Why China’s traditional medicine boom is dangerous

皇后

本文选自 The Economist


FANG YUAN gazes around his crowded shop and says happily that business is booming. He has a reliable supplier in Russia and hospitals and pharmaceutical companies are queuing up to buy what he sells: antlers. Tangles of them lie in huge meshes on the floor. Thousands more, sliced into discs, fill glass boxes. They are used to treat breast disease in traditional Chinese medicine (TCM). The shop looks a bit like a Scottish baronial hall. Deer-head trophies gaze down from the walls, as does a red-fronted gazelle with black horns like scimitars. “I don’t sell those,” he says hastily. “Endangered list.”


Mr Fang is a trader at the world’s largest market for TCM, a system of diagnosis and treatment that goes back 2,500 years. The scale of the business is staggering. The small town where the market is located, Bozhou, is three hours drive from the nearest railway station. Yet the main market (pictured) is the size of a football stadium. Mr Fang is one of almost 10,000 traders—four times as many as there are shops in the colossal Mall of America in Bloomington, Minnesota.


They sell every medicinal ingredient imaginable. There are chips of agarwood, smoke from which is said to clean the lungs. There are dried frogs, gekkos and deer penis which, dissolved in alcohol, supposedly aids recovery from athletic injuries. And there are boxes of Tibetan caterpillar fungus or “the Viagra of the Himalayas”, a gram of which can sell for more than the same weight of gold. This is the market that sets prices for Chinese herbal medicine throughout the country. Before 9am its sampling room is overflowing with wholesale buyers.


The market in Bozhou is both a symbol of an extraordinary boom in TCM, and a consequence of it. The number of hospitals offering TCM in the country of its birth (either by itself or in combination with regular medicine) grew from roughly 2,500 in 2003 to 4,000 at the end of 2015. Since 2011 the number of licensed practitioners has increased almost 50% to 452,000. Around 60,000 TCM medicines have been approved by the government’s food and drug regulator. These account for almost a third of China’s pharmaceutical market, the world’s second largest. In 2015 patients made 910m visits to TCM hospitals and doctors, which, the government said, accounted for 16% of total medical care, up from 14% in 2011.


It has been a stunning resurgence for a practice that was rejected as superstitious after the fall of the Qing dynasty in 1911. TCM is still regarded with deep suspicion by Western-trained doctors and scientists. It has developed partly because of huge demand for preventive medicines that people believe will help avoid the need for more expensive treatment in hospital. And for some, acquiring the costliest TCM products such as caterpillar fungus has become a status symbol. “In the past few years,” says Li Ning of Kang Mei Medicine, a large health-care company, “there has been wider recognition [of TCM] because people have more money in their pocket and care more about their well-being.”


TCM has also benefited from the attention paid to it by Xi Jinping, China’s president. Mr Xi calls it “the gem of Chinese traditional science” and says he uses it. “TCM is in its golden age,” he claims. He urges practitioners to “push for TCM to step onto the world stage”. Since 2012, the year Mr Xi came to power, the Communist Party has been insisting that traditional medicine be made equal in status to what China calls “Western medicine” (ie, the modern form). Since then, the government has issued a stream of plans, policies and instructions aiming to make it readily available to everyone in China by 2020.


Early in 2016 the government published a blueprint for developing TCM over the next 15 years. Traditional medicine, it said, should have equal status in law with modern medicine; it should also be regulated like other types. A “white paper” issued at the end of last year said TCM would play a big role in reforming the health-care system because of its relatively low cost.




Then, in July, came China’s first TCM law, which lays down safety standards for TCM drugs and the ingredients that go into them. It imposes controls on farms which grow medicinal herbs (banning certain fertilisers, for instance) and on medical manufacturers which produce TCM pills. It also loosens some professional requirements. In the past, TCM doctors had to qualify as conventional doctors first and then be licensed for traditional medicine. The new law makes it possible to become a licensed TCM doctor by passing local exams in practical skills and getting recommendations from two others with licences. Some health professionals worry that this opens the door to more quackery.


Its proponents respond that TCM can improve both public health and the health-care system. Traditional medicine relies on herbal and other natural remedies, not expensive diagnostic machines. According to the white paper, average inpatient expenses per visit at public TCM hospitals were 24% lower than at general public hospitals; outpatient expenses were 12% lower. If TCM is as effective as Western medicine—a big if—then it would appear to be an efficient means of improving health.


But evidence that TCM works is scanty. Clinical trials in scientific journals have reported some examples of effective TCM treatments, for example against migraines and obesity. They have found some cases where TCM works well in combination with Western medicine, for example, in treating schizophrenia. However, the overall record is poor.




America’s National Institutes of Health looked at 70 systematic reviews of TCM treatments. In 41 of them, the trials were too small or badly designed to be of use. In 29, the studies showed possible benefits but problems with sample sizes and other flaws meant the results were inconclusive. Shu-chuen Li of Newcastle University in Australia found that only a quarter of the studies he looked at showed some benefits, but most of these were marginal.

One aspect of TCM that may be of some help is its focus on prevention rather than cure, says Martin Taylor of the World Health Organisation’s mission in Beijing. TCM doctors aim to see their patients often, partly because the remedies they offer are supposed to be tailored to the individual and need fine-tuning. An axiom of TCM is that good doctors cure diseases before they appear.

As a result, more attention to traditional medicine implies more attention to primary health care, which is best able to monitor the progress of patients with lifestyle-related ailments (such as obesity) and the diseases of ageing. Though a middle-income country, China has the disease burden of a rich one: non-communicable diseases such as heart disease and diabetes cause 85% of all deaths. If TCM doctors can suggest better diets or persuade the half of adult men who smoke to give up, then they could make a big difference.

A government document called Healthy China 2030 says that without better primary services, the health-care system will not be able to keep up with the demands of the ageing population. But an acute shortage of general practitioners is a huge impediment. Even a patient with a minor ailment usually goes to see a specialist. This adds both to costs, since consultations with such doctors are expensive, and to horrible overcrowding in hospitals. The government would like more people to visit local clinics instead. But many people are reluctant to see GPs, regarding them as inferior to specialists. They might, however, be willing to go to a TCM clinic. Opening more of them could offer some relief to the hospital system.

When administered with caution, TCM can sometimes help people, at least as a placebo. But China’s efforts to promote it as an equal of conventional medicine are fraught with danger. They could result in even more patients with serious illnesses shunning regular treatments in favour of traditional ones. They could also pose an even greater threat to rare species that are often—despite bans on their use—turned into TCM drugs. To reduce such risks, big reforms are needed in the way China manages TCM.

Far tighter controls on the use of animals and plants are needed. According to Meng Zhibin of the Institute of Zoology in Beijing, 22% of the 112 most commonly used natural ingredients for TCM are on various endangered-species lists. Some are from herbs that can be grown on farms, but some are from rare animals that are usually captured and smuggled into the country. Trade in pangolin, an anteater, is banned worldwide. But Wang Weiquan of the Chinese Medicine Association says smuggling continues because domestic pangolin farms are not big enough. TCM proponents do not seem to care. They worry about the future of traditional medicine itself. Wen Jianmin of the Wangjiang TCM hospital in Beijing says the ban on the use of some animals has already led to the extinction of some famous traditional remedies. “If we don’t protect TCM better, Chinese medicine will exist only in name,” he says.

The government also needs to improve safety standards. One example: a genus of plants called aristolochia, used against arthritis, turns out to be carcinogenic. But the government’s desire to improve safety implies more standardisation, and that contradicts the TCM belief that each treatment should be custom made. In 2016 the food and drug regulator revoked 81 licences of TCM makers. Yan Xijun, of Tasly group, a medical firm, says that of TCM pharmaceutical companies that do have licences, “it’s fair to say 50-60% of them more or less have problems that need solving.”

Training TCM doctors in modern medicine would also be a huge help. The government says that traditional medicine should complement the normal kind. That will require doctors who are skilled in both types and who can advise patients when they should be using modern methods of treatment. However, few TCM doctors in China can straddle the two disciplines. The new law, which relaxes requirements that they understand medical science, is a step in the wrong direction.

The long-term goal should be to establish a health-care system that relies on modern medicine and that provides the kind of preventive treatment that TCM claims to offer. The government is exaggerating TCM’s effectiveness. Use of it is so widespread in China partly because few are willing to challenge the science behind it. TCM is distinctly Chinese—to question it is often construed as unpatriotic. Striving for modernity while clinging to tradition is a familiar struggle in China. As the problems of TCM show, achieving the right balance is harder than it looks.

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到底大部分中药是否有效？？？

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这也是最近纽约时报上的文章
中国阿胶需求巨大，非洲驴遭殃RACHEL NUWER2018年1月3日

在非洲，被偷走、被剥皮的驴

[size=0.875]为了满足对阿胶的需求，中国公司开始从发展中国家购买驴皮。非洲是这项贸易的中心，驴皮交易带来的偷窃和虐待动物行为给当地人造成了恶劣影响。RACHEL NUWER

[size=1.125]肯尼亚内罗毕——“就是这里，”莫里斯·恩杰鲁(Morris Njeru)俯视着一片纵横交错的农田说。前不久，他在这里找到了戴维(David)、姆库里诺(Mukurino)和斯科莱奇(Scratch)血淋淋的尸体。它们是他最后的几头驴。

[size=1.125]现年44岁的恩杰鲁是一名市场搬运工，靠自己养的牲口在这座城市里到处送货。今年早些时候，他已经失去了五头驴。窃贼每次都是割开驴的喉咙，从脖子以下剥皮，把驴肉留给兀鹫和鬣狗。

[size=1.125]四个月后，恩杰鲁能找到的只有一只驴蹄。他把它装进衣服兜里，当作纪念。

[size=1.125]恩杰鲁曾经舒适的生活也几乎没留下什么痕迹。没有了驴，他的收入从每天近30美元骤降到不足5美元。他无力再偿还为租一小块房产而欠下的贷款，还担心不得不让孩子从寄宿学校退学。

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[size=1.125]“我的生活彻底变了，”他说。“我靠这些驴养活一家人。”

[size=1.125]对恩杰鲁和全世界其他数以百万计的人来说，驴是食物、水、柴火、商品和人的主要运输工具。但在中国，他们还有另一个用途：生产阿胶。阿胶是一种传统药物，由经过熬煮的驴皮中提取的明胶制成。

[size=0.8125]住在内罗毕郊区的莫里斯·恩杰鲁去年失去了八头驴和维持生计的工作。那些驴只剩下一只驴蹄，被他留作纪念。 RACHEL NUWER

[size=1.125]阿胶一度主要用于补血和平衡阴阳，但现在却被用来治疗一些疾病，从延缓衰老和增强性欲到治疗化疗的副作用和预防女性不孕、流产和月经不调。

[size=1.125]阿胶已经存在了几个世纪，但它在现代的人气增长始于2010年左右。当时，中国最大的阿胶制造商东阿阿胶等公司开始进行大规模的广告宣传。十五年前，中国的阿胶售价为每磅九美元（约合每公斤130元人民币）。现在的售价约为400美元一磅（约合每公斤5700元人民币）。

[size=1.125]随着需求增加，中国的驴只数量——一度为全世界最多——从1100万头减少到不足600万头。一些人估计可能只有300万头。事实证明，增加驴只是一项颇为困难的任务：驴不像牛或猪，不适合密集繁殖。母驴一年只产一只驴崽，并且容易在有压力的情况下自然流产。

[size=1.125]因此，中国公司已经开始从发展中国家购买驴皮。总部设在英国的非营利组织“驴庇护所”(Donkey Sanctuary)去年发布的一份报告显示，全球4400万头驴中，每年大约有180万头因为制造阿胶被杀。

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[size=1.125]“中国对阿胶的需求巨大，且没有减弱的迹象，”该组织的快速响应与活动经理西蒙·波普(Simon Pope)说。“因此，驴像被用吸尘器吸走了一样，离开了依赖它们的人群。”

[size=1.125]北京林业大学的研究人员在11月警告说，中国对阿胶的需求可能会导致驴“成为下一个穿山甲”。

[size=1.125]“中国选择花高价从世界各地进口驴，这可能会导致世界其他地区的驴面临潜在的危机，”相关研究人员在《马兽医杂志》(Equine Veterinary Journal)上写道。

[size=0.8125]随着对阿胶的需求增加，中国驴只数量从1100万头减少到不足600万头。阿胶本质上是驴皮中的明胶。WENG LEI/IMAGINECHINA, VIA ASSOCIATED PRESS

[size=1.125]从吉尔吉斯斯坦到巴西再到墨西哥，进入中国的驴皮来源各异。但非洲仍是这项贸易的中心，无论是从被杀驴只数量还是对当地的影响来说。

[size=1.125]“2016年，驴的生意爆发，”坦桑尼亚靠近肯尼亚边境的蒙杜利地区警司奥巴西·恩古维拉(Obassy Nguvillah)说。“越来越多的人带着驴进入马赛地区，并把驴送到中国人开办的加工厂。”

[size=1.125]恩古维拉负责看守的村庄艾斯拉雷坐落在饱受干旱困扰的广袤热带稀树草原上，村民们一年内就丢了将近475头驴。警方追踪窃贼到灌木丛中找回了175头，但认为其余的都被卖给了屠宰场。由于无力购买替代的驴只，驴主们至今不知该怎么办。

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[size=1.125]“现在因为我们的交通工具，我们的驴子，都不在了，我们都不开心，”卡塔西·莫科(Katasi Moko)说道，她只剩下一头毛驴，另外四头都被偷了。

[size=1.125]还有五头驴的时候，莫科每天可以完成两件事情：比如去遥远的水井打水或者去拾柴。但只剩一头驴，她只够时间做一件事，因为需要来回好几趟。

[size=1.125]“我们的工作量增加了，”她说。

[size=1.125]十四个非洲国家与巴基斯坦一同实施了各种各样的禁令来禁止国际驴只贸易。坦桑尼亚在六月也加入了这个名单，理由是担心如果继续屠杀，国内的驴很快就会彻底消失。

[size=1.125]艾斯拉雷的村长利莫内·山布里(Rimoinet Shamburi)表示，自禁令发布后窃驴事件已在减少，但并未完全消除。他认为这要归咎于肯尼亚的合法贸易。

[size=1.125]“事情还是很糟糕，因为内罗毕有一个支持偷驴的产业，”他说。

[size=1.125]和坦桑尼亚不同，肯尼亚的驴皮贸易没有放缓的迹象。2016年的驴皮价格是2014年的50倍，活驴价格从60美元涨到了165美元，涨幅近三倍。

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[size=1.125]根据政府的一份备忘录报道，肯尼亚的三个屠宰场——均为中国人所有或与中国人合作——两年内处理的毛驴将近10万头。驴皮和驴肉均被运往中国，一般途经越南或香港。

[size=1.125]还有17个毛皮贸易商开设了商店，大多开在内罗毕，并且据说第四个屠宰场也正在筹备。屠宰场主人坚称自己通过创造就业，花高价收购没有用的驴只，正在使这个国家变得更好。

[size=0.8125]肯尼亚的金牛屠宰场。虽然驴只交易的禁令减缓了这个行业在一些国家的发展速度，但在没有禁令的肯尼亚，对驴皮的需求没有减少的迹象。 RACHEL NUWER

[size=1.125]“这个产业帮助了那么多人，”奈瓦沙璀璨明星毛驴出口屠宰场(Star Brilliant Donkey Export Abattoir)的负责人约翰·卡里乌基(John Kariuki)说。“马赛牧民们不用买卖牛羊，他们通过卖驴来支付孩子的学费。”

[size=0.8125]（左）驴在被送往Goldox屠宰场的路上。（右）肯尼亚奈瓦沙的璀璨明星毛驴出口屠宰场的主管约翰·卡里乌基举起一块驴皮。“这项生意帮助了很多人，”卡里乌基说。 RACHEL NUWER

[size=1.125]巴林戈郡的金牛公司驴屠宰场(Goldox Donkey Slaughterhouse)号称一天能处理450头驴，是肯尼亚最大的屠宰场，它也在试着通过向邻里免费供水，为四个当地孩子支付学费来示好。

[size=1.125]批评者认为，这项贸易的利益被夸大了，带来了很多问题。

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[size=1.125]“驴被偷走后，要么在灌木丛中被屠杀，要么以非常恶劣的方式被运走，没有适当的文件或公共卫生标准，”肯尼亚的一名兽医官员说。由于担心遭到政府上级的报复，他要求匿名。

[size=1.125]“我们所有人——驴的所有者和兽医专业人士——都反对这项贸易，但政府不太关心我们的想法，因为它能给他们带来收入。”

[size=1.125]根据2009年的最新普查，肯尼亚约有180万头驴，支持着约1000万人的生活。据肯尼亚驴保护组织(Donkey Sanctuary Kenya)的兽医科学项目开发经理所罗门·奥尼扬戈(Solomon Onyango)预计，到2019年下一次统计公布时，这一数字将大幅下降。

[size=1.125]“肯尼亚的驴只无法维持这种需求，”奥尼扬戈说。

[size=1.125]据该组织称，旺盛的需求已经耗尽了邻国的驴，一些驴是从乌干达、索马里或坦桑尼亚运到肯尼亚的。

[size=0.8125]肯尼亚奈瓦沙璀璨明星毛驴出口屠宰场的驴只尸骸。这些垃圾的处理让当地人很头疼。 RACHEL NUWER

[size=1.125]在极少数情况下，住在屠宰场附近的驴主成功地辨认并救回了自己的驴。因此，Goldox屠宰场的主管卢东林（音）在10月份宣布，该屠宰场将开始发放三天后到账的支票，以便该公司在出现被偷来的驴被村民要回的情况时取消支付。

[size=0.8125]璀璨明星毛驴出口屠宰场的冷库，大多数的驴肉最终会出口到中国。 RACHEL NUWER

[size=1.125]不过，人们对这些屠宰场的抱怨已经不只是它们助长了盗窃行为。那些驴送来时的情况往往非常糟糕，有些驴的腿断了或者有生了蛆的伤口，还有很多处于快饿死的状态。肯尼亚动物保护关爱协会(Kenya Society for the Protection and Care of Animals)提出的虐待动物指控——包括驴在没有食物的情况下日晒雨淋了好几天——导致政府关闭了璀璨明星屠宰场一个月。

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[size=1.125]“他们没有提供食物、水或兽医治疗的动力，”波普说。“从动物福利的角度讲，这种情况极其可怕。”

[size=1.125]他还说，那些死在路上的驴经常被当场剥皮，尸体就留在原地腐烂。

[size=1.125]随着人们不满情绪的加深，驴主和肯尼亚兽医协会(Kenya Veterinary Association)在内罗毕等城市举行了抗议活动。去年7月，恩杰鲁和另外一千多名盗窃受害者在向肯尼亚农业、畜牧业和渔业部(Ministry of Agriculture, Livestock and Fisheries)递交的请愿书中呼吁立即停止驴皮交易。该部门负责监管该行业。

[size=1.125]“有人在盗窃和出售偷来的驴，政府却不制止，”恩杰鲁说。“我向警方报了案，他们却没有采取任何行动。”

[size=1.125]该部门的官员没有回复记者的采访要求，但从去年9月发布的一份备忘录来看，没有迹象表明，官员们将取缔该贸易。相反，该备忘录指出，驴皮行业提供了大量就业机会和经济发展潜力。奥尼扬戈等批评者不赞同这一结论。

[size=1.125]“我们应该为了赚钱去做可卡因生意或者卖象牙吗？”他说。“你不能以发展商业的名义允许那些害人的贸易。”

[size=0.8125]金牛屠宰场附近的驴子尸体倾倒场。当地村民抱怨了污染和恶臭问题。 RACHEL NUWER
[size=0.8125]一头驴在金牛屠宰场溜达。这种动物不适合集约化养殖，在一些非洲国家，它们的数量正在减少。RACHEL NUWER

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