By Edward J. Kennelly, PhD,a and Clara B.S. Lau, PhDb
a Department of Biological Sciences, Lehman College and The PhD Programs in Biochemistry, Biology, and Chemistry, The Graduate Center, The City University of New York (New York, New York, USA)
b Institute of Chinese Medicine and State Key Laboratory of Phytochemistry and Plant Resources in West China, The Chinese University of Hong Kong (Shatin, New Territories, Hong Kong)
Editor’s note: As part of an eight-month Fulbright Scholar Program-sponsored sabbatical in 2014-2015 at the Institute of Chinese Medicine at the Chinese University of Hong Kong, one of the authors of this article (EJK), a pharmacognosist and natural product chemist, conducted research and interviews in collaboration with a local expert (CBSL) on traditional Chinese medicine (TCM) and pharmacy to learn more about the modernization of TCM in Hong Kong. His field research included visits to local herbal markets, TCM clinics, hospitals with Chinese medicine dispensaries, and local Chinese herbal pharmaceutical companies. As detailed in this article, the authors observed a range of approaches to TCM: Some practitioners are employing techniques that have been used for thousands of years, and others are embracing changes that have come about from new technologies.
The announcement of the Nobel Prize in Physiology or Medicine in October 2015 brought traditional Chinese medicine (TCM) to the front-and-center of the minds of people around the world. After extensively reviewing TCM formulae as part of a public health initiative in the People’s Republic of China almost 50 years ago, one of the awardees, Tu Youyou, was recognized for her research team’s discovery of a new treatment for malaria: artemisinin, a compound found in the Chinese medicinal herb qinghao (Artemisia annua, Asteraceae).1,2 After millennia of practice, TCM continues to be used and studied around the world, and it has evolved in modern times.
The traditional practice of Chinese medicine involves diagnoses by trained Chinese medicine practitioners and prescriptions of TCM formulae, which can be administered in various ways. (TCM encompasses many modalities from acupuncture to medicines composed of plant, animal, and mineral products, but this article will focus on botanicals used in TCM.) Typically, these formulae include various raw herbal materials that must be boiled in water prior to ingestion (decoctions), or dried herbal materials or desiccated boiled-water extracts that can be taken in pill form. Often, a formula would be consumed once or twice daily. Before the establishment of Hong Kong’s Chinese Medicine Ordinance (Chapter 549 of the Laws of Hong Kong) in 1999,3 practitioners of Chinese medicine were not legally required to be registered in order to dispense medicines. Today, there are more than 7,000 registered Chinese medicine practitioners in Hong Kong.
Hong Kong is ranked highly in a number of international indices for its public health system and economy, and is one of Asia’s wealthiest and most modern cities.4,5 Although there are many Western medical doctors and clinics in Hong Kong, a strong belief in the use of TCM remains. Many of the findings presented here reflect changes that are occurring with TCM practice in the People’s Republic of China, as well as worldwide.
Hong Kong is on the cutting edge of many of these changes due to its strong economic position in the world and modern research facilities, such as those at the Chinese University of Hong Kong, Institute of Chinese Medicine (CUHK-ICM). A new era in TCM practice in Hong Kong can be traced back to 1997 when Hong Kong was returned by Great Britain to the People’s Republic of China, and the Chief Executive of the Hong Kong Special Administrative Region announced the government’s intention to set up a formal regulatory framework for TCM.6 In the decades that followed, Hong Kong has developed a thriving and regulated TCM marketplace.
Thriving Tradition with a Modern Backdrop
In the narrow streets of Ko Shing Street Herbal Market in Hong Kong’s Sheung Wan neighborhood, there are numerous stores, clinics, and even small manufacturers of TCM products that, at first glance, have changed little since Hong Kong’s colonial period. Stores have bulk herbs displayed in barrels and glass containers. Some high-end TCM pharmacies have the traditional wooden drawers devoted to different herbs, and workers still use old-fashioned balance scales to weigh them. It is a stark contrast to Hong Kong’s modern skyline, with skyscrapers like the 417-meter (1,368-foot) International Finance Centre Two less than two kilometers (1.2 miles) away. The quality of raw herbs from these suppliers and pharmacies can vary significantly, as we found, for example, in our studies on astragalus (Astragalus membranaceus, Fabaceae) root.7
There are more than 500 Chinese herbal medicines listed in Schedule 2 of the Chinese Medicine Ordinance,8 and about 200 of them are commonly used in the local community in Hong Kong.6 A list of 10 common TCM botanicals in Hong Kong — mostly based on the first volume of Hong Kong Chinese Materia Medica Standards6 — is provided in Table 1.
In the TCM clinics of Ko Shing Street and other parts of Hong Kong, one will encounter many highly experienced TCM practitioners working out of herbal stores. This contrasts with the modern environment of certain clinics like the Hong Kong-based chain store Nong’s Modernized Chinese Medicine Clinic, which has 52 modern, modular clinics mostly in shopping malls throughout Hong Kong. At these clinics, TCM practitioners in white coats formulate and dispense processed TCM prescriptions using high-end electronic instruments and innovative technology. While the ancient forms of TCM are still widely practiced in Hong Kong, we observed a growing trend in modernization in the clinics and beyond.
Modern Approaches to Distributing TCM
It is not easy to sustain the often time-consuming practice of TCM treatments in Hong Kong where Western alternatives are readily available and the pace of life does not lend itself to long preparation times. For example, when preparing a Chinese herbal decoction, patients are traditionally instructed to boil complex mixtures of processed raw herbs in water for a period of one to two hours. Such practice is no longer feasible for many residents of Hong Kong with long working hours.
Based on our visits to seven different TCM clinics and local Chinese herbal pharmaceutical companies in Hong Kong (see map below), we observed a trend toward simplifying TCM in several specific ways. First, there has been an effort to create TCM formulae that contain fewer herbs, and that can be marketed as proprietary Chinese medicines or health supplements at local pharmacies for the general public. Patients can simply go to a pharmacy to purchase these products, which do not require a prescription from a TCM practitioner. However, one drawback to using these ready-made formulations is that they do not take into account the personalized medicine approach, which is still regarded as an important part of TCM philosophy.
In addition, many TCM practitioners at both private and public clinics in Hong Kong prescribe extracts that have been processed into granules, which can be dissolved readily in water. Granules are produced by boiling TCM ingredients in water, concentrating the resulting extract (often in a 5:1 ratio), and then spray-drying the extract onto an excipient, such as dextrin. Granules are becoming more popular because they can be easily prepared by TCM practitioners at local pharmacies using modern dispensary equipment. They are also more convenient for patients to consume because they need only to dissolve the granules in a cup of hot water. In fact, the TCM pharmacies operated by the Hong Kong Hospital Authority are dispensing processed raw herbs or granules obtained from a contracted supplier, per patient preference. According to the Hong Kong Hospital Authority, its TCM clinics dispensed about half of its prescriptions as granules in 2014.9 Some studies have found that although granules aim to standardize dosages of a particular botanical, the method by which the granule is produced can lead to variable dosages.10 Although granules are becoming more popular in Hong Kong and throughout Asia, many patients still prefer to have the TCM prepared from the original materials as a water extract or strong tea or tisane (i.e., a decoction). Because of this, some pharmacies provide TCMs as prepared extracts that are given to patients in liquid form that can be consumed directly, and can provide up to a two-week supply. Some even provide same-day courier delivery service to patients within certain areas of Hong Kong.
Quality Control Measures
The safety of TCM is critical for its public acceptance, especially in light of well-publicized problems with some Chinese botanicals. (For example, in the early 1990s, a weight-loss supplement that contained the nephrotoxic and potentially carcinogenic herb Aristolochia fangchi [Aristolochiaceae] caused more than 100 women in Belgium and France to sustain kidney damage.11) The testing and certification industry in Hong Kong is based on internationally recognized standards and is considered to have a high level of integrity and credibility. From the limited observations of one of the authors (EJK), Hong Kong people seem to be acutely aware of problems with product adulteration in the neighboring People’s Republic of China, since they witness, on a daily basis, people traveling from the mainland to Hong Kong to purchase items that have a history of being adulterated in China.12 At Hong Kong pharmacies, it is a common experience to see mainland people with large rolling suitcases filled with such products to bring back home.
Hong Kong has established its own standards for TCM (the Hong Kong Chinese Materia Medica Standards6) that include authentication and quality analyses. There are also safety tests for heavy metals, pesticides, and microbial limits that are conducted by laboratories accredited by the Hong Kong Laboratory Accreditation Scheme. The Hong Kong Hospital Authority has established even stricter requirements for TCM ingredients distributed by its clinics, such as tests for dyes (e.g., auramine O), foreign matter, and toxic substances (e.g., aconitine, atropine, and aristolochic acid — potentially toxic constituents of plants in the genera Aconitum [Ranunculaceae], Atropa [Solanaceae], and Aristolochia, respectively).
In summary, there seems to be a strong commitment to the modernization of TCM in Hong Kong, and great efforts have been made to simplify the practice for the ease of modern peoples’ lives, and to ensure their safety.
Recent Development of Education and Research in TCM
TCM clinical practices and pharmacies in Hong Kong are mostly private. However, the Hong Kong Hospital Authority has partnered with non-governmental organizations and three universities in Hong Kong to support 18 TCM clinics, which had more than one million combined visits in 2014.8 Three Hong Kong universities offer bachelor’s of science programs in Chinese medicine: Hong Kong Baptist University, CUHK, and The University of Hong Kong. In recent years, some universities have started to offer bachelor’s of pharmacy programs in Chinese medicine and various master’s of science programs in Chinese medicine, acupuncture, and other specialized areas. Some Hong Kong universities also have established bachelor’s of science programs in testing and certification that include TCM in their curricula.
The CUHK-ICM has a mission to modernize Chinese medicines through scientific research. The institute has made great attempts to provide scientific evidence that supports the use of Chinese medicines as alternative or complementary therapies in diseases that are not well-managed by Western conventional medicines; to develop evidence-based Chinese medicines for the prevention and treatment of chronic diseases; and to transform the promising research output into commercial, evidence-based herbal health supplements. The authentication team ensures good quality control of the medicinal herbs for both laboratory (animal- and cell-based assays) and human clinical studies. Different research laboratory platforms have been established for the mechanistic studies of different disease areas as well. In addition, through collaboration with various clinical departments at the Prince of Wales Hospital, the efficacy of various herbs and herbal formulae have been further verified in clinical trials.13
In her Nobel Laureate address in Stockholm, Sweden, on December 7, 2015, Tu Youyou noted that there was potential for great new medical discoveries by integrating the best practices of Western medicine and TCM.2 Modern TCM in Hong Kong is certainly moving along that road, from the standardization of medicines to clinical and mechanistic studies. It is an exciting time for TCM development in Hong Kong and beyond, and there have been substantial efforts by CUHK-ICM and other research institutions to use cutting-edge scientific tools to assess the safety and efficacy of many traditional Chinese medicines. With this investment in TCM, the future holds significant opportunities for its increased acceptance by people throughout the world.
The authors would like to thank Bacon Fung-Leung Ng, OTD, manager of the Chinese Medicine Department at Hong Kong Hospital Authority; Kam-Leung Chan, PhD, academic and development manager of the Hong Kong Institute of Integrative Medicine at The Chinese University of Hong Kong; Grace Gar-Lee Yue, PhD, scientific officer at the Institute of Chinese Medicine at The Chinese University of Hong Kong; and also Elia Machado, PhD, assistant professor of Earth, Environmental, and Geospatial Sciences at Lehman College, CUNY, who kindly made the map of Hong Kong field sites. We also thank Wesley Chan (www.wesleyimage.com) for his photography.
Edward J. Kennelly, PhD, is a professor of Biological Sciences at Lehman College, CUNY, and also serves as the executive officer of the Biochemistry PhD Program at the CUNY Graduate Center. He received his PhD in plant biology at Washington University in St. Louis, and completed his postdoctoral training in pharmacognosy at the College of Pharmacy at the University of Illinois at Chicago. After working at the US Food and Drug Administration Center for Food Safety and Applied Nutrition, he joined the faculty at CUNY, and has published many peer-reviewed papers in the field of natural products of medicinal and edible plants. He was a Fulbright Scholar at the CUHK-ICM in academic year 2014-2015.
Clara B.S. Lau, PhD, is currently the associate director of the CUHK-ICM. She also serves as the associate director of the Partner State Key Laboratory of Phytochemistry and Plant Resources in West China (CUHK), and has a courtesy appointment as associate professor at the School of Chinese Medicine at CUHK. With a BPharm and PhD in pharmacy (pharmacognosy) from King’s College London, University of London, United Kingdom, she has a continuous interest in medicinal plants (Western herbals and traditional Chinese herbal medicines) and has more than 20 years of experience in natural products research.
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- Tu, Y. Artemisinin — A gift from traditional Chinese medicine to the world (Nobel Lecture). Angew Chem Int Ed Engl. 2016;55(35):10210-10226.
- Chinese Medicine Ordinance in Hong Kong. Available at: www.cmd.gov.hk/html/eng/important_info/regulation.html. Accessed March 29, 2017.
- Martin W. The 16 countries with the world’s best healthcare systems. January 13, 2017. Business Insider. Available at: www.businessinsider.com/healthiest-countries-in-the-world-2017-1. Accessed May 1, 2017.
- Yau C. Hong Kong pips Singapore to be ranked world’s freest economy for 23rd consecutive year. Ferbuary 16, 2017. South China Morning Post. Available at: www.scmp.com/news/hong-kong/economy/article/2071423/hong-kong-pips-singapore-be-ranked-worlds-freest-economy-23rd. Accessed May 1, 2017.
- Hong Kong Chinese Materia Medica Standards, Volume 1. Department of Health; Hong Kong Special Administrative Region, the People’s Republic of China: 2005.
- Xiao WL, Motley TJ, Unachukwu UJ, et al. Chemical and genetic assessment of variability in commercial Radix Astragali (Astragalus spp.) by ion trap LC-MS and nuclear ribosomal DNA barcoding sequence analyses. J Agric Food Chem. 2011;59(5):1548-1556.
- Schedule 2. Chinese Herbal Medicines. Chinese Medicine Ordinance. Available at: www.elegislation.gov.hk/hk/cap549!en@1999-08-06T00:00:00/sch2?elpid=187017. Accessed May 2, 2017.
- Ngan T. Measures to ensure the quality and safety of Chinese medicines in Hospital Authority. Seminar presented at: Research & Development of Chinese Medicines 2015; September 10, 2017; Hong Kong.
- Zhanga X-L, Liub L-F, Zhua L-Y, et al. A high performance liquid chromatography fingerprinting and ultra high performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry chemical profiling approach to rapidly find characteristic chemical markers for quality evaluation of dispensing granules, a case study on Chuanxiong Rhizoma. J Pharm Biomed Anal. 2014;88:391-400.
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- Homepage. Institute of Chinese Medicine website. Available at: www.cuhk.edu.hk/icm/. Accessed April 13, 2017.