Volker Scheid is Wellcome Trust Research Fellow in the Department of History, School of Oriental and African Studies, at the University of London.

Chinese Medicine in Contemporary China

Plurality and SynthesisBy Volker Scheid

Duke University Press

Copyright © 2002 Volker Scheid
All right reserved.
ISBN: 9780822328575

Chapter One

ORIENTATIONS

With few exceptions, modern textbooks and physicians of Chinese medicine view their tradition as having unfolded in the course of an unbroken development that stretches back over two thousand years. Many Western historians, on the other hand, perceive the same development as a history of ruptures and ongoing adjustment to social change, of the continuous assimilation of extraneous knowledge and a never-ending struggle for identity. Chinese medicine, then, can be conceived of as being shaped by processes internal to itself but also by the desires and resistance of other peoples and things. Consequently, at any point in its long evolution Chinese medicine has been characterized by a diversity that encompasses every aspect of its organization and practice, from theory and diagnosis to prognosis, therapeutics, and the social organization of health care.

The concrete realities of such diversity are rendered visible by even the most fleeting visit to any hospital or outpatient clinic of traditional medicine in contemporary China. No two doctors diagnose, prescribe, or treat in quite the same way. It would be most unusual, for instance, if after consulting ten senior physicians for the same complaint one did not walk away with ten different prescriptions. Chinese physicians and their patients seem little perturbed by this. Both view personal experience, accumulated through years of study and clinical practice and by definition diverse, as a cornerstone of Chinese medicine. Doctors pride themselves on their individual styles of prescribing or needling. They define their identity by emphasizing their place within a medical lineage, but also by demonstrating that they are engaged in reshaping Chinese medicine through the use of biomedical knowledge and technology. Senior doctors state that no good physician ever writes out the same prescription twice, yet they actively collaborate in the formulation and marketing of patent remedies (chengyao [TEXT NOT REPRODUCIBLE IN ASCII]).Western, Chinese, shamanist, and religious forms of healing not only exist side-by-side, they are also integrated in many different ways. Patients move easily from one doctor, clinic, or hospital to the next if the present one does not deliver the expected results. In time-honored tradition (especially if they can afford the expense), they may consult several doctors and compare their prescriptions before deciding which one’s treatment to follow.

There is nothing unusual about such diversity and contradiction. They are documented for other medical traditions undergoing modernization, but also for biomedicine and for Western science at large. Wherever we look, syncretism and ambiguity abound. Nevertheless, diversity is often experienced as problematic by both insiders and outsiders to a particular health care system in the context of first- and second-order inquiries. First-order inquiries are defined here as arising in immediate relation to clinical practice (i.e., as having to do with choosing between different therapeutic possibilities, the ordering of experience, etc.); second-order inquiries analyze first-order processes. Given an environment in which a plurality of possible diagnostic and treatment strategies is imagined possible, physicians and their patients must devise methods to select from the array of available options those considered most useful or appropriate. Such choices may be left to individuals and their families, but there may also be institutionalized procedures or practices that prescribe, enable, or restrict choice.

For physicians in imperial China such methods and institutions included memorization and rote learning, apprenticeship involving the acquisition of tacit knowledge, and the continued interpretation of canonical texts in the light of personal experience. Without a state-controlled teaching system that had the authority to effectively define and police the form and content of medical practice, each doctor was, as Nathan Sivin notes, “expected to arrive at his own synthesis through the interaction of deep book learning and practice. The goal was to be fully responsible for his very limited power over life and death, not to become a technician manipulating bodies.” In contemporary China efforts are being made to replace reliance on subjective experience with objective knowledge according to perceived universal scientific standards; older practices, however, endure.

Chinese patients have always been well versed in accommodating to the wide variety of health care choices available to them. In imperial China it was considered one of the duties of a filial son to care for his parents medically. This was taken to mean that a gentleman or scholar should be conversant with the works of the medical canon. He might prescribe medicines himself, but more usually he would decide on the appropriate treatment based on his medical knowledge. If a family member fell ill, several physicians might be invited to the house to make a diagnosis and submit a prescription. The household would then select from among these diagnoses and prescriptions the one they felt was most appropriate or convincing. This practice still exists. I observed it during my fieldwork in Beijing, as in the case of a rich businessman from Taiwan who was searching for treatment for his terminally ill daughter. He consulted several famous physicians before making a choice. Less well off patients choose between practitioners by considering their reputation, the fees they charge, the service they offer, and the institution at which they practice. Chapter 4 describes in detail several cases of such health seeking and the complex choices it involves.

Descriptions of how individual physicians and patients confront the pluralities of a given health care system can be distinguished from investigations that take these first-order inquiries as their topic. Such second-order inquiries may be intrinsic to a medical tradition, as in the contemporary Chinese medical subdisciplines of zhongyi ge jia xueshuo [TEXT NOT REPRODUCIBLE IN ASCII] (doctrines of schools of Chinese medicine) and zhongguo yixue shi [TEXT NOT REPRODUCIBLE IN ASCII] (history of Chinese medicine). Or they may be extrinsic, as in the case of medical anthropology or Chinese studies. Confronted with a diversity of health care practices and health-seeking behaviors on the descriptive (first-order) level, second-order inquiries strive to explain how and why the diversities discovered arise, how they are structured and relate to each other, and how they compare across different contexts of health care delivery. This book is one such inquiry.

In medical anthropology the concept of medical pluralism is widely employed to flag research into health care systems in which different medical traditions coexist in a cooperative or competitive relation with each other. Conventionally, the most commonly adopted methodology for this purpose is to sort the diverse forms of medical practice encountered in a given context into different medical systems and then to explore how patients and their families choose from them on the basis of distinct cultural knowledge and belief systems.

There are many problems, however, with this kind of analysis. First, contemporary ethnographies demonstrate that patients and their families do not simply make rational choices from the array of therapies available to them. Rather, health-seeking behavior is a dynamic, discontinuous, and fragmentary process involving complex negotiations of social identity and morality, in the course of which people draw simultaneously on local and global perspectives. Second, medical traditions, including biomedicine itself, have been revealed to be far less systematic than had originally been imagined. Rather than possessing clearly definable boundaries, medical systems are permeable to all kinds of technological and ideological influences effecting systemic change and local adaptations. The establishment of biomedicine in non-Western societies, for instance, is not merely a transfer of knowledge, practices, and institutions but involves important accommodations of that which is transferred. So-called traditional practices, on the other hand, can frequently be uncovered as inventions of twentieth-century modernizers profoundly influenced by Western knowledge and thought.

Discourse on medical pluralism has never been able to resolve the ensuing tension between expectation and reality. With regard to Asian medical systems, for instance, researchers have found it inordinately difficult to reconcile assumptions about the systematic nature of these traditions with the observation that, in practice, they are characterized by frequent inconsistencies and low levels of actual systematization. Should this tension be interpreted as a sign of disorganization and, by implication, of the inferiority of Asian medical systems vis-a-vis biomedicine? Or is it instead an essential dimension of these systems, turning them into flexible tools in the hands of skilled practitioners? Is inconsistency a sign that modern physicians no longer understand the theories on which their medicines are based? Are traditions such as Chinese medicine useful but no longer really alive, comparable to the function of Latin during the Middle Ages? Or perhaps consistency is not to be found in medical theories at all, but rather in the “practical logic of the clinical encounter,” which in the case of Chinese medicine may be revealed as a “coordinated use of ‘logically inconsistent’ methods to produce a nuanced specificity.”

Plurality thus continues to be an unresolved problem in all second-order accounts of Chinese medicine. Diversity, readily admitted on the level of description, is all too often reduced to some form of monism on the level of explanation, whether in the form of enduring cultural practices or essences or in teleological narratives of gain or loss. Such search for deeper unities is not merely an attempt at explanation, however. It is also a construction (disguised as representation) of Chinese medicine as a commonsense object. The most important purpose of such construction is comparison, so that attributes of one object can be contrasted with those of apparently similar objects: Western medicine versus Chinese medicine, Chinese medicine in the imperial era versus modern tcm, scholar-physicians versus shamans, science versus traditional knowledge, medicine versus art, and so on. In particular, indigenous, traditional or folk medicines continue to be constituted in anthropological, historical, and professional discourse as the “other” or opposite of biomedicine, even when such constructions are motivated by a critique (often romanticized) of biomedicine itself. Whether Chinese medicine is seen to be an “integrated system” or an assemblage of empirically useful theories and practices, whether it is imagined to be closed or open, whether it is described as holistic or reductionist-all these are not objective aspects of Chinese medicine itself, but indexes as to where, by whom, and for which purposes Chinese medicine has been constituted as an object of description and analysis.

My own encounters with Chinese medicine have shown these dichotomies and the desires motivating their construction-their “logics of equivalence and panics of reduction”-to be flawed. Inmost cases, for each discontinuity described other continuities can be found that break asunder carefully constructed categorizations. And what appears disconnected from one perspective often connects from another. Epistemologically, their frequently unstated a priori assumptions construct distinctly Orientalist knowledge (even in the most charitable sense of the term)-a charge to which any ethnography of Chinese medicine written at the end of the twentieth century must be extremely sensitive. For even when such constructions and comparisons are not a reflection of latent Western imperialisms, they reveal a tendency to construct Chinese medicine in terms of specifically Western discursive categories when a willingness to adapt these categories to the realities of Chinese medicine would perhaps be more rewarding.

In this book I will write a different ethnography of Chinese medicine, an ethnography that accepts plurality as an intrinsic and nonreducible aspect of all medical practice. For this purpose I relate ethnographic descriptions from my fieldwork in Beijing, China, to models about the interrelation between knowledge, technology, society, and self that have been developed in medical anthropology and the interdisciplinary field of science and technology studies (sts). As a result of this dialogue I advance two propositions. The first is negative. It states that Chinese medicine in contemporary China is not a totality. By this I mean that the visible pluralities of Chinese medicine I describe are not reducible to a singular cultural logic or process of cultural production. The second proposition is positive. It argues that Chinese medicine in contemporary China can be modeled as a dynamic process of simultaneous emergence and disappearance. By this I mean that Chinese medicine and the multiple and heterogeneous elements that constitute it are best described as emergent global states, or syntheses, that are produced by local interactions of human and nonhuman elements, or infrastructures. Accounting for and describing the plural and often dispersed interactions at local levels that create, support, destabilize, and tear apart global coherences that are never more than temporarily stable thereby emerges as the new task of any anthropology of medicine.

Ethnographic Orientations

The ethnographic fieldwork on which this book is based was carried out predominantly in Beijing, where I stayed for a total of sixteen months between 1994 and 1999. The final writing up was carried out in Shanghai, where I was able to collect valuable information at local libraries. During my fieldwork in Beijing I observed more than four thousand treatment episodes while working with venerated senior physicians (laozhongyi [TEXT NOT REPRODUCIBLE IN ASCII]); senior consultants (zhuren yishi [TEXT NOT REPRODUCIBLE IN ASCII]); attending physicians (zhuzhi yishi [TEXT NOT REPRODUCIBLE IN ASCII]); undergraduate (benkesheng [TEXT NOT REPRODUCIBLE IN ASCII]), master’s (shuoshisheng [TEXT NOT REPRODUCIBLE IN ASCII]), and doctoral students (boshisheng [TEXT NOT REPRODUCIBLE IN ASCII]); as well as doctors undertaking further training (jinxiusheng [TEXT NOT REPRODUCIBLE IN ASCII]). I attended institutions that ranged from large university teaching hospitals to pharmacies, from prestigious clinics employing only famous physicians to a clinic operated in the evenings from a one-bedroom apartment.

My status as a practitioner of Chinese medicine provided me with numerous opportunities to engage directly with patients. For a while I was the physician-in-residence for the staff of the guesthouse at which I lived. I was invited to conduct many impromptu consultations with perfect strangers in shops and markets and also during one memorable thirty-six-hour bus journey. I developed close relationships with several physicians and their families, with students and laypeople. All of these facilitated my access to contemporary Chinese medicine by a number of routes: from daily discussions with fellow students to semistructured interviews with ten Beijing households concerning specific illness episodes; from a longitudinal observation of a doctoral research project to a quasi apprenticeship with one of my teachers.

Continues…
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