Wednesday, August 29, 2012

Toward an Understanding of Classical Chinese Medicine, Part 2: From Classical to Traditional Chinese Medicine

Our first post in this series is here.

Even if one believes that the theory and praxis of Classical Chinese Medicine (CCM) should be subject in its entirety to the scientific adjudications of what has come to be called evidence-based medicine (EBM) (and I do not believe it should be wholly subject to such a sieve), it is possible to at least imagine how CCM might fall under the rubric of “science” generally in a broad and historically-based construal of the meaning of such an enterprise, as one of the pioneers in the cross-cultural study of CCM, Nathan Sivin, has argued:

“The data collected over the centuries about the body, health and disorders were structured by the concepts of Nature…[of proto-Daoist and ancient provenance], forming a coherent body of theory used to diagnose and treat illness. Classical [Chinese] medicine deserves the adjective ‘scientific’ no less (but no more) than its counterparts in Western culture until recent times. [….] What we call medicine incorporated and imposed order on experience related to every aspect of health, disease, and injury. One Chinese scheme of its major divisions include theoretical studies of health and disorder; therapeutics; the theory and practice of longevity techniques, including sexual hygiene; pharmacognosy, and veterinary medicine. [….] Prescriptions made up of both crude drugs and extracts were commonly used in combination with a great variety of other therapeutic means, including acupuncture and moxibustion” (Sivin 1990: no pagination).

The fact that we can make sense of Nivin’s description as giving as an introduction to a science of sorts, that we find it intelligible and plausible, speaks to the question of commensurability/incommensurability between CCM and Western scientific medicine, which is clearly a matter of degree (cf. medicine in the West ‘until recent times’ above) and is arguably aspectual in nature. Or, we might see the relation between EBM and CCM as in some ways analogous to that between laws and social norms, two sets of “rules,” the former formal and the latter informal, with some conceptual and practical overlap between the two sets, and including mutual interaction between at least some of the parts of both sets (as when, for example, social norms give way to laws or laws reinforce or even bring into being social norms). The sets are therefore distinguishable, and thus there is some measure of prima facie incommensurability owing to linguistic, conceptual, ontological and explanatory differences between EBM and CCM we have yet to discuss (and thus deserve systematic exploration). Finally, and perhaps most importantly, we might begin to think what is could mean for EBM to be diagnostically, physiologically, and therapeutically focused on the body, while CCM encompasses the whole person (herein lies the intuitive attraction of ‘holistic’ medicine): the body in this case including the “heart-mind,” xin (or ‘mind-heart,’ the source of both intellectual and emotional reactions, encompassing what we intend by the term ‘consciousness’ in cognitive and conative senses, but even more, the notion of mind, where mind is not reducible to the brain and the body is a necessary but not sufficient condition for the mind, the latter extending out into the world, as we say). Xin lies at the heart of the Chinese understanding of the person or shenti. As Yanhua Zhang explains, while shenti can be translated as “body,” it does not have the “container” connotations one finds in English (and derived from its roots in Old German) and the associated images of a physical, objective, and anatomical entity. Shenti, writes Zhang, “implies a person or self with all the connotations of the physical, social, and mindful” (2007: 55).

For now, let us cash in our earlier promissory note on the difference in meaning between what is termed “Traditional Chinese Medicine” (TCM) and CCM. Oddly perhaps, it so happens that TCM is not, in fact, traditional Chinese medicine, and thus what is ostensibly meant by the term is more accurately called Classical Chinese Medicine. Perhaps we’re a bit jaded when it comes to the precise scope of such nomenclature: the World Series in baseball is not truly global, and most of us are familiar with euphemisms and doublespeak like “Peacekeeper Missile,” “collateral damage” and “pacification programs.” In many not insignificant respects, it so happens that TCM is decidedly modern, a selective appropriation of specific medical modalities mined from what is better termed Classical Chinese medicine (CCM). What was christened “TCM” in the second half of the twentieth involves the ideological legitimation (see below for the motley motivating interests) and selective use of classical Chinese diagnostic techniques and therapeutic regimens by the People’s Republic of China (PRC) under Mao Zedong in the late 1950s and early 1960s. Whatever one thinks of the specific ideological rationale for the recognition of the therapeutic value of CCM among Chinese Communists under Mao, it is important to recognize that Western science and medicine has not been allowed to wholly trump indigenous medical doctrines and therapeutic modalities and practices in China, thus “Diversity is observable at every level of Chinese medical discourse and practice” (Zhang: 9), and TCM is not subject to the sieve of Western biomedicine, let alone EBM.

At first the Communists followed in the footsteps of their Nationalist government opponents in characterizing traditional Chinese medicine as exemplifying superstition and magical thinking, in other words, a theory and practice inimical to modernity in general and Western biomedicine (xiyi) in particular. Interestingly, from the early nineteenth to early twentieth centuries in China there was an effort toward a via media or rapprochement between the old and the new from within the medical profession by those committed to the hallowed “ideal of the broadly educated master physician” (the movement now referred to as the Chinese-Western Integration School) as they attempted to incorporate some features of modern biomedicine “into the traditional mother body of Chinese medicine” (Fruehauf 1999, sans pagination). The terms of this incorporation, however, were set by the parameters of CCM. This endeavor was historically superseded by the naked politicization of Chinese medicine in the first half of the twentieth century when adjectives denoting and connoting the traditional properties of CCM, much like the Confucian worldview, became “despicable symbol[s] of everything old and backward” (Fruehauf), the Nationalists and Communists alike adopting attitudes akin to the Jacobin revolutionaries toward the ancien régime.

Mao’s later public embrace of CCM (as TCM) garnered widespread support among the masses, a noticeable portion of which had earlier taken to the streets when Kuomintang public health officials initiated legislative proposals with the goal of abolishing the “Old Medicine.” Baptised “Traditional Chinese Medicine,” colleges became its first institutional vehicle, with hospitals and clinics as well soon vigorously propagating putatively traditional Chinese medicine. While nominally hearkening back to an earlier era, Mao clarified the nature of State-directed TCM, speaking of “Chinese-Western medicine integration” in a manner that assured everyone that classical Chinese medicine would no longer be transmitted through the venerable hands of its lineage holders, that is, from master to disciple, with modes of transmission primarily “secret” and “personal” (cf. Hsu 1999). To be sure, Mao’s programmatic efforts to modernize Chinese medicine, in effect to standardize its knowledge and practice with the considerable resources available to the State, has long and well-established precedent in Chinese history. But standardization in this case is accomplished in reliance on philosophical, political, bureaucratic, scientific, technological, and pedagogical ideas, methods and institutions ineluctably associated with modernity. Of course it is naïve, even fantastical, to think CCM could carry over into our time and place unscathed or unaffected by a confrontation (at the levels of both doctrine and practice) with this or that facet of modernity (if you prefer, post-modernity). But we might consider—as a thought-experiment, an act of imaginative counterfactual reasoning—how the nature and pace of such a confrontation (and negotiation) might vary, depending on several sorts of variables, for example, its leading agents: The State? Physicians? Regional public health officials? Politicians? Physicians and their patients? Sectors of civil society free from State coordination or manipulation electoral outcomes? And so on. Hsu (1999) proffers the following motivating interests in support of the official and informal ideological sanctioning of TCM in the People’s Republic of China: “nationalism, Confucian values, humanitarian ideals, reformist and Enlightenment movements, the pragmatic politics of a party in pursuit of power, and economic considerations fo how to allocate manpower and scarce resources” (7). These motley interests remind us why we should distinguish between TCM and CCM, even if the latter has also been subject to historical forces that assure us its doctrine and therapies have never been frozen in time (cf. the reasons for Peter Eckman’s (2007) further distinction between TCM and ‘TOM,’ traditional Oriental medicine, the ‘mother discipline’ from which the former emerged).

CCM is in a subordinate and severely circumscribed role vis-à-vis not only Western biomedicine but TCM as well, a result of Mao’s vision of “Chinese-Western medicine integration,” as Hsu makes clear: “TCM…is generally referred to as the ‘modernised’ (xiandaihuade), ‘scientific’ (kexuehuade), ‘systematic’ (xitonghuade), and ‘standardised’ (guifanhuade) Chinese medicine” (7). Insofar as traditional or classical Chinese medicine is indissolubly bound up with ancient religio-philosophical ideas (e.g., dao [or tao], qi [or ch’i], yin/yang, wuxing [Five Phases], and shen [spirit]) essential to its doctrine, as well as shamanic, temple-based, divinatory, qigong (breath control or meditation), and home-based herbal drug and other pre-modern practices that conspicuously clash with Mao’s variation on the Marxist-Leninist ideological theme, it is not too difficult to distinguish TCM from CCM. Indeed, Mao’s “Chinese-Western medicine integration,” as TCM, calls to mind Eric Hobsbawm’s oft-cited because important observation that “‘Traditions’ which appear or claim to be old are often quite recent in origin and sometimes invented” (Hobsbawm and Ranger 1983: 1). Insofar as biomedical science and EBM serve as the sieve through which classical Chinese therapeutic modalities must pass before they are rationally or scientifically (hence medically) acceptable in the West, it would appear biomedicine is following in Mao’s footsteps: “At the least traditional end of the spectrum, dominant during the Cultural Revolution, acupuncture became merely a form of physical therapy devoid of any theoretical basis” (Eckman 2007: 182). And those attracted to TCM because they are generally enamored of all things exotic and Orientalist, might consider the fact that acupuncture and moxibustion had been used in Europe for roughly 300 years and were popular among physicians in early nineteenth century America before their recent ascendancy as a therapeutic regimen prominent in alternative or complementary medicine (see Sivin 1990, no pagination). All the same, it would be inaccurate to portray TCM as a rigid, unchanging discipline. Actually, depending on the political climate at the time, TCM has encompassed a wide variety of approaches—although it has never explicitly accommodated the more mystical, spiritual and shamanistic practices. Nevertheless, even that may be changing with the recent interest in the medical uses of both external and internal Qi Gong. These practices are inextricably connected to meditation and other “spiritual” methods, and as yet have no experimentally verifiable material basis. (Eckman 2007: 89)

Chinese Communists have of course stressed the limitations of the historically dominant model of physicians identified as “largely [an] hereditary office holding elite before the present millenium, but one based increasingly on wealth and achievement from the eleventh century on” (Sivin 1999). Furthermore, and consequently, they keenly appreciate the historical distinction “between the relatively few literate, well-born physicians who left the enormous written record, and the plebian practitioners of every stripe, generally illiterate for most of Chinese history, who cared for the overwhelming majority of the population” (Sivin, 1999). And yet the “enormous written record” referred to here, as Sivin says, was not primarily or merely “abstact bodies of theories, but keys to diagnosis, prognosis, and therapy. Mastering them was a necessary step on the way to becoming a good doctor.” To repeat: such mastery was achieved in the intimate interpersonal context of the master/student relationship defined by its personal and secret modes of transmission of medical knowledge and practice. The distinction between elite and plebian doctors was (and is) transcended in part by the nature of the transformation of CCM into TCM under the aegis of the PRC, effectively serving to democratize aspects of CCM that were once the prerogative of well-born physicians and their equally if not better-placed patients. I would argue that one salutary aspect of this democratization was well expressed in China’s “barefoot doctor” program, an ambitious, imaginative, and long-overdue attempt to extend the concrete achievements and virtues of urban public health into the countryside (on the eve of the 1949 revolution, about 80 percent of the population were rural peasants). Still, the “democratization” of Chinese medicine (e.g., the ‘barefoot doctor’ program) has been purchased at a high price: Recent institutional developments, most of them tied to market imperatives and priorities established in the wake of “cowboy capitalism” in China and which give pride of place to Western medical concepts and practices, are “finaliz[ing] the process of ‘evolution by integration’ that Mao had prescribed for Chinese medicine 40 years ago—a process that involves gutting the indigenous art of its spirit and essence [or religious and philosophical warrant] and subsequently appropriating its material hull (i.e., herbs and techniques) into the realm of a medicine that declares itself scientifically superior” (Fruehauf 1999).

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