Taiwan Today

Amother stews meat in an assortment of herbal medicines every week for her family and especially for her son, who is preparing for the senior high school entrance examination. She says the father of one of her son’s classmates, a practitioner of traditional Chinese medicine (TCM), recommends the dish as being able to boost “brain power.” Meanwhile, an experienced art designer says she seldom goes to Western medical doctors, even if she catches a cold, because she dislikes the kinds of medicine they prescribe. Instead, she prefers treatment from a doctor of TCM. Elsewhere, a young university graduate says he found an effective remedy for pain in his knees and back, injuries suffered during his compulsory military service, in TCM treatments such as acupuncture, cupping and massage. And then there is the case of a business owner who has turned to Chinese medicine to help him lose weight.

These individuals are just a very small slice of the diverse range of people in Taiwan who undergo TCM treatments for health-related concerns. Some 30 to 40 percent of Taiwan’s 23 million people seek medical help from TCM or opt for a mix of Western and Chinese treatments, according to Sun Mao-feng, chairman of the board of the National Union of Chinese Medical Doctors’ Associations and vice president of China Medical University Hospital (CMUH) in central Taiwan’s Tai­chung City, the first local institution to offer both Western and TCM treatment options. As of the end of 2009 and excluding dentists, there were around 43,000 doctors in Taiwan, with about 12 percent of them practicing traditional Chinese medicine. In 2010, patients could seek treatment from 16 hospitals wholly devoted to TCM, more than 3,000 TCM clinics—about one-third the number of their Western medical counterparts—and the TCM departments established at 80 of the approximately 500 Western medical hospitals around the country. Such departments have been set up at most of the national-level hospitals with teaching facilities, including Taipei Veterans General Hospital, which in 1990 formed its Center for Traditional Medicine, formerly a ward devoted to acupuncture. A number of TCM treatments are even covered under the National Health Insurance (NHI) program, launched in 1995, making Taiwan a forerunner in the incorporation of traditional medicine as an integral part of universal healthcare coverage. “Taiwan is truly pioneering in this regard and is even ahead of mainland China,” says Sun, referring to the place TCM originated.

While patients in Taiwan have long been willing to seek both Western and TCM treatments, doctors of the two disciplines have not always shared the same openness. In fact, for many years there was not much contact between the two medical traditions. That is beginning to change, however, and one recent sign of increasing connections between Western and traditional Chinese medicine was the 2009 inauguration of the Center for Complementary and Integrated Medicine at National Taiwan University Hospital (NTUH) in Taipei. The move is significant because since it was founded in 1895, the first year of half a century of Japanese colonial rule in Taiwan, the hospital has been considered one of the most prestigious in Taiwan and a bastion of Western medicine.

Offering Alternatives

For the time being, the new center offers only counseling services centered on the use of Chinese herbal medicines and tai chi chuan exercises, an ancient form of Chinese martial arts, in addition to information on other forms of alternative treatments such as music therapy or faith-based counseling. The center was inspired by three hospitals in the United States that specialize in treating cancer that NTUH leaders visited in 2007. They were impressed by the results of cancer treatment and pain relief achieved by the hospitals’ complementary medicine offerings. In the United States, the National Institutes of Health established the first Office of Alternative Medicine in 1991, which became the National Center for Complementary and Alternative Medicine in 1998. “Western medicine has yet to offer fully satisfactory cancer treatments and more often than not there are concerns over the side effects of its most effective therapies,” says Yu Chia-li, director of the Division of Immunology, Rheumatology and Allergy at NTUH and chairman of the hospital’s new unit for complementary care. “Medicine is a complicated thing that involves not just physical aspects,” he adds. “Despite its somewhat inadequate evidence base, traditional medicine would at least give greater mental support to patients, especially those suffering malignant diseases, and prepare them mentally for a more confident, pleasant treatment process.”

Yu, a professor in the Institute of Molecular Medicine at National Taiwan University, says TCM has a role to play, especially in treating cancer and chronic diseases as well as managing pain, where the effectiveness of Western remedies is limited. That role could be a crucial one in the future. According to the World Health Organization’s (WHO) Global Status Report on Noncommunicable Diseases 2010, chronic illnesses including cancer, heart disease and diabetes have reached epidemic proportions and become the leading causes of death worldwide, bringing about more deaths than all other causes combined. In 2008, 36 million people died due to noncommunicable diseases including cardiovascular diseases, diabetes, cancer and chronic respiratory diseases. The figure represents 63 percent of the 57 million deaths reported globally that year. The report, the first of its kind from the WHO, warns that, as the impact of such chronic diseases increases and as populations age, resultant annual deaths are expected to continue rising worldwide. As it happens, TCM doctors, including senior physicians Wu Cheng-hua and Lin Jaung-geng, who both trained at the CMUH-affiliated China Medical University (CMU), have served in Taiwan’s foreign medical aid programs for many years. CMUH’s Sun Mao-feng says that staff from his hospital and CMU, where Sun also teaches, have taken part in annual tours abroad to provide medical services.

Huang Jong-tsun, the president of CMU and a former minister of education, explains that while Western medicine aims at curing a disease, Chinese traditions emphasize ways to stay in good health, which he believes would be very helpful in preventing the health problems that are expected to rise in a rapidly aging society like Taiwan’s. “Chinese medicine treats not only the illness of a person but also the person who has the illness, so it’s easier to shape a good relationship between doctors and patients,” Huang says. “That human orientation can attend to different personal needs and help individualize therapies.” The university president notes that Chinese medicine can work in a way that does not interfere with Western medical treatments. He believes that an ideal integration of Western and Chinese medical traditions involves training doctors in both disciplines. Today, more than 2,600 doctors in Taiwan’s medical system hold certification in both Western and Chinese medicine, most of them graduates of CMU.

Established in 1958, CMU offered Taiwan’s only college courses in traditional Chinese medicine for decades. In 1998, it was joined by Chang Gung University in northern Taiwan’s Taoyuan County. TCM graduates train and are certified in both traditions, but must choose to practice either traditional Chinese or Western medicine. “Such doctors, even if they go into the Western system, have Chinese medicine blood running in their veins,” Sun says. “And that builds a bridge between the two traditions.”

Choice of Practice

The acupuncture specialist notes that in the past, most of the university’s TCM students eventually chose to practice Western medicine, “because Chinese medicine had yet to build sound training systems on the one hand, and because [TCM] held an inferior status compared with Western medicine on the other,” he recalls. In recent years, however, the proportion of graduates of CMU’s eight-year Chinese medicine program has been evenly divided between practicing TCM and Western medicine. This has occurred alongside domestic and global trends toward reexamining and recognizing traditional forms of medicine.

In the mid-1980s, CMU set up its School of Post-Baccalaureate Chinese Medicine in order to accept students who already had a degree in another discipline. The five-year program allows for certification as a TCM doctor only, although it still requires a considerable number of classes in Western medicine. A similar program at I-Shou University in southern Taiwan’s Kaohsiung City began recruiting students in 2010, while Tzu Chi University in eastern Taiwan’s Hualien City and Chung Shan Medical University in Taichung are planning to follow suit. The new TCM training programs can be seen as a response to the end of a special examination system that allowed self-taught or otherwise unrecognized TCM practitioners to be certified, regardless of their educational background, if they passed two rounds of tests. The ban, which was set to come into effect in June this year, ends more than four decades of the system that has produced more than 60 percent of all TCM doctors now practicing in Taiwan.

The changes are not without controversy, however, as there is a significant number of TCM students who do not have an officially recognized degree, but have passed the first examination under the old system. Such students now find themselves without any entryway into a recognized program, although they might have been studying TCM for many years. Hence, a number of these students are urging authorities to recognize their success in the first-round TCM exam as an alternative qualification that would allow them to take entrance examinations for the post-baccalaureate university programs.

With respect to medical services that draw on both traditions, Huang Lin-huang, chairperson of the Cabinet-level Department of Health’s (DOH) Committee on Chinese Medicine and Pharmacy (CCMP), considers a better model to be one in which a Western doctor and a traditional Chinese doctor treat a patient at the same time. Medical institutions using this model include Taipei City Hospital’s Linsen Chinese Medicine Branch and Taoyuan Chang Gung Memorial Hospital. CMUH offers outpatient services in which the patient consults two doctors, both of whom hold certificates in Western and Chinese medicine. “The two doctors are able to draw on their stronger expertise in one or the other tradition,” Sun Mao-feng explains.

Huang Lin-huang says that as TCM doctors are now given more input and professional recognition in Western medical systems, it is easier to find common ground between the traditions. “Two decades ago, a Chinese medicine doctor was not allowed to use even simple modern instruments like flashlights or blood pressure monitors,” he says. “Now they can do typical Western medical jobs such as interpreting the results of X-rays or biochemical tests.” By working together, Western and Chinese medical traditions can develop their own strengths and reinforce each other, Huang Lin-huang says.

For CMUH’s Sun Mao-feng, however, the usual labels of “Western” and “Chinese” medicine are misleading and should be replaced by the distinction between “modern” and “traditional,” or “classical,” medicine. He explains that modern medicine, which is a collective result of modern scientific developments, has incorporated contributions from Western and Chinese-speaking societies. On the other hand, traditional Chinese medicine has first and foremost been a philosophical system. “It seems that the latter has a veil of mystery about it,” Sun says. “But a willingness to understand and communicate on the part of a Western doctor, such as by reading the ancient texts on Chinese medicine, would remedy those ‘mysterious’ aspects.”

For his part, CMU president Huang Jong-tsun emphasizes that traditional Chinese medicine is now an interdisciplinary field that welcomes input from modern science such as the advanced technologies available in neurology, molecular medicine, biological engineering and medical imaging. Among other things, medical instruments have been developed to help with the typical TCM practices of feeling the patient’s pulse or examining the tongue.

The CMU president points out that the modern development of Chinese medicine and its integration with Western traditions require the research capabilities of major medical centers. That is a difficult task for TCM, given the decentralized state of TCM healthcare. “In contrast with Western medical systems that see a large number of doctors attracted to big medical centers, which thereby gain strength in medical research, [small] local clinics are the most active sector in Chinese medicine,” Huang Jong-tsun says. As of the end of 2009, slightly more than one-third of Taiwan’s Western doctors worked in local clinics, while the figure was nearly 90 percent for TCM doctors. On the other hand, the close connection of TCM doctors to local communities points to a unique social role they hold in Taiwan’s public health environment. Sun Mao-feng compares the healthcare services available at Chinese medical clinics at the grassroots level to the role of primary care physicians in Western family medicine. TCM doctors use few complex machines and they speak in terms such as “too much bodily heat” that can be readily understood by ordinary Taiwanese. “I hope that our Chinese medicine practitioners cherish their intimate relationship with people and the role they can play in public health and community medicine instead of just aspiring to achieve great fame,” Huang Lin-huang says.

Covering the Costs

Currently, payments for TCM services account for only around 4 percent of the NHI’s some NT$500 billion (US$17 billion) annual budget in Taiwan. With respect to traditional Chinese medicines, for example, the NHI covers only powdered concentrates and excludes other popular forms such as syrups, pills or slices of raw herbs ready for decoction. The DOH’s Huang Lin-huang says that the government plans to expand NHI coverage to include non-concentrated powdered herbal products.

The CCMP chairperson says that the government’s management of traditional Chinese medicines focuses on safety, quality and effectiveness, in that order. Taiwan’s herbal medicine manufacturers are required to pass a “Good Manufacturing Practices” standard, for example, that was put in place by the DOH and the Ministry of Economic Affairs in 2002. In addition, as more than 80 percent of Chinese medicinal materials come from mainland China, they were given a major section in the Cross-Strait Medical and Health Cooperation Agreement signed in December 2010 in Taipei. Among other things, the governments on both sides of the Taiwan Strait agreed to work together on building quality and safety standards, as well as on inspecting traditional Chinese medicinal materials for import or export. The agreement also allows for the establishment of mechanisms to communicate and cooperate on major events concerning the safety of traditional Chinese medicinal materials.

Sun Mao-feng says that TCM practitioners have a role in making their case to the government to fund more NHI payments for traditional Chinese medicines. TCM service providers must earn patients’ respect for the profession on the one hand and expand the evidence base of TCM’s effectiveness on the other, he says. During the past decade the CCMP has subsidized clinical trials of traditional Chinese medicines at 17 teaching hospitals in Taiwan among other efforts. Such scientific support is crucial for the modern development of TCM theories and practice, according to Yang Ling-ling, a professor at Taipei Medical University’s College of Pharmacy and director of CMUH’s Chinese Medicine Translational Research Center. She believes that traditional Chinese medicine offers a living legacy for healthcare and that Taiwan has its own strengths in this field such as the capability to process and prepare herbal materials to a medicinal standard. “Traditional Chinese medicine needs modern science and technology to unlock its full power,” says Yang, who is eager to see Taiwan help it play that role.

Write to Pat Gao at kotsijin@gmail.com