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— updated 1998-01-19
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— updated 1998-01-19
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Dilemmas in regulating the practice of Chinese herbologyAmerican herbalists' realpolitik, essay #4. Regulatory problems in distinguishing Chinese herbal medicine (TCM) and Ayurveda vs. western herbalism. An exploration of problems arising from attempts to over-regulate herbal practice, including a general decline of common sense, abuse of power by regulatory institutions, and the rise to power of corporate and professional monopolies. by Roger W. Wicke, Ph.D. |
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IntroductionThe American public has greatly increased their use of herbal products in the last decade, and this trend shows every sign of continuing. Along with increased usage comes concern about product quality, potential toxicity, and professional regulation and certification of herbalists. This report discusses several of the issues that regulators must consider, specifically regarding the practice of traditional Chinese herbology in the United States. Freedom of choice vs. protection from dangerous substancesMost legislation governing the delivery of health care is enacted in the hope of increasing the quality of health care for the general public. Yet the quality of health experienced by the public is dependent both on professionally delivered care and on the ability of individuals to make intelligent decisions for themselves in the areas of diet, sanitation, avoidance of environmental toxicity, and lifestyle habits. The latter requires the unrestricted availability of information, guaranteed by the First Amendment. The use of herbal products historically has fallen somewhere in between the realm of lay knowledge and professionally administered services. The use of herbal products such as cocaine, opium, and belladonna have often been restricted to use by health professionals because of the obvious dangers of side effects, including addiction. Herbs such as cinnamon, ginger, garlic, mint, fennel, cloves, and chili pepper (all of which are entries in the official Chinese materia medica) are common table spices, unrestricted in their use, even though excessive amounts of garlic may cause insomnia in certain individuals, prolonged and excessive usage of chili peppers may lead to ulcerative colitis, and prolonged and excessive use of ginger or cloves may lead to urethritis and cystitis. However, cultural familiarity with these herbs and spices usually leads to prudent usage. Other herbs, such as nutmeg, have been shown to be hepatotoxic and mildly hallucinogenic, but because of cultural traditions are generally used in only small amounts a few times each year; American cooks would become outraged if their supplies of nutmeg at Christmas and Thanksgiving were restricted. The absence of a sense of proportion in public policy frequently leads to uproars over potential hazards newly discovered in some herbal product such as comfrey, which contains small amounts of hepatotoxic pyrrolizidine alkaloids. However, the potential damage from such mild toxicity cannot possibly compare with that of ethyl alcohol; alcohol has wrought irreparable damage to millions of livers, yet can be consumed in private without restraint because it is socially acceptable to many. Clearly, any legislation regulating the use of "herbs" must distinguish between specific herbs with potent, addictive, or otherwise dangerous properties, and herbs that can be safely used under most circumstances when consumption is kept within culturally determined norms. The official Chinese materia medica contains several thousand plant, mineral, and animal products, collected from around the world. A few of these products are toxic or dangerous and require special knowledge for their safe use. Most, however, are herbs comparable in hazardousness to cinnamon, ginger, garlic, mint, fennel, cloves, and chili pepper. Any regulation that attempts to restrict the use of "Chinese herbs" will lead to the absurd conclusion that these latter herbs must be restricted in usage by the general public. Because there is much overlap between what are considered Western herbs and Chinese herbs, any legal distinction becomes impossible and meaningless. The Canadian government has recently issued guidelines that acknowledge distinct classes of herbal products •[1]•:
These guidelines emphasize development of voluntary professional and ethical standards and a common-sense approach toward herbal products that have a long history of traditional usage. Historical background of the practice of herbal methods in China and other countriesThroughout history, lay people have traditionally used herbs and spices not only to season food but to improve and maintain their health. In China, most lay people, including rural laborers are familiar with the 100 to 200 herbs in the Chinese materia medica that comprise the overwhelming bulk of ingredients (95% or more) in most traditional herbal formulas. They are also familiar with the basic terminology used by traditional Chinese herbalists to choose herbs and herbal formulas. Consequently, most Chinese extended families have at least several family members who are knowledgeable in the use of simple herbal formulas for common family health problems. Herbs are frequently added to food recipes with the specific intent of improving the health of certain family members. During the 1930's and 1940's, before the takeover of the country by the Communists, the Nationalist government under Chiang Kai Shek sought to restrict and eventually eliminate the use of traditional Chinese herbs. The first step taken by the Nationalist government was to require registration of all practicing Chinese herbalists. They were then required to study and pass examinations in the use of Western medicine, and just before 1949, these doctors were increasingly restricted from using Chinese herbs in their practices. Fortunately, the strong extended family tradition in China provided a safe haven for herbalists continuing to practice; most rural herbalists ignored the official government restrictions. During the Communist Revolution, Mao Ze Dong himself was treated by traditional Chinese doctors. After the revolution, he restored traditional herbal practice and established it as the major health care system of China, to be supplemented by Western methods when herbs and acupuncture were inadequate. In spite of the atrocities committed by Mao during the revolution, his health reforms to restore traditional practices were widely supported; in addition, he realized that Western-style health care would quickly bankrupt the fragile Chinese economy. To this day, the Chinese health care system heavily relies upon lay knowledge of the use of herbs to handle basic family health care problems. Rural people are channeled through a hierarchy of progressively more experienced practitioners if their problems cannot be handled by family or "barefoot doctors", which are comparable to paramedics in the U.S. In many other areas of the world where traditional cultures are relatively intact, herbal knowledge is shared by a wide variety of people, from mothers, lay herbalists, to specialists in herbal medicine. The lesson from these other cultures for the United States should be to encourage knowledge of basic health care, including herbs, at all levels to improve overall health and to reduce costs. If people lack knowledge or experience, the remedy is not to restrict them further, but to educate them. According to Thomas Jefferson: I know of no safe depository of the ultimate powers of the society but the people themselves: and if we think them not enlightened enough to exercise their control with a wholesome discretion, the remedy is not to take it from them, but to inform them. Rather than declare chili pepper to be a restricted substance due to its hazards (since it can lead to ulcerative colitis if used in excess over prolonged periods), it would seem much better to promote common sense and knowledge among lay people rather than to burden government with monitoring yet one more aspect of private behavior. Government can promote such common sense best by encouraging the free flow of information about herbs and by actively dispensing information to the public when it deems necessary. Relationship between the practice of traditional Chinese herbal medicine and acupuncture in ChinaTraditional Chinese herbal practice and acupuncture share a common theoretical and philosophical framework. They both utilize a common system of categorizing differences in patterns of a body's response to everyday stresses and environmental conditions. The unique way in which each individual responds to such changes determines the best method for maintaining and improving one's health. Certain individuals may react to certain foods or types of weather by feeling sluggish and fatigued, yet other individuals may feel energized by these conditions. The way in which individuals respond differently to the same circumstances allows one to match these patterns of responses to various body types, much as an athletic trainer would tailor a program to an individual's body type and goals. The rules and traditional guidelines for choosing specific herbs and acupuncture points, while they may become very detailed, are based upon common-sense distinctions. However, the rules and guidelines for traditional Chinese herbology are unique to that discipline; an acupuncturist would not be able to choose herbs using the body of knowledge about acupuncture points, locations, and needling techniques, etc. To illustrate how such rules work, consider the following example. Most Americans who have had watermelon know that it tastes good and relieves one's thirst on a hot, dry summer day. Yet this watermelon will not seem nearly as good when one is shivering during a cold rain and is not thirsty. Likewise, any mother will know that prune juice may relieve certain types of constipation, and that one would not want to drink it in cases of diarrhea, regardless of how much iron it is reputed to contain. These examples may seem trite, but reveal the absurdity of insisting that we should call upon licensed health care practitioners to help us decide when to eat watermelon and drink prune juice. In the traditional Chinese herbal system, the decisions of when and when not to use specific herbs are based on numerous common-sense criteria such as these. Because the technique of acupuncture involves the insertion of needles into the body, it requires specialized training to avoid damaging body tissues and organs. Historically, it has generally been practiced by a professional class for this reason. Herbs, however, have been used by a much wider variety of people, because the technique of administering herbs is extremely simple: cooking in water and drinking. The physiological consequences of consuming a poisonous plant, while potentially deadly, have been a necessary aspect of human survival since the beginning of our species. Humans have learned to pay attention to their physical and mental reactions to foods and plants both to avoid poisons and to detect beneficial effects of herbs in improving health. The dilemma faced by every government regulator of herbal products is that to restrict the use of non-poisonous and potentially beneficial herbs invades a basic and deeply ingrained aspect of human existence. It is as if government had decided that citizens were no more competent than three-year-olds whose every bite were monitored and controlled by their parents. Chinese herbal methods, while sharing a common philosophy of health with traditional acupuncture, require learning an independent body of knowledge. A traditional acupuncturist without specific training in herbal methods would be at as great a disadvantage as an herbalist attempting to perform acupuncture without specific training in this latter discipline. In China, the two professions are often practiced independently; acupuncturists-only, herbalists-only, and acupuncturist-herbalists are all frequently encountered. According to the National Commission for the Certification of Acupuncturists (NCCA) •[2]•, acupuncture and herbology represent distinct and independent bodies of knowledge:
The regulatory difficulties in distinguishing "Chinese" herbal practice from other types of herbal practiceChinese herbology is not unique in its philosophical emphasis upon recognizing individualized, whole-body patterns and modes of reacting to environmental conditions, foods, and herbs. Ayurveda, Unani, and ancient Greek Hippocratic medicine all incorporated methods for differentiating body types, or "constitutional" types, and tailoring choice of foods and herbs to the unique needs of each individual. All these systems recognize that to best promote improved health in a specific individual, herbal formulas must be tailored to the individual. What may enhance one person's physical potential and improve health may not work in the same way for another person. Traditional Chinese, Ayurveda, Unani, and ancient Greek herbal methods, like many indigenous herbal traditions, share a common philosophy based on observing the perceptual reactions of a person on taking an herbal preparation. The following rule applies in all these traditions: "If taking it consistently enhances your whole-body sense of well-being, it is probably beneficial; if you experience persistent discomfort, you should consider that it may be inappropriate for you." Just as in the examples of a person deciding whether to take prune juice or watermelon, described previously, paying attention to the physical results and our perceptions will lead to prudent usage of most herbal products. Most of the mishaps involving herbal products arise from using a product persistently in spite of clear side-effects. If only people would be educated to pay closer attention to their physical sensations, they might avoid over 90% of these mishaps, such as the reported cases of prolonged ingestion of cayenne pepper leading to ulcerative colitis. In such cases, an individual who consumes such quantities of cayenne will have noticeable discomfort long before a medical crisis arises. All the systems of herbal practice (traditional Chinese, Ayurveda, Unani, and ancient Greek herbology) which are based on such whole-body patterns of perceptual awareness have the potential for promoting common sense in the use of herbal products. Because the Chinese materia medica includes herbs from around the world, legally distinguishing "Chinese" herbs would be practically impossible and logically meaningless. Where an herbalist's inventory is originally grown is not a sensible criterion for creating legal distinctions between different types of herbal practice. While it might seem possible to distinguish Chinese herbal methods from other traditional systems by the form of the thought processes involved and the practical criteria employed in choosing herbal formulas for individual body types, this becomes more an issue of linguistic distinction than a practical one. Ayurveda, Unani, and ancient Greek methodologies are all similar to traditional Chinese herbology in their focus on whole-body patterns and categorization of physiological responses to herbal preparations. While each system may have different terminology to describe particular phenomena, the concepts employed in one system will also be relevant to making decisions in each of the others. Thus, to define a type of thought process, rather than the terminology, as unique to Chinese herbology would be erroneous. Because the basic ideas underlying all these traditional methodologies of herbal practice are similar, an herbalist in any of these traditions would enhance his or her skills by studying the knowledge of the other systems. To arbitrarily pass regulations compartmentalizing each tradition, to prohibit a Chinese herbalist from claiming to practice "Ayurveda", and to prohibit an Ayurvedic herbalist from claiming to practicing "Chinese" herbology would be unfounded, since the underlying thought processes are similar even though the technical terminology from each tradition is different. While it is in the interest of everyone that herbal practitioners inform clients honestly and accurately of the nature of their training and experience, it would not serve the public to arbitrarily pigeonhole herbalists into legal categories based on their original training, since this tends to discourage cross-fertilization of knowledge. It would seem in the public's interest that knowledge from each tradition be freely used by herbalists whose highest goal should be to help their clients to the best of their ability. Cultural isolation and compartmentalization are inimical to this goal. Historical abuses of monopoly medical licensureAccording to the National Commission for the Certification of Acupuncturists (NCCA), the value of licensing herbal practice has been a hotly contested issue •[3]•: Certification began as a compromise between those who supported licensure and those who wished to abolish licensure because it was all too frequently used, not to protect the public as was its aim but rather to protect the practitioners by erecting ever higher standards in order to limit the number of practitioners. Frequently these 'higher' standards proposed by professionals were more related to turf protection than to competency to practice. One proposal which would avoid the abuses inherent in monopoly-licensure systems is to promote voluntary certification. Upon learning that a certifying agency has established practical standards of quality, members of the public may choose to patronize only such certified practitioners. However, if the certifying agency succumbs to political favoritism, bribery, or other questionable or fraudulent practices, individuals have immediate recourse in their ability to freely choose or to not choose which health practitioners and professional groups to patronize. The widely varying traditions and methods of using herbal products in America would naturally incline a just and equitable government to promote standards of quality among all herbal methodologies without allowing monopolization by any special interest group. During the Middle Ages, the herbal tradition of Europe was effectively destroyed by the Catholic Church •[4-7]• by:
Government standards for professions can become a double-edged sword: the power to enhance quality of health care and protect the public has frequently transformed into a tool of oppression and destruction. A Chinese legend tells of an eminent and talented physician of the Tang Dynasty named Zhong Kui, who aspired to pass an examination to serve in the Imperial bureaucracy as a court physician. •[8]• Examiners of these times were often corrupt and expected bribes. Zhong failed to pay such a bribe, and after several attempts at passing the exam, committed suicide on the steps of the imperial palace in protest. Shortly thereafter, the emperor was afflicted by feverish dreams of a terrifying demon. Zhong Kui then appeared to him in one of these dreams and chased away the demon, curing the emperor of his nightmares, after which the emperor had Zhong Kui designated as the "Great Chaser of Demons for the Whole Empire". In the United States, individual freedom and eternal vigilance must act in the stead of Chaser of Demons Zhong Kui. The disadvantages and dangers of restricting the practice of herbology to a privileged special interest group far outweigh any possible benefits to the public. To control and restrict access to a wide variety of plant products that have long enjoyed traditional usage and are well tested by experience would violate the common sense and historical experience of herbal traditions around the world. The English people during the rule of King Henry VIII felt so strongly about their right to freely use herbal remedies that the King was moved to make a declaration that lay herbal practice should remain free from restriction or licensure throughout the kingdom •[9]•. The text of this document vividly describes the attempts of the medical profession to monopolize health care for economic gain and prevent poor people from obtaining inexpensive herbal remedies. King Henry's decree stands in striking contrast to the centuries of repression of herbal traditions in Europe by the Church of Rome. Since the time of King Henry VIII, British laws rarely prohibited unlicensed practitioners from offering basic health services, including the providing of herbs for maintaining health; usually, legal penalties applied only to individuals misrepresenting their professional status and training •[10]•. The control of approved practice was left by Parliament to voluntary professional bodies. The relative lack of regulation of medicine during the first 100 years after U.S. independence led to a proliferation of medical philosophies and methods, some of which were drastic, toxic, and occasionally deadly. Prolific use of leeches to bleed patients, jalap (ipecac) to induce violent purgation, and the use of toxic compounds such as calomel (mercurous chloride) were popular among "Regular" physicians. Benjamin Rush, the first American Surgeon General, advocated the use of all the foregoing remedies •[11]•. Other groups of physicians recognized the dangers of such methods and advocated safer techniques, including the use of herbs, diet, and homeopathic remedies. Ironically, those physicians who were labelled as the "Regulars" by medical historian Richard Shryock, accused the Botanic physicians and Homeopaths of "Quackery". In retrospect, regardless of whether the remedies of the latter groups were effective, it is probable that they inflicted considerably less damage upon their patients. The public, overwhelmingly preferring the services of the Botanics and Homeopaths, deserted the Regulars •[12]•. In retaliation and in a desperate attempt to preserve their economic status, the "Regulars" lobbied state legislatures to place increasingly onerous restrictions upon botanical and homeopathic practitioners. The public was outraged by these restrictions, refusing to support any monopoly of practice by the Regulars. During the early 19th century, State legislatures, one by one, began to repeal such restrictive legislation •[13]•. Recognizing that a more subtle approach was necessary, the Regulars formed a national professional association to support their goals, the American Medical Association (AMA). Instead of dealing with state legislatures, the AMA chose to focus its efforts on influencing medical school curricula. It established standard curriculum for medical schools that prohibited the study of botany and botanical medicines. The U.S. medical schools that continued to emphasize plant pharmacology and natural remedies were blackballed by the Flexner Commission of 1909 to 1910, leading to a cutoff of funding from the Rockefeller and Carnegie Foundations, which heavily funded the Regular (allopathic) medical schools. Botanically-oriented medical schools were forced to close their doors. As botanical physicians and homeopathic practitioners died, none took their place, effectively destroying these professions until the recent resurgence of interest in herbs among both health professionals and lay people •[14]•. Today, in spite of the public's demand for herbal products and the pharmaceutical industry's continued derivation or extraction of up to 50% of all pharmaceuticals from plants, U.S. medical schools have eliminated the study of botanical medicines from the curriculum. Many medical schools in Europe, however, do offer such training, including those of Switzerland, Germany, France, and Great Britain. Conclusion: Avoid professional monopolization of herbal practice to protect the public.In considering appropriateness tests which might be applied to licensing of a profession, the mere economic convenience to the profession should not be a factor. The New Jersey Professional and Occupational Licensing Study Commission, which according to the U.S. Department of Health, Education and Welfare •[15]•, "may provide a useful model for State licensing studies," uses the following guidelines for deciding the merits of licensing particular groups •[16]•: Their unregulated practice can clearly harm or endanger the health, safety and welfare of the public and when the potential for harm is easily recognizable and not remote or dependent upon tenuous arguments; The historical record reveals the severe destruction that professional monopoly interests can wreak upon valuable knowledge traditions. While the health professions should be encouraged to voluntarily improve the standards of practice among their members, licensure legislation that creates a de facto monopoly of herbal practice by a special interest group (acupuncturists, physicians, or other health professionals), is neither in harmony with international consensus nor with the lessons of history. Rather, voluntary professional associations can effectively promote standards of quality without denying the freedom of choice that is essential to protect the public from institutional abuses. References
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