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Journal of Integrative Medicine: Volume 14, 2016   Issue 2
Traditional Chinese medicine in the UK in the past forty years: an interview with Professor Bo-ying Ma
Xiao Ye (College of Humanities and Social Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China )

Citation:Ye X. Traditional Chinese medicine in the UK in the past forty years: an interview with Professor Bo-ying Ma. J Integr Med. 2016; 14(2): 77–83.

  

1 Background

Chinese medicine was brought to the UK more than three hundred years ago, but it has only gained acceptance and recognition among the British public in the last several decades[1]. Since ‘Western medicine and traditional Chinese medicine (TCM) arise in different cultural backgrounds and show different characteristics, especially in the thinking styles for making diagnoses’[2], it is not surprising that it takes a long time for Chinese medicine to be incorporated into a foreign culture. On 26th March, 2015, Prof. David Walker from the UK Department of Health reported that ‘There is not yet a credible scientific evidence base to demonstrate risk from both products and practitioners of Chinese medicine which would support this step (Ye notes: This step means the implementation of statutory regulation). There is also very limited evidence of effectiveness of herbal medicines in improving health outcomes. This makes it difficult to establish the boundaries of good practice which would be required for both educational qualification and implementation of statutory regulation.’[3] His statement shows that Chinese medicine is still struggling to gain foothold in the UK’s mainstream medical world.
From February 2015 to August 2015, the author took an academic trip to the EAST Medicine Research Center, University of Westminster, UK. In the efforts to understand the current climate of TCM in the UK, the author conducted an interview with Prof. Bo-ying Ma, who is a well-known Chinese British expert, educator and practitioner of TCM. Being a visiting professor of many universities in the UK, France and China, and the president of the Federation of TCM Practitioners UK, Prof. Ma has an excellent professional reputation and has always been devoted to promoting TCM around the world. This interview was conducted in Chinese, and later transcribed into English for the purposes of this article.

  

2 Interview

Ye: Prof. Ma, it is nice to have a chance to speak with you. You are a well-known professor in the world of TCM and have been in the UK for more than thirty years, so could you please say something about how the current state of TCM in the UK came about?
Ma: Yes. The earliest recorded contents of Chinese medicine appeared in Europe 350 years ago, but the real rise of acupuncture in the UK, like in most other Western countries, occurred after American President Nixon visited China in 1972. In the beginning, many Westerners went to Southeast Asia, China (Hong Kong, Taiwan) and Japan to learn acupuncture. After the Cultural Revolution in China (1966–1976), Westerners started to learn acupuncture directly in mainland China, and obtained the World Health Organization training certificate. These practitioners then brought TCM back to their countries by opening acupuncture clinics, treating patients with acupuncture, setting up acupuncture courses or colleges, publishing papers and books, and establishing associations.
Ye: Are there any indigenous cases that further contributed to the rise of TCM in the UK?
Ma: Yes. In 1980, Dr. Gwei-Djen Lu and Dr. Needham Joseph, two well-known professors from the University of Cambridge, wrote a book entitled Celestial Lancets: A History and Rationale of Acupuncture and Moxa[4], which systemically introduced the history and new research results of Chinese acupuncture and acupuncture anesthesia, causing a sensation. Acupuncture, Qigong, and terminologies of Chinese medicine such as yin-yang, wu-xing and qi began to be known and understood by the general public.
Another event that occurred in the late 1980s was that Ding-hui Luo, a doctor of Chinese medicine in London’s Chinatown, cured cases of eczema. This drew the attention of David Atherton, a dermatologist of Western medicine. He conducted investigations and studies on it, then published a series of papers starting in 1992. His research showed that Chinese medicinal herbs provided a therapeutic option for children with extensive atopic eczema which had failed to respond to other treatments[5]; his findings anticipated a wider therapeutic potential for traditional Chinese medicinal plants in atopic eczema and other skin diseases[6]. These events were widely reported, painting Chinese medicine in a very positive light. As a result, Chinese medicine became more and more popular in the UK.
Ye: That is really good news for the international transmission of Chinese medicine, but I heard that Chinese herbs are not allowed for use in most European countries. Is the UK an exception?
Ma: Yes, it is. Chinese herbs are allowed for use in all the nations of the British Commonwealth. These benefits are from an old British tradition that anyone is able to apply herbs to treat diseases under Henry VIII’s decree in 1543. The British government introduced the Medicine Act in 1968, such that herbal products of the third party can be sold in the market. Hence, Chinese herbs entered the market for treatment as “non-licensed drugs”.
Ye: In respect to herbal applications, the environment of TCM in the UK seems far better than other European countries. So, did Chinese medicine then quickly become popular in the UK?
Ma: Yes. Since about 1992, a number of doctors of Chinese medicine from China obtained work permits and were employed by businessmen to practice medicine in the UK. Many British people who learned acupuncture from China or Western herbalists who further studied Chinese medicine began to practice Chinese medicine as well. Statistics from the Royal Botanical Gardens showed there were over 3 000 clinics of Chinese medicine in the UK in 1998. The number of Chinese herbal companies went from zero to as many as twenty. More than sixteen private colleges of acupuncture and Chinese herbal medicine were set up in the country, including some universities that provided acupuncture and herbal courses. A host of indigenous Chinese medicine practitioners and acupuncturists graduated from these schools, and some of them became quite successful in practicing Chinese medicine and acupuncture. Moreover, more than ten associations of acupuncture and Chinese herbal medicine emerged to voluntarily regulate practitioners in this field.
Ye: The situation of Chinese medicine in the UK is extremely good, right?
Ma: 1998 was the climax of Chinese medicine in the UK. However, just as Lao Zi said, ‘There is luck within disaster and disaster within luck’. During the boom years of Chinese medicine in the UK, many adverse elements were looming. For example, misunderstandings and misjudgments regarding Chinese medicine arose due to cultural differences; some British authorities were stubborn and had biases against Chinese medicine; practitioners of Chinese medicine were not legally recognized; Chinese medicine was incorrectly reported as unsafe due to misunderstandings and exaggeration. And because of the lack of government oversight on the Chinese medicine market, anyone could practice Chinese herbal medicine or acupuncture with little or no knowledge of Chinese medicine. Many practitioners from China have poor English, so they are unable to communicate effectively with patients and doctors of Western medicine. Some of them cannot adapt to British society and even fail to observe the British laws. Thus a culture of rejecting TCM, spearheaded by some doctors and pharmacologists of Western medicine, came into being. In particular, the financial crisis in 2008 gave the industry of Chinese medicine in the UK a serious blow. Many clinics and companies of Chinese medicine closed down, and those repercussions can be felt even today.
Ye: That’s really a disaster. Could you tell me some representative events?
Ma: The first setback of TCM in the UK was a case of kidney failure caused by Longdan Xiegan Wan[7], in which Guan Mutong (Caulis Aristolochiae Manshuriensis) is an ingredient. Guan Mutong contains aristolochic acid, which is toxic in large doses. Aristolochic acid poisoning was first diagnosed at a clinic in Brussels, Belgium, when cases of nephritis leading to rapid kidney failure were seen in a group of women who had all taken the same weight-loss supplement, Aristolochia fangchi, which contained aristolochic acid. This nephritis was termed “Chinese herbs nephropathy” (CHN) due to the origin of the weight-loss supplement[8]. In 2002, the Medicines and Healthcare Products Regulatory Agency (MHRA) of UK sued the clinic of Chinese medicine and this stirred a public clamor. At that time, I was invited as an expert witness of Chinese medicine in the court for defense. After a long period of interrogation, the court announced that the clinic of Chinese medicine was not guilty.
Ye: I heard that the court debate was very dramatic, wasn’t it?
Ma: Yes, but the key is that you must have evidence. The accuser was MHRA of the UK government, which is quite powerful, and had invited many expert witnesses to testify on the toxicity of Chinese medicines and Longdan Xiegan Wan’s ability to cause kidney failure. I was the only expert witness for the defense. I have the education background of Western medicine before learning Chinese medicine, so I understand the language and general principles of Western medicine. My strategy was to use their own words to refute themselves.
The Western medicine doctors who had treated the patient were graduates from the University of Oxford. They were highly qualified in the eyes of the British public, so their testimony was easily accepted by the jury members. After their testimony was presented in the court session, the overwhelmingly dominant opinion was that this patient’s uremia was caused by Longdan Xiegan Wan. However, I proposed my objection to their diagnostic principles. In terms of diagnostics of Western medicine, ‘diagnosis of exclusion’ can be applied when no direct evidence is present. For this case, if we could exclude possible causative reasons one by one, the last left one would surely be the culprit. People generally believed that aristolochic acid from the Longdan Xiegan Wan was the chief culprit. The kidney disease caused by the aristolochic acid is called interstitial nephritis. Nevertheless, a table in a textbook published by the University of Oxford lists 94 drugs that can lead to interstitial nephritis, including aspirin, paracetamol and some antibiotics. I checked the medical file of this patient and found that she had taken such medicines before, but they had not excluded them. Thus I said their judgment was not in accordance with the diagnostic criteria of Western medicine and there was also no direct evidence because an experiment conducted in Belgium revealed that gastric infusion of aristolochic acid in rats hadn’t resulted in interstitial nephritis[9].
Then, the chief prosecution lawyer wanted me to submit by claiming “doctors all around the world believe that Longdan Xiegan Wan is the culprit for kidney failure” and “Longdan Xiegan Wan in this case is overdosed”. I refuted his claim. Doctors were indeed interested in Longdan Xiegan Wan’s effects on the kidneys, but they were mostly “concerned” about the connection, rather than “believed” it. As for the dosage, I said your calculation was wrong, my calculated dose was ten times less, so how can I agree with your claims?
My testimony was persuasive enough that jury members were unable to reach a uniform opinion. The British law is that verdict can only be made after the jury members have reached an unanimous agreement. Sometimes, if there is only one dissenter among the jury members, he/she may not be accounted. Therefore, the court session and jury members were dismissed and the accuser could appeal in two weeks. Half a year later, a new court session and jury members were assembled. They reached a unanimous agreement that the clinic of Chinese medicine was not guilty.
Ye: If this clinic of Chinese medicine was judged as guilty, the consequence might have been tremendous.
Ma: Yes. When I went out of the court gate that day, flocks of media reporters and journalists with their cameras had already been on site, waiting for the verdict that the clinic of Chinese medicine was guilty. However, they were disappointed and went away dejectedly. If the verdict had been otherwise, the news would surely have reported it unfavorably next day, and Chinese medicine in the UK would have suffered greatly.
Ye: Do doctors of Western medicine and pharmacologists always have prejudice against Chinese medicine?
Ma: Yes. Some “experts” in the British Commission on Human Medicines once posted a press release, saying that it is risky to apply Chinese herbs in any circumstances, placing Chinese medicine in extremely unfavorable light.
Ye: This case seems a grave misunderstanding of how Chinese herbs work. It is true that some herbs are quite toxic, but those are never applied alone. Their toxicity is reduced either by processing, or by small dosage, or by a combination with other herbs. Sometimes, even a certain degree of toxicity of the herbs is required to treat diseases by regaining balance, though this method should only be used by learned and experienced doctors of Chinese medicine.
Ma: You have some points here, but very often, people unfamiliar with Chinese medicine will not listen to your logic, and they will not try to understand your point of view. Another such event occurred in November 2000, when the British House of Lords released the blue book of the Science and Technology Committee, in which it categorized Chinese medicine and acupuncture into the 3a group (Ye notes: The House of Lords Select Committee on Science and Technology’s Report on Complementary and Alternative Medicine (HMSO 2000) proposed that complementary and alternative medicine therapies fall into three broad groups. The first group embraces what may be called the principal disciplines, which are already regulated in their professional activity and education by Acts of Parliament. Each of these therapies claims to have an individual diagnostic approach. The second group contains therapies which are most often used to complement conventional medicine and do not purport to embrace diagnostic skills. The third group can be split into two sub-groups. Group 3a includes long-established and traditional systems of healthcare. Group 3b covers other alternative disciplines which lack any credible evidence base.[10]), and claimed Chinese medicine and traditional acupuncture as having no scientific evidence, but only a therapy related to some religions and philosophies. This categorization meant that no support would be granted to this field in aspects of finance, education, or research.
Ye: It must have been a shock to the field of Chinese medicine in the UK. Did members of this profession fight back?
Ma: Before the release of the blue book, the House of Lords actually posted advertisements for all academic associations of complementary and alternative medicine to solicit scientific evidence for assessment. However, fellows in TCM field just thought their concern was only in treating diseases and politics was none of their business. As a result, endorphin associated with acupuncture anesthesia was used as evidence by a Western acupuncture association; and artemisinin was claimed as scientific evidence by a Western herbal association. These professions were thus placed by the House of Lords in the first group with scientific evidence. Hence, we lost the opportunity to respond to the requests. Later, we tried our best to fight for the rights. In March 2001, the British Ministry of Health decided to list Chinese medicine and acupuncture in the first group, aligning it with Western herbal medicine and Western acupuncture for Statutory Registration. Two working groups preparing for the registration of Chinese medicine and acupuncture respectively were established, but Chinese medicine was classified into the herbal medicine category, which degraded the academic status of doctors of Chinese medicine. And acupuncture was separated from Chinese medicine as an independent classification. They really misunderstood Chinese medicine.
Ye: How did the fellows of Chinese medicine strive for their rights?
Ma: We tried to work together and actively asked for participation in the process of democratic legislation. In February 2002, we established General Council of TCM and it was later merged with other organizations to become the Chinese Medicine Council. We tried to implement the self-regulation of doctors of Chinese medicine in the UK and lobbied the Ministry of Health for legal status and healthy development of Chinese medicine in the UK. Progress was made in January 2005 in that the Ministry of Health assembled representatives of academies of Chinese medicine; doctors of Chinese medicine using both herbs and acupuncture, acupuncturists and Western herbalists were all included in the legislation process separately and equally, and the doctor title of Chinese medicine was protected. After three years of discussion and debate, reports of the working group were released in 2008 and the legislation process would just be completed before the last step, namely the deliberation of the parliament.
Ye: It seems your efforts were quite effective.
Ma: Yes, but later changes were surprising and disappointing. The Ministry of Health took no further actions after the reports and ministers changed many times over the years. Most surprisingly, a new minister in the Health Ministry in 2011 abruptly declared in magazines without consulting the fellows of Chinese medicine in advance that first, there was no consideration for any registered legislation for acupuncture; second, Chinese medicine and Western herbal medicine could only be registered together as the herbal category; third, the doctor title of Chinese medicine was no longer under legal protection. Herbalists including practitioners of Chinese medicine would probably be registered under Health and Care Professions Council (HCPC). The situation of Chinese medicine striving for lawful rights and interests in the UK retrogressed to that before 2005. The future of Chinese medicine was thus darkened.
Ye: I am sorry to hear that. Are there other adverse events?
Ma: Yes, the prohibition of patent Chinese medicine is a big one. In 2004, MHRA was entrusted by the European Union (EU) to propose the European Directive on Traditional Herbal Medicinal Products (THMPD). The initial intention of this legislation was that patent Chinese medicine was quite toxic and risky for patients. The related article was that patent Chinese medicine could only obtain Marketing Authorization on condition that it had been used in European countries for more than 15 years and in China for 30 years, and evidence of non-toxic effects must be provided. In April 2011, no patent Chinese medicine was allowed to be imported and those in storage could be used before the expiration date. However, no more than two years later, the MHRA suddenly announced that all kinds of patent Chinese medicine, including those in storage, were prohibited as of the end of April 2014. This caused great economic loss for clinics of Chinese medicine, and patients were deprived of the benefits of patent Chinese medicines.
Additionally, several British professors of Western medicine and pharmacology are “professional” criticizers of Chinese medicine and acupuncture. They always claim that Chinese medicine and acupuncture exert only placebo effects and Chinese herbs have great toxicity. Around 2007, they even collected signatures of 100 professors to oppose the legislation of Chinese medicine, acupuncture and Western herbs. They have never been open to understanding the viewpoint of Chinese medicine. Their so-called research experiments of acupuncture are totally against the “gold standard” advocated by themselves, and many people are misled by them.
Worst of all, the unexpected financial crisis in 2008 greatly affected the UK. As Chinese medicine and acupuncture are not covered by the state health insurance, British people were unable to afford the fee of treatment from Chinese medicine. When business was flourishing, the five major chain companies of Chinese medicine could afford even the highest rent. But by 2012, they were unable to make ends meet and basically closed down. The largest chain company reduced its clinics from 110 to 11. The profit of wholesale companies of Chinese herbs dropped by 50%–70% and several big companies closed down.
Ye: The situation of Chinese medicine really became bad in the UK!
Ma: Yes, but we should admit that British people have an open mind and are generally kind to Chinese people and Chinese medicine. For example, when Chinese medicine in the UK was at a low point, on 24th July, 2013, I took advantage of a dining opportunity together with Jeremy Hunt, a newly appointed Minister of Health, to submit a letter calling for salvation of Chinese medicine in the UK. I got the reply in August and the Ministry of Health finally agreed to establish a new working group to discuss registration legislation and other issues of Chinese medicine in December 2013. This new group had about 30 people, including government officials from the Ministry of Health, MHRA and other departments, representatives of Western medicine, members of parliament, representatives from management organizations like HCPC and Production Services Association, lawyers, seven representatives of Western herbs, three representatives of Chinese medicine and one representative of Indian herbs. From the end of January to November 2014, altogether four plenary sessions were held, but they were all managed by the MHRA and statements from representatives of Chinese medicine were always ignored and not recorded. At the end of the session, all the representatives of Chinese medicine unanimously agreed that the legislation conditions had been mature, but the government officials presiding over the session showed no approval. On 26th March, 2015, Prof. David Walker, the head of the working group, reported independently that no legislation for herbal medicines, including Chinese medicine, was needed. He provided six options of management organizations and methods for selection. This report met immediate opposition from organizations of Western herbal medicine and Chinese medicine. However, one point is different from previous outcomes: the reason for no necessity of legislation is that by investigation, gastrointestinal discomfort occurs only at the time of taking herbs and remits spontaneously, so he concluded that herbs, including Chinese herbs, have small risks to patients. Prof. Walker thought that ‘as a first step it would be helpful for the sector organizations to develop an umbrella voluntary register’. Additionally, the British government would discuss THMPD again with the EU. This indicated that the legislative foundation of EU’s THMPD had been swayed.
Ye: It is good to hear so much about the history of Chinese medicine in the UK in the last forty years. Apparently, the period from 1970s to the beginning of the 21st century was the ascending part of Chinese medicine in the UK, while the period after that till now is descending, though there is still hope for it to flourish in the future. Since you have experienced all the ups and downs of Chinese medicine here and have always been active on the stage of promoting Chinese medicine, what do you think are important issues to developing Chinese medicine further in the UK?
Ma: There is still a long way to go in respect to the general public’s acceptance of Chinese medicine and we should always work hard to achieve that target. I think we should abide by the following points. First, Chinese medicine is an integrated whole and a kind of advanced ecological medicine (Ye notes: Ecological medicine is firmly rooted in the science of conventional medicine and additionally recognises the key importance of external influences (such as nutrition and environment, e.g., exposure to toxins and?lifestyle) and internal influences (such as gut bacteria, genetic disposition, allergy, nutritional deficiencies and biochemical disturbances) in causing disease. Ecological medicine aims to maintain or restore health by making use of those same influences in a therapeutic way.[11]). Chinese medicinal formulas, acupuncture, moxibustion, Tuina, dietary therapy and Qigong are all effective medical modalities under the theoretical guidance of Chinese medicine. Its theoretical and clinical applications are certainly outside of the realm of Western herbal medicine, so at the time of seeking legislation, doctors of Chinese medicine should never be managed and registered as herbalists. We have great confidence in Chinese medicine’s theory, clinical efficacy, approach, capability and its future.
Second, doctors of Chinese medicine must be aware that patients’ health and safety are the most important goals. Good morality is a must in medical practice. The top-priority concern of the British government is safety rather than efficacy. Judging from the history of Chinese medicine in the UK, we can see that just a single unsafe event could spoil the whole system of Chinese medicine in another culture. Hence, we should have treatment safety as our top priority, efficacy as the second, and profit the third.
Third, the quality of Chinese herbs must be ensured. They must be genuine and able to meet standards of the Good Distribution Practice, the Good Manufacturing Practice and so on. They must be free from contamination of heavy metals and pesticides. Chinese patent medicines are effective, safe and economical products for patients. We should insist on legal use of Chinese patent medicine. Of course, detailed reports on its toxicity and side effects according to the standards of Western medicine should be included.
Fourth, we must communicate well with doctors and scholars of Western medicine. We should help them recognize, understand and support TCM. The global age of Chinese medicine can only arrive when it has been accepted by Western medicine. In this respect, doctors of Chinese medicine should be good at English, try their best to enhance clinical efficacy and conduct evidence-based medicine (EBM) research on the clinical practice of Chinese medicine. The EBM has many levels of standards, we should not always use the ‘gold standard’ (Ye notes: randomized controlled trials are often assigned the highest level of evidence, namely the ‘gold standard’.) to measure Chinese medicine, because modern research methods and equipment are still not sufficient to achieve that. Instead, we can use other levels of standards to convince scholars of Western medicine (Ye notes: Since the introduction of levels of evidence, several organizations and journals have adopted variation of the classification system. For example, the Center for Evidence-Based Medicine developed levels of evidence for therapeutic studies, in which there are other levels of evidence, such as “outcomes” research, ecological studies, individual-control study, case series, and expert opinion without explicit critical appraisal.[12]). Once doctors of Western medicine have had effective experience by using Chinese herbs and acupuncture by themselves, and truly understand Chinese medicine, I am sure they will view our profession much more positively.
Ye: Thank you so much!

  

3 Conclusions

In the UK, TCM is still viewed as foreign medicine from a foreign culture. It is unavoidable that TCM will encounter resistance and rejection when it tries to develop in that foreign land. That is a general law of cross-culture transmission. Only those who can adapt to the different environments are able to survive. It is reasonable to believe that Chinese medicine can survive in the UK, because it is clinically effective, and is an advanced ecological medicine Chinese medicine professionals in the UK should always be aware that safety, efficacy and communication with Western medicine providers are their top priorities.

4 Acknowledgements

I would like to thank Senior Lecturer, Jane Wilson and Dr. Alicia for their timely guidance and kind support.
This work is supported by a 6-month grant given to the author by the China Scholarship Council and Zhejiang Planning Project of Philosophy and Social Science in year 2015 (Project code: 15NDJC24YB).

5 Competing interests

The author declares no competing interests.

  
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