At first glance, Bangkok's Thian Fah Hospital looks more like an antique temple than a medical facility. Bright red columns topped with upturned roofs flank the entrance gate. Just outside, a food cart hawks fried bananas and sausages. A shrine to the Chinese deity Guanyin dominates the center of the compound.

Yet behind this colorful facade stands one of the oldest private hospitals in Bangkok. More than a century ago, Thian Fah opened its doors to Bangkok Chinatown's poor at a ceremony attended by the then-king of Thailand, Rama V. Today, the compound contains a Western medicine hospital, a dental clinic and a kidney dialysis center. It is best known, however, for its traditional Chinese medicine clinic.

"Thian Fah is the purest charity hospital in Thailand," says Zhi Lin, who sits on Thian Fah's board of directors, speaking in Mandarin. "All of our Chinese medicine services are free. Not only do we not charge patients for their visits, we also give them their prescriptions for free." Lin says the hospital treats between 300 and 400 patients per day, most of them urban poor living in and around Bangkok's Chinatown.

Click above to take a look inside the Thian Fah Foundation Hospital in Bangkok's Chinatown.

The entrance to Thian Fah Hospital on Bangkok Chinatown's Yaowarat Road.
(Photo by James B. Cutchin)

X

Thian Fah could be a textbook case study supporting the World Health Organization's (WHO) recent decision to incorporate traditional Chinese medicine (TCM) into their International Classification of Diseases. The WHO announced in 2018 that the 11th edition of the document, set to be presented at the World Health Assembly for adoption by member states this year, includes a chapter dedicated to TCM diagnoses. These encompass a range of specialized TCM terms such as "Wasting thirst disorder," a rough analogue to diabetes. The document is hugely influential, serving as the basis for more than 70% of healthcare expenditures worldwide, according to the WHO.

The decision by the global body to officially recognize TCM has been controversial. While supporters laud the move as an important step for the field of complementary and alternative medicine, opponents decry it as an abandonment of the WHO's commitment to science-based medicine. Critics of TCM point to the potential dangers from untested herbs with scant evidence for efficacy or safety in controlled clinical trials. Some even allege that political pressure from China may be the true driving force behind the new policy.

The WHO's own 10-year strategy for traditional medicine, released in 2014, suggests that the organization's endorsement of TCM is based on a laudable goal: supporting universal access to healthcare services. Western medicine can be expensive. The WHO's strategy cites a study on neck pain, where physiotherapy and general practitioner treatment were found to cost about three times as much as manual therapy — a catch-all term for various types of massage and muscle manipulation commonly used in traditional medicine. An additional study shows patients whose general practitioners knew alternative medicine had lower health care costs and lived longer. Both studies are listed under the heading "Benefits of using T&CM [Traditional and Complementary Medicine]."

To its proponents, however, TCM is not all about cost-saving. The WHO strategy also mentions "whole-person care" and disease prevention, which TCM practitioners often tout as defining features of their craft.

On the other side of the world from Thian Fah, in the heart of Santa Monica, California, sits the Emperor's College of Traditional Oriental Medicine. The school and clinic occupy most of a two-story office complex just a few blocks from the city's famous pier. Some 200 students are enrolled in the school's Master of Traditional Oriental Medicine program, with an additional 50 in the Doctor of Acupuncture and Oriental Medicine program.

"One of the common threads that bridge their [our students'] stories are personal testimonies of their healing experience," says Amber Johnson, director of admissions for Emperor's College. "Unfortunately, our healthcare system in the United States is really challenged in a lot of aspects and people don't feel like they are getting the care that is needed."

Johnson says that many students gain an interest in TCM after unsuccessful treatments in the mainstream medical system leave them disillusioned and open to alternatives. When acupuncture succeeds where prescription drugs have failed, they become advocates of TCM and want to pursue a career in the field.

"I would say most of them have had some sort of profound experience with acupuncture," says Yun Kim, president of the Emperor's College. According to Kim, Western medicine's proclivity for steroids and painkillers leads to treatments that mask symptoms rather than dealing with the underlying issues. "It's not really getting to the root of the problem," says Kim.

Click above to take a tour of the Emperor's College of Traditional Oriential Medicine.

The Emperor's College classrooms, offices and other facilities are spread throughout this medical plaza in Santa Monica. (Photo by James B. Cutchin)

X

Acupuncture is the main way most Americans will encounter TCM. Forty-seven states have laws regulating the practice of acupuncture, with an estimated 35,000 state-licensed practitioners nationwide. Acupuncturists are now a common feature in many U.S. cancer treatment facilities, presented as an option to patients for managing nausea and vomiting caused by chemotherapy. Most herbal mixtures, on the other hand, are considered supplements under federal law and are regulated only by the Dietary Supplement Health and Education Act of 1994. The act defines such supplements as a food product, limiting their ability to be used in a mainstream clinical setting. In 2012, the National Institutes of Health reported that a quarter of Americans using acupuncture had it covered by their insurance. To date, no major insurers cover herbal medications.

Ji Zhang, one of Los Angeles' most established Chinese herbalists, is an instructor at the Emperor's College. Zhang sees patients at his private clinic, Ji Acupuncture and Herbs, which he opened in 1994.

"Acupuncture is like surgery, herbs are like drugs," says Zhang. "Many people in the U.S. know [about] acupuncture for pain management, but not many people know herbs are good for a much wider variety of things. Gynecology, dermatology, many things can be worked out through herbs."

Zhang describes acupuncture as a small, niche area of TCM, which overshadows the bulk of the field's scope in the United States. "In Chinese hospitals you will have over 10 different [TCM] departments. Only one is acupuncture, all of the rest are herbs. The treatment range is much greater." Zhang says he successfully treats everything from infertility to asthma using herbal remedies.

Despite his conviction of their efficacy, however, Zhang is not optimistic about the future of TCM herbal medicines in the U.S. healthcare system. He says the main sticking point is how drugs are tested and approved by the U.S. Food and Drug Administration (FDA).

"They require a single chemical. One herb includes so many different components," explains Zhang. "We don't use a single herb, we use a formula that can include over 10 different herbs that work together. During the boiling, some chemical reaction also occurs. Every week we might use a different formula. How can you do a clinical trial on that?"

This sort of variation, inherent in the traditional administration of TCM, creates quality-control issues unacceptable to many Western regulators. It is also why some practitioners would prefer a move away from clinics based around one-off personalized decoctions (boiled herbal mixtures). Instead, they favor a more systematized application based around so-called patent medicines — standardized, prepackaged herbal treatments, often in tablet or pill form.

Weijun Zhang (no relation) of the University of California, Los Angles Center for East-West Medicine, works at the boundary between TCM and the mainstream U.S. healthcare system. His organization operates several Los Angeles-area clinics which treat patients through a mixture of TCM and mainstream medical procedures. The center also leads a range of research and educational programs to promote the integration of the two fields.

"Herbs come in three different types," says Zhang. "One is raw, one is patent herbal medicine and then there is single-ingredient. The final one is basically a Western drug."

Three types of herbs (from left): a raw herbal perscription, a box of Po Chai Pills patent medicine and a bottle of bai shao (white peony root) extract. (Photos by James B. Cutchin)

Zhang gestures at an illustration of the three types of herbal application methods as he continues. "These two, no problem," he says of patent herbs and single-ingredient medicines. "This one, is questionable," he says pointing at the raw herbal treatment. He goes on to explain that variability and lack of standardization are the key flaws in the traditional clinical model.

"The issue is this — for this week I see you, and you are this pattern," Zhang says, referring to the patterns of symptoms used to diagnose patients in TCM. "I prescribe some herbs, I combine them, I use them in some formula. This isn't so fixed, so this part is questionable in terms of evidence [of effectiveness]."

Zhang says that the chemical variability of raw herbs themselves are also an issue with standardizing performance in the classical TCM setting. "If you harvest the same herbs today and then harvest them in the summertime, they're different even though they have the same name. But you [the doctor] still prescribe the same thing because you believe your diagnostic system is correct. But actually, the stuff is different. So how do you prove this with evidence? You cannot."

Zhang contends that patent medicines address this issue by offering standardized doses of TCM herbs. He divides these products into three main types: new formulas identified through private-sector or academic research, family recipes passed down through generations at private clinics and well-documented classical formulas.

"These," Zhang says of the first type, "are produced under industrial standards. They've undergone rigorous research." He holds that the second type end up undergoing similar procedures before reaching store shelves. "Before a company produces it, they will want to see evidence that it works and that it's safe," says Zhang.

Zhang says the final type, classical formulas, have had their effectiveness time-tested. "They've been used for 2,000 years; they've already proved it's useful. There's no issue of evidence with these."

Thian Fah's approach to TCM prescriptions could be seen as somewhere between raw herb and patent medicine applications. Experienced herbalists from China select and dictate volumes and ratios of ingredients, which are then sent through an assembly line spanning multiple floors. Dozens of workers grind, mix, boil and package decoctions on a near-industrial scale. A winding store room snakes its way through the halls behind the hospital's prescription counter, baskets of vacuum-sealed pouches stacked on shelves, in refrigerators and on the floor.

Zhi Lin explains that this is done for the benefit of Bangkok Chinatown's poor, many of whom may not have access to cooking facilities at home to prepare raw prescriptions. "We take care of everything here," Lin says proudly. "It's much more convenient for them this way."

Sumed Wong is a local Thai-Chinese businessman who grew up in the neighborhood around Thian Fah. He has come to the hospital's acupuncture clinic seeking relief for chronic back pain, which he says has proven resistant to treatment through Western medicine.

"They just want to keep giving you drugs," says Wong. "I think it's not good in the long term."

Unlike many of Thian Fah's patients, Wong is not in need of charity. After his visit, he drives his large black SUV to the other side of Bangkok's Chinatown for a second opinion.

Scenes from Hua Chiew TCM Hospital (clockwise, from left): Hua Chiew's main entrance, a patient waits for his prescription outside of Hua Chiew's pharmacy, one of the hospital's proprietary tri-lingual flyers, a view from Hua Chiew's lobby. (Photos by James B. Cutchin)

Hua Chiew Hospital is another of Bangkok's leading TCM providers. Unlike Thian Fah, the organization is a social enterprise and not a charity, leading to a greater emphasis on profit from its operations. The hospital is in the midst of a major transformation, having invested nearly $50 million in upgrading facilities and expanding services over the last decade. Shiny rows of new benches with chrome frames and crisp grey cushions line the granite floors of the hospital's large lobby. Posters, brochures and display stands of sleek marketing and instructional materials can be found on nearly every surface. A sizeable information desk features a perky attendant, ready to help direct patients to the appropriate location.

Despite the pristine new facilities, Wong's visit to Hua Chiew leaves him unimpressed. "It's basically the same [as Thian Fah]," he says of the hospital's service and treatment quality. "The main difference just seems like they charge a lot more."

Patients at Hua Chiew are given a choice between raw herbs, vacuum-sealed decoctions and herbal extracts when filling their prescriptions. In terms of standardization, the hospital's bulk-production method is similar to Thian Fah's, with large volumes necessitating elements of assembly line production that provide a more consistent product than might be seen the most traditional clinical setting.

Yet, while a focus on convenience may have inadvertently led Thian Fah and Hua Chiew closer to Weijun Zhang's ideal of standardized treatments, even the most stringent adherence to the principles described by the researcher are unlikely to satisfy staunch critics of TCM.

Arthur Grollman, of New York's Stony Brook University, led the team that first identified aristolochic acid as a potent carcinogen. The compound is found naturally in plants in the Aristolochia family, several of which have long been used in certain TCM remedies treating ailments such as arthritis, easing childbirth and assisting in weight loss. It was this final application that started Grollman on a series of research projects, spanning two continents and consuming the better part of a decade, which would prove the compound's toxic effects.

In the early 1990s, roughly 100 otherwise-healthy Belgian women suddenly developed a chronic kidney disease which eventually led to kidney failure. The common thread linking these women was the ingestion of a weight-loss supplement containing a variety of Aristolochia. Their condition was similar to a then-unknown disease found in certain farming communities in the Balkans. The traditional method of preparing bread in these areas involved mixing wheat grains with the seeds of another plant in the Aristolochia family native to the region.

Arthur Grollman in his lab at the Renaissance School of Medicine at Stony Brook University. (Photo courtesy of A. Grollman)

The similarities in these two conditions led Grollman to hypothesize that conditions among the Belgian women and those in the Balkan farming communities were caused by the consumption of aristolochic acids. Testing Grollman undertook with a European team bore this out, showing that both groups had developed kidney cancer as a result of their exposure to aristolochic acid.

The results prompted Grollman to turn his attention to Taiwan, where prevalence of this particular type of cancer was among the highest in the world, and where the use of herbs containing aristolochic acid was markedly high. A research project led by Grollman showed that the use of herbs containing aristolochic acids contributed significantly to the instances of kidney cancer and chronic kidney disease in Taiwan.

Today, herbs containing aristolochic acid are banned in the U.S., Canada, Australia and many European countries. The FDA identifies aristolochic acid as a "potent carcinogen and nephrotoxin," and authorizes its agents to confiscate products containing it. In 2002, the WHO's International Agency for Research on Cancer concluded that, "Herbal remedies containing plant species of the genus Aristolochia are carcinogenic to humans." The organization reaffirmed this conclusion in a 2012 evaluation incorporating new evidence that had emerged in the decade prior.

Grollman says that there are likely many more unidentified toxic compounds in TCM herbal remedies. "Of the 20,000 herbs [used in TCM], none of them have been properly tested for toxicity," says Grollman. "I use the example of aristolochic acid because it's such a well-documented example that even the Chinese have to accept it."

Despite the evidence, China's acceptance of aristolochic acid's toxicity has been lukewarm. The China Food and Drug Administration (CFDA) has restricted use of some, but not all, herbs containing aristolochic acid since 2003. A report published by the CFDA in 2017 found 47 TCM herbal products on the market in China containing the compound.

Aristolochic Acid's Contribution to Liver Cancers

A large-scale 2017 study found that aristolochic acid signatures were present in more than three quarters of liver cancer cases in Taiwan and nearly half of those in mainland China. The research suggests that, despite efforts to restrict access to the substance, significant portions of the population are still being exposed to herbs containing aristolochic acid.

Source: Science Translational Medicine

Grollman says that China's reluctance to fully acknowledge aristolochic acid's toxicity is due to implications this would have for the whole system of herbs currently utilized in TCM. "That's why they were so embarrassed by Aristolochia," says Grollman, "because none of those herbs are tested and you have no idea what else might be present there."

To Grollman and other critics of TCM, such as Donald Marcus of the Baylor College of Medicine, aristolochic acid is a cautionary tale embodying the dangers presented by more widespread adoption of the practice. They argue that time-tested remedies are not necessarily safe, despite a lack of documented harm during their long history of use.

"Their argument is that we have been using these things forever and haven't noticed any issues with them," explains Marcus, "but the problem is that the latency period for some of these effects can be quite long." To illustrate, he points to the clinical symptoms of kidney disease resulting from aristolochic acid consumption, which can remain latent for years or even decades.

"There is a self-fulfilling prophecy around saying that herbs aren't harmful, so you don't look for potentially harmful effects and don't attribute issues to the herbs," says Marcus. "Ricin comes from a plant. The toxicity of herbs can be severe and fatal."

Opium, the substance at the heart of one of the most severe health crises the U.S. has faced in decades, also comes from a plant. Between 1999 and 2017, nearly 400,000 Americans died from opioid overdoses, according to the Centers for Disease Control and Prevention. Nearly 70% of the record-setting 70,200 fatal U.S. drug overdoses in 2017 involved an opioid. Every day that year, an average of 130 Americans died from opioid overdoses.

The roots of this crisis were not, however, in any herbal remedy. Two decades ago, major pharmaceutical companies such as Purdue Pharma began aggressively marketing prescription opioid medications as safe, non-addictive painkillers. Won over by the companies' sales representatives, doctors began prescribing opioids such as OxyContin to millions of Americans, writing nearly 58 opioid prescriptions per 100 Americans in 2017 alone. More than 200,000 of the opioid overdose deaths in the past two decades involved prescription opioids. Between 8% and 12% of people prescribed these legal, FDA tested and approved medications for chronic pain relief develop an opioid use disorder, according to the National Institutes of Health.

Even pharmaceuticals used in strict accordance with regulator instructions are not without risks. The FDA issued 39 Class I recalls in 2017 alone, flagging these previously approved products with a reasonable probability of causing, "serious adverse health consequences or death." Baycol, a cholesterol-lowering drug, killed 52 people before it was pulled from shelves in 2001. ADHD medication Cylert was on the U.S. market for 30 years before the FDA withdrew approval for potentially fatal liver toxicity.

Few would argue that any of this discredits Western medicine, which has alleviated untold human suffering and is one of the foundational pillars of the modern world. It also does not address the concerns raised by Grollman and Marcus, who see herbal medicine's largely unregulated state as a serious and underrecognized heath hazard. It does, however, help explain why many people may turn to TCM in spite of these risks. Inundated with news of mainstream medicine's shortcomings, and often having experienced these themselves, some appear to see gambling on untested herbs as a comparatively palatable option.

TCM's rise to prominence has not been an entirely organic process. China has played a subtle but important role in the practice's modern renaissance, promoting its use through overt policy doctrine and, some critics allege, covert political maneuvering.

"Once Margaret Chan got into office about 10 years ago," Grollman says of the WHO's director general from 2006 to 2017, "the organization really began being strongly influenced by China."

The People's Republic of China embraces an explicit policy of promoting TCM both at home and abroad. The Chinese Communist Party (CCP) intends to create universal access to TCM services in their country by 2020, as well as "actively introduce TCM to the rest of the world," according to a 2016 white paper. One important benefit the CCP sees in TCM is its cost-saving potential. The paper states that 2015 outpatient per visit expenses at public TCM hospitals in China were 11.5% lower than general public hospitals, while in-patient costs per capita were nearly 25% less.

The Value of China's TCM Exports

Aside from the anomalous year of 2016, which saw China's overall lowest exports since the height of the global financial crisis in 2009, China's TCM exports have grown every year for the past decade.

Sources: U.S. China Economic and Security Review Commission, U.S. National Institutes of Health, China Daily, National Administration of Traditional Medicine of the People's Republic of China

While there is almost certainly also an economic component to the country's drive to promote TCM abroad — China exported more than $3.9 billion in TCM products in 2018 alone — the greatest benefit China may see is a rise in its soft power. Despite spending lavishly on soft power promotion, an average of $10 billion per year by some estimates, few efforts have produced near the international prestige boost that global adoption of TCM could provide.

The former head of the WHO, herself a native of Hong Kong, was rarely equivocal about her support for TCM. In one official speech to a group of TCM practitioners in Singapore, Chan said, "I am Chinese, and I have used traditional Chinese medicine throughout my lifetime. I have no doubt that these preparations soothe, treat many common ailments, and relieve pain."

Later in the same speech, Chan alludes to the placebo effect as an important component of the TCM process, saying, "Controlled clinical trials can evaluate the intervention of the herbal product, but not the full experience. Moreover, complaints of pain, anxiety, and stress nearly always have a subjective dimension. The placebo effect is a well-documented scientific phenomenon."

Chan's attitude toward TCM, viewed as both a remedy and placebo, mirrors that of China's leaders. Mao Zedong, who created the modern incarnation of TCM in the 1950s by unifying various local traditions throughout China and removing the more mystical elements from the practice, was reported by his personal doctor, Li Zhisui, to have not believed in it himself. Instead, Li held that Mao's promotion of TCM was born from political necessity and the desire to increase healthcare access among China's poor.

Regardless of his personal beliefs, it was during this period that Mao served as the architect of what would become one of TCM's greatest triumphs. In 1967, the Chinese leader commissioned a secret military project to develop new antimalarial drugs for use in jungle warfare. One of the research teams, led by pharmaceutical chemist Tu Youyou, was tasked with investigating possible cures within Chinese medicine. Artemisinin, and the process for extracting it from the raw Artemisia annua herb, were discovered by Tu and her team in a fourth century Chinese medical text. Tu's findings eventually enabled the development of cheap and effective antimalarial drugs based on artemisinin and its derivatives. In 2015, she became the first Chinese national to receive the Nobel Prize in Physiology or Medicine for her work.

Mao, like his counterparts today, also wanted to promote TCM to the outside world. During Richard Nixon's historic 1972 visit to China, first-lady Patricia Nixon was shown an acupuncture demonstration on a 68-year-old woman. The years following saw several highly publicized demonstrations to foreign doctors visiting China, including Isadore Rosenfeld's controversial account of an open-heart operation using only acupuncture as anesthesia. Then, as today, the acceptance of and support for TCM abroad was not only helpful for boosting China's cultural prestige, but was also useful as a domestic promotional tool. References to the WHO's support for TCM regularly appear in official Chinese media reports and can be found at several points in the 2016 CCP white paper.

By 2020, China plans to establish 30 overseas TCM centers to spread access to the practice and educate local populations on its uses. Most of these centers have already been built, in locations ranging from Morocco and Kyrgyzstan, to Ukraine, the United Arab Emirates and Austria. A majority are situated along countries included in the Belt and Road Initiative, China's massive infrastructure and investment program designed to establish transport and trade links through countries representing 65 percent of the world's population.

Despite the fact that many of these nations have little preexisting culture of TCM use, they make up more than half of China's total TCM exports. They represent the key proving grounds for China's ambitions to turn its traditional medicine into a global phenomenon.

Four hundred miles from Bangkok, in Thailand's northern reaches, sits the ancient city of Chiang Mai. Past winding alleys and dusty streets, removed from touristy pubs, eateries and massage parlors, the city's Chinatown bustles with the sounds of business. Dry goods, cheap plastic toys and clothing are wedged between food hawkers, tailors, mechanics and goldsmiths. The air is heavy with a strange mixture of gasoline, dust and fried food.

Not far from Warorot Market, a hive-like, multistory structure packed with merchant stalls of every sort, an unassuming storefront is hung with red paper lanterns. Inside lies Chiang Mai's oldest Chinese herbs shop, the Chip Aun Tong Dispensary.

Click above to take a look inside Chiang Mai's oldest TCM herbs shop, the Chip Aun Tong Dispensary.

The Chip Aun Tong Dispensary in Chiang Mai's Chinatown has a huge inventory of raw herbs and patent medicines, which it sells to many other local clinics. (Photo by James B. Cutchin)

X

The space is an eclectic mix of wooden shelves, glass display cases and various instruments for measuring, weighing and preparing TCM remedies. Colorful bottles of patent medicines compete for space with jars and bags containing various raw ingredients. The outside market smells are replaced with a scent somewhere between potpourri and dried seafood.

Near the back of the space, Ms. Wang, wife of the shop's in-house TCM doctor, Sheng Zhang Wang, sits pouring over a pile of accounting documents. Her son, the fourth generation of their family to run the Chip Aun Tong Dispensary, stands in a corner grinding herbs for a patient's decoction.

Wang says she has noticed the shop's TCM services becoming increasingly popular in recent years, particularly among foreigners. When asked why, she says that greater awareness of TCM's benefits among non-Chinese and improved quality standards within the industry have played important roles. She pauses for a moment before continuing.

"Of course, it also has to do with China's rise," she says as a rare smile creeps onto her face. "People respect China now, so they are more interested in learning about Chinese medicine."