A Historical Perspective

Lyren Chiu, RN, PhD

Abstract:

Traditional Chinese Medicine (TCM) is widely practiced within the Chinese immigrant community in Canada and is part of the Chinese lifestyle. During the past four decades, the overall involvement of the two systems can be seen as comprising four phases: 1970s – Opening the ‘Bamboo Curtain,’ 1980s – Lobbying the government and struggling for legal status, 1990s – Becoming a designated health profession, and 2000s – Heading toward professionalism. In BC, while TCM is now covered by a legal framework, some knowledge is necessary about the factors that might facilitate or inhibit its professionalization and the implications for a future relationship between TCM and Western medicine. More studies are needed to understand how immigration, legitimization, and integration interact in determining the role of TCM and to develop the most effective integration of TCM and Western medicine.

Key Words: Traditional Chinese Medicine (TCM); Western Medicine; Alternative Health Care

Throughout most of their history in Canada, Chinese people have comprised less than 1% of Canada’s population (Li, 2003). An estimated 92% of all Chinese Canadians immigrated to Canada after 1967, when restrictions on Chinese immigration were lifted (Li, 2003). Presently, Chinese is the largest visible minority group in Canada (Statistics Canada, 2007), accounting for 3.5% of the Canadian population (29.6 million) and 26% of the visible minority population (Statistics Canada, 2007).

Traditional Chinese Medicine (TCM) is widely practiced within the Chinese immigrant community and is part of the Chinese lifestyle (Chiu, 2006; Chiu et al., 2006). In general, immigrants tend to seek care outside of the conventional medical system according to their own values and beliefs (Blanch & Levin, 1998; Lin, Tardiff, Donetz, & Goresky, 1978; Zuess, 2003; Lin & Cheung, 1999). Specifically, most Chinese immigrant mothers practiced traditional healing on a daily basis, though individuals who are acculturated to the dominant Canadian society tend to adopt conventional health practices (Chiu, 2005).

TCM is popular in British Columbia (BC) and in Ontario because of the increasing sizes of the Chinese populations that reside in these regions. Both BC and Ontario have passed legislation to regulate TCM and acupuncture and other provinces seem poised to establish their own jurisdictions in the near future. With the increasing number of Chinese immigrants, more Canadian physicians are becoming aware of TCM and, to continue delivering high quality health care, the health care system needs to adapt its services to the cultural diversity.

Currently, some tensions exist between TCM and Western medicine that is impeding their integration and creating isolation and mistrust, along with asymmetric power relations among the professionals. During the past four decades, the overall involvement of the two systems can be seen as comprising four phases: 1970s – Opening the ‘Bamboo Curtain,’ 1980s – Lobbying the government and struggling for legal status, 1990s – Becoming a designated health profession, and 2000s – Heading toward professionalism (Chiu, 2008).

1970s – Opening the “Bamboo Curtain”

Interest in TCM was noted in 1972 when US President Nixon encountered acupuncture for its analgesic effect in China, and later published an article about his experience with acupuncture in Time Magazine which led to further interest in acupuncture in the US.

The BC government was intrigued by the popularity but could not determine the legal status of acupuncture practice in the early-1970s. In 1972-1974, Dennis Cocke of the Ministry of Health of BC, appointed an Acupuncture Advisory Committee under the BC College of Physicians and Surgeons to establish and evaluate two acupuncture pain clinics (at the Vancouver General Hospital and at the Victoria General Hospital) and to make recommendations to the Minister on the future practice of acupuncture in BC, since the College had exclusive right to practice medicine, under the Medical Act (Acupuncture Association of BC, AABC, 1984).

After 12 years, the College of Physicians and Surgeons had not generated a final report to the Ministry of Health, though the College was dictating regulations for the practice of acupuncture in BC and, since 1974, had prosecuted seven acupuncturists (AABC, 1984).

1980s – Lobbying the government and struggling for legal status

Although acupuncture practitioners in BC drafted legislation in 1986, they were sometimes prosecuted by the College of Physicians and Surgeons.

In 1981, the Minster of BC appointed a Medical Advisory Committee under the Ministry of Health to examine the role, qualifications, and standards of practice of acupuncture by the medical profession (not by acupuncturists) in BC (AABC, 1984). The Committee was comprised of members of the College of Physicians and Surgeons and one registered nurse. Minister Nielsen informed the Acupuncture Association of BC (in a letter of March 15, 1983) that the committee was “actively addressing the acupuncture by the medical profession in the Province” (AABC, 1984, p.8).

The Acupuncture Foundation of Canada (AFC), with its membership restricted to physicians, dentists, and veterinarians, attempted to establish itself as the representative of acupuncture in Canada (AABC, 1986). The attempt, however, was disapproved by the International Congress of Acupuncture, which consisted of representatives from 96 countries. The Congress cited the AFC members as having inadequate hours of training and an ignorance about TCM theory and philosophy (AABC).

Due to the lack of trust and mistreatment shown by the medical profession, the AABC intensively lobbied the government for legislation since the association’s incorporation in 1974. Mary Watterson, President of the AABC in 1984, was quoted by the Vancouver Sun as saying, “the association has already delivered over 13,000 petitions to the Minister of Health and letters of support from community organizations representing more than 50,000 British Columbians” (AABC, 1986, p. 56; Watterson, 1984). In addition, “over 12,000 petitions have been signed in support of MLA John Reynold’s motion for the legalization of acupuncture and other health care approaches being prohibited under the Medical Practitioners Act” and “over 6,000 more petitions have been signed by British Columbians requesting acupuncture legislation” (AABC, p. 56). In 1983, 54 acupuncturists were practicing in BC (Vancouver Sun) and in 1986, over 30,000 patients paid from their own pockets for acupuncture treatments (AABC).

In 1985, MLA Dennis Cocke introduced a private member’s bill to amend the Medical Practitioners Act to legally recognize acupuncturists (Vancouver Sun). Nevertheless, the bill did not go far, and in 1986, the AABC submitted a position paper to the BC government to delineate regulations, qualification requirements, examinations, standards of training, competencies, rules of practice, and codes of ethics, along with a drafted proposal for an Acupuncturists Act.

1990s – Becoming a designated health profession

TCM became a designated health profession in the 1990s. In 1991, five associations of acupuncturists in BC, representing 236 practitioners, applied to the Health Professions Council for designation under the Health Professions Act, which enabled TCM to move away from the reign of conventional medicine. In 1993, the Council, after holding extensive stakeholder consultations, recommended that acupuncture be designated as a health profession. In 1996, acupuncture regulation was created under the Health Professions Act and the College of Acupuncturist of BC was formed to administer the regulation.

In 1992, the Traditional Chinese Medicine Association of BC submitted an application for the designation of TCM as a self-regulating health profession. The Canadian SinoBiology Practitioners Association and the Pacific Region TCM Practitioner and Acupuncturist Society submitted second and third applications in 1996 to have TCM designated as a health profession. In June 1999, the BC government announced the creation of the College of Traditional Chinese Medicine Practitioners and Acupuncturists of BC (CTCMA), with its roles being to protect the public and regulate the profession. The functions of the CTCMA include providing public education and members’ continuing education service, granting licenses to TCM practitioners and acupuncturists in the province, defining core competencies, and enforcing standards of practice.

After nearly 30 years of lobbying, and after a self-regulatory system for TCM was implemented, BC became the first jurisdiction in North America to officially designate TCM as a profession.

2000s – Heading toward professionalism

In the 2000s, four Canadian provinces regulated acupuncture (BC, Ontario, Alberta, and Quebec), and TCM is regulated in BC and Ontario. In BC, TCM is heading towards having a professional status, and on April 12, 2001, TCM and Acupuncturist Bylaws were passed. On April 12, 2003, a valid professional license, issued by CTCMA, became a requirement for practicing TCM and acupuncture in BC. As of 2007, four annual examinations are administered for those seeking licenses.

In BC, a two-year registration grace period was allowed for acupuncturists (ending in June 2001), and for TCM practitioners (ending in April 2003). While many practitioners felt disadvantaged in their profession because of the exceptions, others were unaffected. “They will eventually fade out if they could not meet the requirement of core-competencies” said a TCM doctor. In BC, while TCM is now covered by a legal framework, some knowledge is necessary about the factors that might facilitate or inhibit its professionalization and the implications for a future relationship between TCM and Western medicine. In any case, the TCM profession has been making a significant effort to install the TCM medical practices in Canada. In BC, about 1,400 registered practitioners currently practice TCM.

Furthermore, a historic breakthrough occurred in TCM in April 2008, when it was made more accessible to low-income earners in BC by its inclusion under MSP premium assistance.

Future Implications

Instead of being an ethnic practice, for decades, TCM has become another health care option for all Canadians. Some physicians have even undergone training and been incorporating acupuncture into their conventional medical practices (Goldszmidt, et al., 1995; Ko & Berbrayer, 2000; Verhoef & Sutherland, 1995). In July 1984, the College of Physicians and Surgeons reported that about 0.02% of the physicians in BC use acupuncture in conjunction with their practice (Crellin, et al., 1997). Today, while a tension still exists between the two medicines, Western medicine is more open than ever before to the alternatives (Chiu, 2006). The interest of physicians in TCM emerged more from Canadian consumers (with the increasing numbers of Chinese immigrants), and from the public’s concerns about alternatives, along with media promotion (Crellin, et al., 1997).

In September 2008, the Canadian Research Institute of Spirituality and Healing organized a forum to invite both TCM and Western medicine researchers and practitioners to discuss issues related to the integration of TCM with Western medicine. The conference participants believed that, by returning to the source, a deeper insight can be achieved into the spiritual values and basic principles that support the therapeutic practice of traditional medicines. Also, through the rediscovery, new approaches may be considered that fully respect the fundamentals, while generating harmonious integration.

Integrative medicine has been defined as involving the “act or process of integrating” or “the act of combining into an integral whole” (Merriam-Webster Online Dictionary, 2008) and, according to Dr. Steven Aung, is “a spirit of cooperation and creativity between two or more medical systems and their practitioners for the benefits of their patients” as well as “the combined knowledge of old and new healing therapies into medical practice.” Three types of integration have been seen in BC: integrative medical practitioners, integrative consumers, and collaborative teams (Dr. Lyren Chiu). Dr. Chiu suggests using a complementary model for allocating equal powers to both medicines and an East meets West model to incorporate the values and essence of both medicines. Dr. Chiu, as do most Chinese, believes, “TCM and Western medicine complement each other” and their integration could help “treat both symptoms and causes.” Drs. Jason Hitkari and Lorne Brown presented a shared care approach with patient-centred care that offers patients choices of safe and beneficial therapies. The synergy that results from this type of integration can go beyond a simple combination of different modalities of care, as both collaborative and complementary components are present in integrative medicine.

To stimulate further cooperation between the two medicines, the professionalization of TCM could create a common ground for integrated interactions between TCM and Western medicine. According to Abbott (1998), professionalization is a process of moving an occupation toward a higher status, perhaps beginning with “a school, an association, examinations, licensing, an ethics code …” (p.431). In BC, TCM is currently moving in this direction. Professionalization is essential for an organization to attain the kind of recognition, both official and public, that would constitute the foundation for integration. To achieve professionalism, TCM needs to establish and enforce codes of conduct, standards of practice, as well as evaluation procedures for competence.

TCM also needs to embrace evidence-based practice, accredited education, and standardization of medical records. As Abbott (1998) suggests, TCM practitioners in BC should consider their future in “the context of larger social and cultural forces, …other competing professions, and …other ways of providing expertise,” (p. 433-434) in addition to the “likely evolution and the consequences of that evolution.” (p.432)

Although the CTCMA has set entrance standards for each of its designated titles, the education program must be carefully reviewed. Currently, no accreditation body is established to examine the various programs. Recently formed by principals and deans of TCM colleges across Canada, the Canadian Association of TCM & Acupuncture Colleges intends to provide TCM accreditation services. The government should support and ally with the voluntary organization to encourage high quality education programs.

In previous studies, patients who avail themselves of both TCM and Western medicine, were found to believe that each possesses strengths that can complement the other’s weaknesses (Chi et al., 1996; Chiu, 2006; Chiu et al., 2006). This, in turn, suggests the desirability of creating a more integrated system of conventional and complementary and alternative health care to allow the bringing together of all strengths to balance “the weaknesses inherent in different systems of health care” (Owen, et al., 2001, p. 156). For the sake of patient safety, TCM practitioners must be cognizant of the reasons for patients being treated by their Western counterparts, and vice versa. A formal referral system would also provide for communication channels between the two systems that would help prevent over-prescribing and adverse drug interactions (Chiu, 2006). As Chi and his associates suggested, the creation of a referral system could be an important step in integrating the two systems.

For a referral system to function in this context, the participants must possess at least basic knowledge about the other disciplines or professions. Thus, the curricula of the TCM schools should include courses related to Western medicine, and vice versa. As the findings of our previous studies suggest, many barriers exist in TCM research that impede the development of evidence-based practice, thereby hampering the professionalization of TCM (Chiu, 2006). Since the BC government supports the creation of a college for TCM and acupuncturists, logically, it should consider allocating TCM research funding to advance its professionalization.

Various kinds of evidence support TCM practice, including research findings, clinical experiences, and patient preference (Craig & Smyth, 2002). Research in TCM differs from clinical evaluations of conventional drugs, since randomized controlled clinical trials (RCT) are limited when evaluating efficacy, risk, and benefits of TCM. Preliminary studies must first be undertaken before appropriate RCT can be designed. Ethnographic, epidemiological, observational, survey, and cohort methodologies also contribute to TCM research findings (Bodeker & Kronenberg, 2002). In addition, TCM research methodologies need to be developed that fit its theory and complicated mechanisms. Adequate funding is of central importance. The Canadian government should support alternative health care, as it is consistent with the country’s broad “international and multi-cultural character” (Crellin, et al., 1997). Multiculturalism is a fact of Canadian life and thus should be part of the Canadian health care system, and with the growing cultural diversity, even greater pressure will be put on the official health care system to have broader perspectives and a greater responsiveness to patients of all backgrounds and beliefs. To achieve this view, Western medicine must be recognized as a culturally determined institution that reflects the values and worldview of the dominant segment of Canadian society (Chiu, 2006). In addition, “traditional medicine may at times be the first-line treatment for the poor and those who do not speak the language of the dominant society.” (Bodeker & Kronenberg, 2002, p. 1585). More studies are needed to understand how immigration, legitimization, and integration interact in determining the role of TCM and to develop the most effective integration of TCM and Western medicine.

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Correspondence to: Lyren Chiu, RN, PhD.

Canadian Research Institute of Spirituality and Healing.

28-1863 Westbrook Mall, Vancouver, BC, V6T 2J7

Telephone & Fax. 604-288-0038

Email: lyren.chiu@gmail.com