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Adam Burke, PhD, MPH, LAc, Yim-Yu Wong, PhD and Zoe Clayson, ScD

Adam Burke is with the Institute for Holistic Healing Studies, Department of Health Education, San Francisco State University, Calif. Yim-Yu Wong is with the Department of International Business, College of Business, San Francisco State University. Zoe Clayson is with the Department of Health Education, San Francisco State University.

Correspondence: Requests for reprints should be sent to Adam Burke, PhD, MPH, LAc, Department of Health Education, San Francisco State University, 1600 Holloway Ave, San Francisco, CA 94132 (e-mail: aburke{at}sfsu.edu).

	INTRODUCTION

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
In the United States, traditional Chinese medicine (TCM) is recognized by the National Institutes of Health as an effective complementary and alternative medicine modality, widely used by consumers and growing as a profession.^1–3 Ironically, while TCM is expanding in the United States, it may be contracting in China as a result of dramatic health care reforms and changing cultural values. There is, however, little information in Western literature explicitly delineating the impacts of these forces on TCM. The purpose of this inquiry was to interview a sample of select respondents, particularly individuals from a major Chinese college of traditional medicine, regarding their perceptions of the field. The results provided insight into the survival and assimilation of indigenous health systems in a modern world.

In the late 1970s, Deng Xiao Ping introduced elements of the market economy into China. During the 1990s, significant health care reforms were also initiated. These reforms placed a new emphasis on profitability, economic autonomy for health facilities, and decentralization of public health services and contributed to the demise of the rural cooperative medical system.^4–6 These reforms also produced fundamental changes in health care financing, including replacing free universal health care with fee-for-service and private insurance strategies.^4,7 This has contributed to increased medical care costs, higher out-of-pocket expenses, growing inequity in access, a reduction of prevention programs in poor areas, and pricing policies that encourage overprescribing drugs and high-tech services.^4,7,8–10 As a significant percentage of all health care delivered in China is in the form of traditional treatments,¹¹ such reforms will invariably affect this ancient healing system as well.

	METHODS

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
Field interviews of key respondents were conducted to assess the potential impacts of reform. The primary interview site was the Chengdu University of Traditional Chinese Medicine (CUTCM), one of the major traditional medical schools in China. CUTCM is located in Chengdu, a modern city of 10 million people, and the capital of Sichuan Province. Sichuan is well known as a premier region for medicinal herb cultivation and sales.

A convenience sample of 14 individuals was selected for their knowledge of TCM and Chinese culture. It included journalists, CUTCM hospital administrators, clinicians, faculty, a graduate of CUTCM who had just completed her bachelor’s degree and was leaving for graduate public health study in the United States, and a Western student working on his TCM master’s degree (n = 14, female 50%, age range 23 to 57 years). Although this was a nonrepresentative sample, with generalizability limitations, these select individuals were able to provide diverse and informed perspectives on this issue.

Semistructured 1-hour interviews were conducted during a 2-week period in June 2001. Questions were based on the hypothesized impact of health care reforms on TCM. They included questions on perceived changes in utilization, relationships of such changes to health care reform, and the status of TCM in modern China.

	RESULTS

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
The respondents’ narratives were content analyzed using a grounded theory approach.¹² The following 4 major themes emerged:

1. Structural Changes
TCM services face increased competition from for-profit Western medical hospitals, clinics, and pharmacies, have more uninsured patients with higher out-of-pocket payments, and feel impacts of policies that encourage prescribing drugs and high-tech services. One administrator reported that these reforms "have provided consumers with more options and that has impacted utilization of services at CUTCM."

2. Modern Values
Culturally there has been a shift toward Western medicine among younger, educated people. Several of the journalists expressed this sentiment. One of them referred to TCM as "antiquated, nonscientific, and based on superstition." Even students attending TCM colleges often pursued non-TCM careers in Western health care settings on graduation.

3. Lifestyle Factors
The move toward Western medicine parallels peoples’ increasingly busy lifestyles. One clinician noted, "People do not have time for frequent visits or preparing herbal teas."

4. Alternative to Western Medicine
Despite cultural changes, many individuals still seek TCM because it is effective and offers a more personalized and pleasant patient-provider experience. One doctor stated, "The patients come back because the staff listens and offers encouragement and support."

	DISCUSSION

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
The results of these interviews on TCM parallel the published information on the impact of health reforms on Western health services. Pressures to modernize, Westernize, and compete globally are potentially reducing the cultural significance of TCM. As China’s population grows, economic disparities widen, and health care costs escalate, this may not be a prudent course. The availability of effective, low-cost traditional medicines may ultimately become a critical resource. It may be wise for China, the United States, and other countries to examine ways to assist and promote their own indigenous health systems. The loss of such systems through modernization and unsupportive health care policies may remove a valuable source of care for individuals who may be culturally and linguistically isolated from conventional services. True pluralism in health care creates a resource that is socially desirable and important to preserve.

	Acknowledgments

 
This investigation was supported by a Research Infrastructure in Minority Institutions award from the National Center for Research Resources with funding from the Office of Research on Minority Health, National Institutes of Health P20–RR11805.

Human Participant Protection

The protocol was approved by the San Francisco State University committee for the protection of human subjects.

	Footnotes

 
Contributors

A. Burke designed the study and conducted the surveys, analyzed the data, and wrote the brief. Y.-Y. Wong contributed to writing of the paper, providing expertise in Chinese economics. Z. Clayson assisted with data analysis and writing of the brief.

Peer Reviewed

Accepted for publication August 21, 2002.

	References

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
1. NIH Consensus Conference. Acupuncture. JAMA.1998;280:1518–1524.[Abstract/Free Full Text]

2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA.1998;280:1569–1575.[Abstract/Free Full Text]

3. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA.1998;280:788–794.[Abstract/Free Full Text]

4. Bloom G, Xingyuan G. Health sector reform: lessons from China. Soc Sci Med.1997;45:351–360.

5. Carrin G, Ron A, Hui Y, et al. The reform of the rural cooperative medical system in the People’s Republic of China: interim experience in 14 pilot counties. Soc Sci Med.1999;48:961–972.

6. Wong VC, Chiu SW. Health-care reforms in the People’s Republic of China—strategies and social implications. J Manage Med.1998;12:270–286.

7. Hesketh T, Zhu WX. Health in China. The healthcare market. BMJ.1997;314:1616–1618.[Abstract/Free Full Text]

8. Gao J, Tang S, Tolhurst R, Rao K. Changing access to health services in urban China: implications for equity. Health Policy Plann.2001;16:302–312.[Abstract/Free Full Text]

9. Hu TW, Ong M, Lin ZH, Li E. The effects of economic reform on health insurance and the financial burden for urban workers in China. Health Econ.1999;8:309–321.[Medline]

10. Liu X, Liu Y, Chen N. The Chinese experience of hospital price regulation. Health Policy Plann.2000;15:157–163.[Abstract/Free Full Text]

11. Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ.1997;315:115–117.[Free Full Text]

12. Charmaz K. Grounded theory: objectivist and constructivist methods. In: Norman D, Yvonna L, eds. Handbook of Qualitative Research. Thousand Oaks, Calif: Sage Publications; 2000:509–536.

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