In mid-February 2020, during the peak of the Covid-19 outbreak in China, Liu Lihong, a slight man with a wispy beard, made his way into Hankou Hospital No. 8 in Wuhan. Dressed in an all-white infectious disease suit, the only equipment he carried was a small box of acupuncture needles.
Liu is the author of Sikao Zhongyi (literally “Contemplating Chinese Medicine,” now translated as Classical Chinese Medicine), a book that has sold more than 500,000 copies since it was first published in 2001 and has made him one of China’s most famous practitioners of traditional medicine. Now sixty-three years old, he has emerged as an inspiration to thousands of Chinese who are eager to rediscover their roots and see in these healing arts one of the few living branches of traditional Chinese culture. Liu’s mission is to revive what he sees as authentic Chinese medicine, in contrast to the much-simplified version that has been taught in Chinese universities since the 1950s. But as the government has moved to restore traditions over the past decade, such as recognizing older ways of educating practitioners, Liu has become part of the mainstream. His visit to Wuhan was a dramatic effort to show that Chinese medicine isn’t a relic of the past but can solve urgent medical problems today.
Soon after the pandemic started, officials established protocols for treating Covid-19 that included Chinese medicine. They also included traditional practitioners among the thousands of medical personnel summoned to Wuhan. Then they exported these treatments to countries around the world, including Iran, the Netherlands, and Italy, as part of relief missions intended to bolster China’s international image.
For practitioners like Liu, these were decisive victories, showing how their healing arts are still relevant. But they raise a crucial question: Can China’s indigenous medicines adapt to changing times in their own way as in the past, or will they be co-opted by the Chinese Communist Party as it remakes itself into the guardian of a past that it was once eager to destroy? And will this support diminish Chinese medicine’s image abroad, making it appear to be little more than a tool of Chinese soft power?
Writing in English about the medicine that Liu and his colleagues practice presents an immediate problem: what to call it. In Chinese, it is simply zhongyi, or “Chinese medicine”—the term I use in this essay. Outside China, the unfortunate term “traditional Chinese medicine,” or TCM, has taken hold, even though it doesn’t exist in Chinese.
This discrepancy is more than a pedantic curiosity. “TCM” gives the misleading impression that it is unchanging, bound to ways of doing things that are hundreds or thousands of years old. While Chinese medicine still uses texts dating back twenty-five hundred years, it has changed radically over the centuries, with practitioners publishing hundreds of books that debate theories, discuss case studies, and propose new treatments for new ailments. Nowadays, most Chinese medicine practitioners in China can read an X-ray and prescribe antibiotics.
“TCM” was coined by party propagandists, first appearing in 1955 in English-language publications aimed at foreign audiences. The term has the dual function of reassuring foreigners that Chinese traditions are alive and well while distancing the party from them. Like other groups that wanted to modernize China over the past hundred years, the Communists initially saw Chinese medicine as a relic of a backward past that had to be discarded. But unlike other bulwarks of traditional Chinese life that the party immediately suppressed upon taking power in 1949—especially religion and clan associations—it survived and at times thrived under Communist rule.
Initially, this happened out of necessity. By some estimates, China in the early 1950s had just 10,000 practitioners of modern medicine—now often called biomedicine. (In Chinese, it is widely called xiyi, or “Western medicine,” since it was often brought by Christian missionaries.) At that time, China had up to 500,000 practitioners of Chinese medicine—primarily those using herbs, which make up the bulk of treatment, and other methods, such as acupuncture, cupping, and massage. That forced the party to incorporate it into its national health plan.
Later, these domestic healing arts were encouraged as emblematic of the non-Westernized peasant-style society imagined by Mao Zedong. The example of this best known in the West was the barefoot doctor movement of the 1960s, when rural aid workers were given rudimentary training in Chinese and biomedicine and sent out to the countryside to offer very basic medical care.
But despite these eye-catching initiatives, the largest share of funding in the People’s Republic has always gone to biomedicine. Although Chinese cities, towns, and most villages today have a parallel structure of biomedical and Chinese medicine clinics and hospitals, money has been lavished on elite biomedical facilities that can compete with the best in the world. Chinese medicine remains a stepchild, often housed in shoddy buildings and only allowed to survive if “modernized” by the state.
The biggest change involved destroying how it was taught. In the past, masters of one of the many schools of Chinese medicine taught disciples; in the 1950s, however, the Communists homogenized these different approaches into a single version that was incorporated into textbooks for use in state schools. This allowed the government to strip Chinese medicine of many of its theoretical underpinnings, which were based on traditional philosophical ideas not readily explained by science and thus were discarded as superstitious.
One example is the existence of twelve primary “meridians,” or channels, that carry qi, a form of energy, through the body, much as arteries carry blood. The problem is that meridians and qi do not show up on magnetic resonance imaging (MRI), computed tomography (CT), or any other sort of modern medical equipment.
Yet they underlie practices that have gained widespread acceptance outside of China. In acupuncture, for example, the locations where the needles are inserted into the skin are not nerve points, as many people imagine, but points along the meridians. The points and their names are assigned according to philosophical concepts related to Taoism, making them seem distinctly unscientific. So while meridians and qi do not appear to exist according to science, they are part of an internally logical system that yields coherent treatment methods that many patients feel are effective. That has led Western doctors to add some elements of Chinese medicine to their repertoire and has convinced some insurance companies to cover it.
Although it has gained some acceptance abroad, Chinese medicine’s lack of funding has made it an undesirable profession in China. Many students of Chinese medicine ended up there simply because they could not test into schools of biomedicine. For them it is a consolation prize, so they often practice grudgingly and without real conviction.
Thus many of these practitioners do not believe that their field has much to offer other than palliative treatments or placebo effects. Career paths contribute to the problem. Just as in biomedicine around the world, students of Chinese medicine test into graduate school and conduct experiments. Most experiments have nothing to do with Chinese medicine; they are simply efforts to find in its pharmacopeia useful plants whose active chemical compounds can be identified, isolated, and used to treat specific illnesses—much in the same way that aspirin is based on acids found in the willow tree. This was how the state envisioned modernizing Chinese medicine and probably what Mao meant when he called it “a great treasure house.”
The culmination of this kind of research came in 2015, when Tu Youyou of the China Academy of Traditional Chinese Medicine won the Nobel Prize for discovering a treatment for malaria. She led a team that extracted the compound artemisinin from the plant Artemisia annua, which Chinese medicine had used for centuries to fight malaria.
Many viewed this as a victory for Chinese medicine, but in fact it was the opposite. Practitioners typically diagnose patients based on complex theories of the body. Then they prescribe roughly half a dozen to twenty ingredients, mostly plants, which are boiled into a tea that is taken two to three times a day for several days. After that, the patient returns to the doctor for a new examination and the prescription is refined based on the patient’s progress. Using one plant or mineral to cure an illness has precedent in Chinese medicine, but such cases are outliers.
It was this sorry state of pseudo-modernization that Liu railed against in his book. Like others in contemporary China, he was arguing for a return to Chinese traditions as a reaction to the country’s tumultuous twentieth century, when for decades major pillars of its civilization were equated with backwardness. This began to change in the 1980s and 1990s, as many Chinese started to wonder what really remained of their millennia-old culture.
Liu writes of a new generation of students who wanted to understand how Chinese medicine functioned but who were perplexed because their teachers in clinics and hospitals would often use antibiotics and other biomedicines with a few basic Chinese medicine prescriptions tossed in: “What they witnessed was Chinese medicine used as a sort of decoration.” The biggest problem remains that students of Chinese medicine do not read or understand the classic works on which it is based. The government’s simplified curriculum gives them a cursory overview of these texts but basically uses Chinese medicine as a kind of herbal tool kit. “As far as they are concerned, it is unlikely that there is anything worthwhile to gain from reading the medical classics,” Liu writes. “This disregard for the Chinese medicine classics is the highest hurdle.”
Liu’s book tries to remedy this by offering a primer to one of the most important of these classics, the Shanghanlun, or Treatise on Cold Damage. Compiled sometime before the end of the Han dynasty in 220 CE by the scholar Zhang Zhongjing, it is one of the four canonical texts of Chinese medicine and the first to recommend complex decoctions of herbs. These are prescribed according to six disease patterns, which provide flexible templates for practitioners to analyze a disease.
While the Treatise on Cold Damage is taught to most Chinese medicine students in China, Liu understood that few modern Chinese possess the cultural background to make real use of it. So he goes to great lengths to explain essential concepts, such as the importance of time—that diseases, including epidemics, change not only over the course of a year but even over a day. Because a central concept of the Chinese worldview is that the human body is a microcosm of the universe, these links are not coincidental but fundamental to how diseases are analyzed and cured.
Those kinds of discussions made Liu’s book radically different from most Chinese medicine books, which usually describe which prescription works best for which ailment—a sort of handyman approach to Chinese medicine formulas. Liu, by contrast, elevates Chinese medicine to the position it occupied in traditional society as an integral branch of high culture, practiced by some of society’s most accomplished and literate people.
The book’s genesis is especially revealing. In the 1990s Liu met Heiner Fruehauf, a Portland-based practitioner and teacher of Chinese medicine. Some years later, Liu gave a series of lectures on the Treatise on Cold Damage to a group of Fruehauf’s American students from the National University of Natural Medicine in Portland who were visiting China. He recorded and transcribed his talks, later editing them into book form. The fact that he was addressing a foreign audience accounts for his basic explanations of Chinese philosophy—for example the function of time. In an earlier era, these explanations would have been unnecessary for Chinese readers, but now they were the book’s main selling point.
Liu and Fruehauf have remained close friends, with Fruehauf enlisting two of his students and Sabine Wilms, a well-known translator of Chinese medical classics, to create the English edition of Liu’s book. Fruehauf also wrote an elegant introduction that attempts to distinguish the government’s brand of TCM from a more authentic version that he calls “classical Chinese Medicine.” This term is now gaining popularity among many Western practitioners who shy away from the scientized world of TCM.
Classical Chinese Medicine is probably of most use to practitioners who are unable to read Chinese. Like any medical text, it is at times dense and specific. But a market for it does exist, and the translation is already in its third printing. Just as in China, many patients in the West feel that biomedicine is excellent for acute illnesses but often fails at treating chronic conditions that do not fall neatly into its clear-cut categories.
Inside China, however, Liu’s book has had a more profound effect, changing how techniques are practiced and contributing to a revival of traditional culture. Some practitioners began to seek out older doctors, especially those who had trained before the 1950s. Emulating pre-Communist practices, younger doctors would kowtow three times before their elders to become disciples and learn directly from them. Others set up health retreats or private practices that eschewed TCM’s simplified diagnoses and prescriptions. Mirroring a broader crisis of faith about the direction of Chinese society, many people began to see in Chinese medicine an alternative to the Communist Party’s scientized and commercialized world. Self-help books abounded, and lay practitioners set up blogs and chatrooms to discuss the latest in what they viewed as authentic Chinese medicine.
It took the rise of Xi ten years later, in 2012, to give Chinese medicine the boost it needed. In 2016 the government started a fifteen-year program to promote it. The next year, fifth graders in one Chinese province began taking classes in Chinese medicine as part of their cultural literacy studies. Most significantly, Beijing implemented a national law that guaranteed official protection and support for it.
As part of its effort to promote Chinese culture abroad, the state has pushed international organizations to accept Chinese medicine as a legitimate healing art. In 2018 the World Health Organization included it in its influential International Statistical Classification of Diseases. This is a diagnostic tool used by more than one hundred countries to classify disease and death, making it possible to compare statistics, guiding how insurers cover illnesses, and setting research agendas. The WHO included a supplementary chapter, for optional use only, of 150 disorders and 196 disease patterns that originated from Chinese medicine and are now commonly used in East Asia.
For advocates of science-based medicine, the WHO’s move was an outrage. Given Xi’s strong backing of Chinese medicine, critics of it in China are less vocal than before, but foreign publications, such as Scientific American, Nature, and The Economist, pointedly said that without scientific proof of its efficacy, Chinese medicine was, as the Economist headline had it, “state-sponsored quackery.”
These demands to evaluate it by Western scientific standards are not new but are more difficult to satisfy than many think. One major problem is that isolating the active compound in a formula of a dozen ingredients is dauntingly complex, especially since the doctor changes these ingredients as the patient’s condition develops. And then there is the way Chinese medicine treats the body. In biomedical terms, what does it mean when a Chinese medicine practitioner looks at a choleric person with high blood pressure, regular alcohol consumption, and dark stools and urine, and says she has “damp heat”? And what does it mean when the solution is to “clear” this heat by a change in lifestyle and taking herbal teas? Must one correlate this practice with a biomedical diagnosis? Since the 1950s, state-sponsored research centers have attempted to do this but have made little headway.
Another problem is that clinical drug trials are extremely expensive. They are routinely carried out by pharmaceutical companies, but only because they can yield profitable products. This isn’t the case for traditional formulas and treatments, which most countries and international bodies do not allow to be patented because they are seen as a form of collective cultural heritage—much in the same way that a composer cannot copyright a traditional tune and demand royalties every time it is performed. So although some global pharmaceutical giants conduct research into Chinese medicine, most do so as window dressing for their business in China—as an effort to appear sensitive to local culture or, at best, a hope that they might discover something akin to Dr. Tu’s antimalarial drug. None is willing to spend huge amounts of money studying herbal formulas that they cannot patent and sell.
For the Chinese government, the answer to this conundrum has been to tighten production standards of herbal treatments to make them safe, and also to give Chinese medicine every opportunity to show its efficacy. Last year, this is what happened in Wuhan.
When news began to circulate that Chinese medicine was being used to fight the coronavirus, skeptics leapt to the barricades. The New York Times ran a typical article with the headline “In Coronavirus, China Weighs Benefits of Buffalo Horn and Other Remedies” and cautioned that “experts” were doubtful of its “efficacy.” The article followed a tried-and-true way of writing about Chinese medicine: highlight the funniest-sounding ingredient in a formula, give a literal translation of the formula’s name, which often comes across as bizarre because it is based on a traditional idea or parable, then conclude with a homily that Chinese medicine isn’t scientifically proven. (There was, the Times said, “no clinical proof that the roots of various plants, licorice, and the Peaceful Palace Bovine Pill can help combat the deadly disease.”) Almost always, these articles failed to mention that biomedicine also didn’t have a cure for Covid-19 or that Chinese medicine has been used to fight epidemics for centuries.
Indeed, when Zhang Zhongjing compiled the Treatise on Cold Damage, he wrote in an introduction that he lost two thirds of his family to epidemics that afflicted China as the Han Dynasty collapsed in the third century. That’s why he focused his efforts on combating “cold damage,” which mainly refers to febrile diseases, primarily caused by viruses.
And yet it wasn’t a forgone conclusion that Chinese medicine would be part of the battle against the Covid-19 outbreak in Wuhan. Nearly twenty years earlier, it was initially excluded from fighting the SARS epidemic. This time around, though, its practitioners were involved early on—a clear sign of changing government priorities.
For Liu, it was a personal mission. No longer affiliated with a government hospital, he lobbied to go to Wuhan, explaining in a speech he gave later that he wanted to get to the “front lines” to show Chinese medicine practitioners that their healing arts really could help in a national crisis. Since his book came out twenty years ago, Liu said, the lack of self-confidence in the field has only grown, hence his desire—like Zhang Zhongjing’s two millennia earlier—to grapple with the greatest health care challenge of his generation.
Liu wrote that he had goosebumps of fear when he and his team arrived in Wuhan, its streets empty except for people in hazmat suits: “I would be lying if I’d say that we weren’t afraid!” he wrote. Learning how to put on the cumbersome suits was “not so easy for an old Chinese medicine doctor who is not used to such complexities and who has two klutzy pairs of hands and feet.”
Like all Chinese medicine practitioners, Liu based his diagnoses on external observation, primarily taking the pulse, observing the tongue, and questioning the patient—not easy while wearing three pairs of gloves and goggles. Of all these observations, the pulse is the most important, with practitioners using their fingers to feel three distinct points on the radial artery below the wrist on each arm. One of them, on the right hand just under the wrist, indicates the condition of a patient’s lungs.
Liu found that Covid-19 patients had a “slippery” pulse, meaning it was present but rolled out from under the finger like a bead of mercury on glass—a clear indication of a condition that Chinese medicine calls “dampness.” Patients also had white, sticky coatings on their tongues and a lack of mucus that they could expectorate. Liu decided on acupuncture to give immediate relief and prescribed herbal formulas to clear heat from the lungs. He reported that patients felt calmer and that their breathing was more regular.
Over the year and a half since Liu made his trip to Wuhan, 4,900 other practitioners of Chinese medicine have served on the front lines, accounting for 13 percent of medical personnel in the pandemic’s epicenter. Of China’s 70,000 patients diagnosed with Covid-19, 91.5 percent used some form of Chinese medicine in conjunction with biomedical treatments. Considering that only about 15 percent of medical services in China use traditional practices, this was a significant difference.
This led to national treatment guidelines, recommending which herbs to prescribe depending on the disease’s progression, and studies showing that Chinese medicine helps reduce the severity of Covid-19. The World Health Organization reported that under normal circumstances 13 percent of people who contract the disease become seriously ill, but China’s National Health Commission reported that only 2 to 5 percent of patients in hospitals using Chinese medicine in addition to biomedicine became seriously ill.
These are not definitive findings and will not convince critics. One problem is that the variables were too great—the quality of care in the hospitals was reportedly different. That led some, including China’s best-known pandemic fighter, Zhong Nanshan, to cast doubt on the usefulness of integrating Chinese and biomedical approaches.
Yet with Chinese medicine being touted as another sign of the country’s rejuvenation under Xi, it is likely to continue spreading in ways unimaginable a century ago—another effort by Chinese people, and now their government, to reassert the value of traditions and promote them around the world.