a great deal of time is still wasted in other ways, may be seen as "catching up" to Western practice, but it has not been offset by adopting time-consuming but important aspects of modern medicine such as thorough physical examination (consultations are not customarily private, and outpatients remain clothed).
At the same time, health care is regaining some of its old diversity. Since the mid-1980's the government has allowed practitioners who do not fit into orthodox categories, even those who manipulate "superstition," to practice again. I was surprised ca. 1985 to see a large sign on a Hangzhou street advertising a snake-venom curer--surprised because I had been led to believe that such old popular methods no longer existed. Dr. Thomas Ots of Hamburg has documented a large trance healing cult in Nanjing. Perhaps most significant, popular religion has revived along the southeast coast and elsewhere, and is hugely popular again. Today, as in Chinese communities outside the mainland, healing flourishes (intensely annoying the ideologists) as the cutting edge of religious organization.
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