History of Integrative Medicine in Hong Kong
Dr Edwin Chau-leung YU
Honorary President, Hong Kong Association for Integration of Chinese-Western Medicine
INTRODUCTION
With Chinese medicine (CM) deeply rooted in Hong Kong’s Chinese culture, empirical practice of CM has been the norm since the early days of Hong Kong. Western medicine (WM) had its humble beginnings in Hong Kong in the form of established services for colonial government staff; WM was subsequently extended to the Chinese population through missionary efforts. The scourge of the plague pestilence in 1894 gave WM an advantage whence enforced laws and regulations and the swing to scientific philosophy set a trend that snowballed WM dominance.
Since the late 19th century, Hong Kong residents have been seeking treatment from both CM and WM. CM was given an official status by the Basic Law in 1997. There came about the Chinese Medicine Ordinance in 1999 and the humble beginnings of Integrative Medicine.
Since the late 19th century, Hong Kong residents have been seeking treatment from both CM and WM. CM was given an official status by the Basic Law in 1997. There came about the Chinese Medicine Ordinance in 1999 and the humble beginnings of Integrative Medicine.
THE FOUNDING AND MISSION OF THE HKAIM
In 1999, a group of doctors with CM training gathered to study how CM could become useful in the Hong Kong medical scene. With the guidance of academic advisers, these doctors held meetings on various logistical, legal and academic aspects. Around this time, the University of Hong Kong formed a liaison with the Chinese Association of Integrative Medicine (CAIM) in Beijing. In 2001, spearheaded by Professor SP Chow, the brainstorming group of Hong Kong doctors, scientists, and university professors in WM and CM joined hands and formed the Hong Kong Association for Integration of Chinese-Western Medicine (HKAIM). Since then, the HKAIM has led the development of Integrative Medicine (IM) in Hong Kong at four broad levels:
1. Socio-economic-political level,
2. Professional and bedside practice level,
3. Education and training level, and
4. Research and basic conceptual level.
2. Professional and bedside practice level,
3. Education and training level, and
4. Research and basic conceptual level.
The Association gained steady momentum under the leadership of its successive presidents, Shew-ping Chow, Wing-man Ko, Vivian Chi-woon Taam-Wong, Edwin Chau-leung Yu, Zhao-xiang Bian and Kahang Or. The HKAIM expanded to over 700 members inclusive of doctors, nurses, therapists, pharmacists, scientists and students. A good fraction of the members on the HKSAR Chinese Medicine Development Committee (CMDC) formed in 2013 were members of HKAIM. The Association has worked very hard to promote a dialogue between the practitioners in both fields. Indirectly, through its key members, the HKAIM has also impacted policies at the universities, the Hospital Authority (HA), the Department of Health (DH) and the Food & Health Bureau (FHB).
THE DEVELOPMENT OF INTEGRATIVE MEDICINE
Along with the HKAIM as the formal common platform for WM and CM came increasing cross-discipline interaction and development. The SARS epidemic in 2003 made an important milestone for such crossdiscipline fertilization. While our city was baffled by a life-threatening infection which WM offered no definitive medical solution, news of good recovery from SARS traveled in from Mainland China. The HKAIM invited while HA engaged the CM professors with SARS experience in Guangzhou to travel to Hong Kong to share their expertise. Their presence in the local scene2 enabled the setup of protocols incorporating CM as a research arm in the HA service, leading to the establishment of the post-SARS tripartite CM clinics run by the HA, universities and non-governmental organisations (NGO) as well as the establishment of Centres for Training and Research (CMCTR) working to provide evidence-based CM service and training for CM graduates, targeting to enhance healthcare delivery in the public sector.
The vision for the development of IM has evolved. To start with, the mainland developed a good environment for IM through support in clinical practice, training, scientific research and policy making. Awareness of different local and global policies and systems started our Hong Kong IM approach. It involves quality practice, mutual development and research projects from different disciplines. The system, recognised by mainland officials, is to bring the two streams of CM and WM together. The following describes some major IM activities.
The vision for the development of IM has evolved. To start with, the mainland developed a good environment for IM through support in clinical practice, training, scientific research and policy making. Awareness of different local and global policies and systems started our Hong Kong IM approach. It involves quality practice, mutual development and research projects from different disciplines. The system, recognised by mainland officials, is to bring the two streams of CM and WM together. The following describes some major IM activities.
EDUCATION: MAGNIFYING CM EXPERTISE AND WM UNDERSTANDING
A. From CM to WM
Degree programmes were set up at the Hong Kong Baptist University (HKBU) in 1998, and subsequently at the University of Hong Kong (HKU) and the Chinese University of Hong Kong (CUHK). Master degree courses were offered. M.Ph, Ph.D and post Doctorate positions are mostly for CM research.
The Chinese Medicine Council of Hong Kong has run a continuing medical education (CME) programme since 2004. The HKAIM, often in collaboration with HA, has been active in providing educational seminars in which WM specialists and CM experts together expound on how diseases can be best managed. CM associations and UGC-funded programmes delivering CM lectures at different universities, as well as various conferences and seminars, would nowadays also invite WM specialists as speakers. Since 2009, CM graduates are offered 3-year in-service training programme at the tripartite clinics3. Scholarships have also been set up to train potential leaders in CM specialties in renowned centres in Mainland China. A broader audience of CM & WM professionals, academics and managers have joined annual conferences of the International Conference on Modernised Chinese Medicine (ICMCM) since 2002, those of Consortium for Globalization of Chinese Medicine (CGCM) since 2003, and seminars on CM developments held by the Innovation and Technology Commission (ITC) since 2013.
The Chinese Medicine Council of Hong Kong has run a continuing medical education (CME) programme since 2004. The HKAIM, often in collaboration with HA, has been active in providing educational seminars in which WM specialists and CM experts together expound on how diseases can be best managed. CM associations and UGC-funded programmes delivering CM lectures at different universities, as well as various conferences and seminars, would nowadays also invite WM specialists as speakers. Since 2009, CM graduates are offered 3-year in-service training programme at the tripartite clinics3. Scholarships have also been set up to train potential leaders in CM specialties in renowned centres in Mainland China. A broader audience of CM & WM professionals, academics and managers have joined annual conferences of the International Conference on Modernised Chinese Medicine (ICMCM) since 2002, those of Consortium for Globalization of Chinese Medicine (CGCM) since 2003, and seminars on CM developments held by the Innovation and Technology Commission (ITC) since 2013.
B. From WM to CM
To increase mutual understanding, it is imperative that CM practitioners acquire more knowledge about WM practice. In Mainland China, IM started with WM doctors learning CM in the 1950s. In Hong Kong, the part-time CM degree courses organised by SPACE of HKU in the 1990s played a significant role in grooming certain WM doctors who had attended these courses as IM leaders. The HA organises CM certificate courses for WM doctors to promote CM-WM communication. In 2017, the HKAIM made a breakthrough in promoting clinical IM via interactive workshops in which a mixed WM-CM panel offered expert-led clinical and caseillustrative discussions while one third of the audience were WM practitioners.
Since 2003, the HKAIM, in collaboration with the HA, organise conferences involving both local and global academicians as speakers, covering a broad range of topics including cancer, infectious diseases, cerebrovascular and cardiovascular diseases, skin diseases, pain acumoxa, acupuncture, geriatrics, chronic diseases, Chinese Medicine Hospital operation, and IM. Since 2013, the HKAIM has run courses, with good response, as these courses enable the CM practitioners to learn directly from WM experts so that the CM practitioners could understand the whole spectrum of WM.
Since 2003, the HKAIM, in collaboration with the HA, organise conferences involving both local and global academicians as speakers, covering a broad range of topics including cancer, infectious diseases, cerebrovascular and cardiovascular diseases, skin diseases, pain acumoxa, acupuncture, geriatrics, chronic diseases, Chinese Medicine Hospital operation, and IM. Since 2013, the HKAIM has run courses, with good response, as these courses enable the CM practitioners to learn directly from WM experts so that the CM practitioners could understand the whole spectrum of WM.
SERVICES
A. Service Provision
The HA, tasked with developing one CM Clinic in each district since 2000, built up tripartite collaboration involving the HA, the universities, and NGOs and formed the 18 CMCTRs. Clinical IM protocols were developed in Kwong Wah Hospital (KWH). CM services were all along provided only in clinics. The first primary care clinic with CM-WM joint consultation was started by HKBU in Queen Elizabeth Hospital in 2006.
Since 2007, HKBU has collaborated with the Hong Kong Anti-Cancer Society to provide integrative CM and WM service, including but not limited to stroke rehabilitation, pain syndrome, and late-stage cancer with 6 inpatient beds in the Nam Long Hospital, which Cancer Society Jockey Club Cancer Rehabilitation Centre. These two institutions started the Dr & Mrs Michael SK Mak Integrated Chemotherapy Centre for cancer patients in 2012.
Since 2007, HKBU has collaborated with the Hong Kong Anti-Cancer Society to provide integrative CM and WM service, including but not limited to stroke rehabilitation, pain syndrome, and late-stage cancer with 6 inpatient beds in the Nam Long Hospital, which Cancer Society Jockey Club Cancer Rehabilitation Centre. These two institutions started the Dr & Mrs Michael SK Mak Integrated Chemotherapy Centre for cancer patients in 2012.
Within a decade, there has been much IM development: geriatric services in Princess Margaret Hospital (PMH), FungYiu King Hospital, Shatin Hospital, and Haven of Hope Hospital; the Duchess of Kent Children's Hospital introduced neurological rehabilitation3. This movement later expanded to allow WM inpatients to request for referral for CM services with parallel or sequential CM/ WM consultation and intervention. More than 20 hospitals are now providing some degree of such service. Evidence-based medicine (EBM) is being held as the key principle that the Government steers the development of services integrating CM and WM.
IM for specific diseases include early treatment for mental health at the Tang Shiu Kin CMCTR collaborating with clinical psychologists from Queen Mary Hospital and CM practitioners trained at Kowloon Hospital. Acute low back pain was piloted at the Accident & Emergency Department in Pok Oi Hospital. In response to the growing demand for pain management in cancer patients, multiple initiatives have been undertaken. At the Prince of Wales Hospital Cancer Centre, acupuncture has been used for pain in advanced cancer. The Ha Kwai Chung CMCTR, along with the Cancer Centre of PMH, explored IM services to provide comprehensive services for cancer patients. Ngau Tau Kok Chinese Medicine Centre and the United Christian Hospital collaborated in trials of CM and WM for treating chronic pain with acupuncture and/or massage. Finally, for low back pain, stroke and cancer, IM service protocols were upgraded via the Integrated Chinese-Western Medicine (“ICWM”) Pilot Programme by the HA in 2014.
The year 2013 marked the Government’s initiation of the CM hospital. It will operate under the collaboration between CM and WM. In 2018, the Chinese Medicine Hospital Project Office was set up under FHB to plan and develop the CM Hospital for 400 beds.
IM for specific diseases include early treatment for mental health at the Tang Shiu Kin CMCTR collaborating with clinical psychologists from Queen Mary Hospital and CM practitioners trained at Kowloon Hospital. Acute low back pain was piloted at the Accident & Emergency Department in Pok Oi Hospital. In response to the growing demand for pain management in cancer patients, multiple initiatives have been undertaken. At the Prince of Wales Hospital Cancer Centre, acupuncture has been used for pain in advanced cancer. The Ha Kwai Chung CMCTR, along with the Cancer Centre of PMH, explored IM services to provide comprehensive services for cancer patients. Ngau Tau Kok Chinese Medicine Centre and the United Christian Hospital collaborated in trials of CM and WM for treating chronic pain with acupuncture and/or massage. Finally, for low back pain, stroke and cancer, IM service protocols were upgraded via the Integrated Chinese-Western Medicine (“ICWM”) Pilot Programme by the HA in 2014.
The year 2013 marked the Government’s initiation of the CM hospital. It will operate under the collaboration between CM and WM. In 2018, the Chinese Medicine Hospital Project Office was set up under FHB to plan and develop the CM Hospital for 400 beds.
B. Patient-driven IM service and referral systems
Studies in Hong Kong showed that, over the years, some 40% of chronically ill patients use both CM and WM at the same time. In this patient-driven clinical setting, CM practitioners not only use techniques from traditional CM theory and practice but also utilise modern CM research results. In the CM clinic of the HKU, for example, CM oncologists will take into account patients’ WM data and will use CM and coordinate herbal actions according to the tumour types, stages, and stage of WM treatment.
For the government, CM has to be promoted on the basis of evidence-based Chinese medicine (EBCM). For frontline practitioners of both disciplines, mutual respect and acceptance arise from mutual trust built during interactions in a conducive system/environment. In 2014, the Hong Kong Institute of Integrative Medicine (HKIIM) embarked on IM clinics staffed by both CM and WM professionals; mutual referrals are facilitated by specialised nurses.
For the government, CM has to be promoted on the basis of evidence-based Chinese medicine (EBCM). For frontline practitioners of both disciplines, mutual respect and acceptance arise from mutual trust built during interactions in a conducive system/environment. In 2014, the Hong Kong Institute of Integrative Medicine (HKIIM) embarked on IM clinics staffed by both CM and WM professionals; mutual referrals are facilitated by specialised nurses.
RESEARCH
Interest of WM workers in CM started early since the 1970’s. Acupuncture for heroin addicts pioneered original research. That for induction of labour in post term pregnancies was studied. Development of mouse models for CM patterns in spinal condition, and herbal medicine for prevention of amputation in diabetic gangrene were other pioneering examples.
A. Seeking Good Evidence-based CM
There are some pillars to build up evidence-based medicine in IM. For one, evidence of CM effectiveness for diseases needs to be demonstrated. For the major disease burdens, the HA commissions systematicreviews of RCTs and new RCTs, resulting in many publications in English peer-reviewed journals. Since 2009, research training courses have been offered to CMPs in CMCTRs to enhance their basic knowledge.
Besides, clinical research activities need to be promoted. HKBU started clinical research on irritable bowel syndrome, functional constipation, rheumatoid arthritis, and Parkinson's disease. CUHK conducts research on diabetes, hepatitis, lung cancer, asthma, rheumatism, carpal tunnel syndrome, gallstone, multiple sclerosis, and functional gastrointestinal diseases. HKU combining principles and methods of traditional and modern medicine, works on the prevention and treatment of cardiovascular and cerebrovascular diseases, neuropsychiatric diseases, chronic pain, and malignant tumours as well as acupuncture and its effectiveness and mechanisms. Other universities in Hong Kong also establish their CM institutes. Work is also done for modernising CM. HKUST with years of neuroscience research worked up >100 herbs for neurodegenerative diseases, Parkinson’s disease and depression. After 2010, HA has established a mechanism to commission and review Chinese medicine (CM) research projects. Topics include CM-WM interactions, obesity, traumatic brain injury and insomnia, dysphagia after swallowing, etc.
Besides, clinical research activities need to be promoted. HKBU started clinical research on irritable bowel syndrome, functional constipation, rheumatoid arthritis, and Parkinson's disease. CUHK conducts research on diabetes, hepatitis, lung cancer, asthma, rheumatism, carpal tunnel syndrome, gallstone, multiple sclerosis, and functional gastrointestinal diseases. HKU combining principles and methods of traditional and modern medicine, works on the prevention and treatment of cardiovascular and cerebrovascular diseases, neuropsychiatric diseases, chronic pain, and malignant tumours as well as acupuncture and its effectiveness and mechanisms. Other universities in Hong Kong also establish their CM institutes. Work is also done for modernising CM. HKUST with years of neuroscience research worked up >100 herbs for neurodegenerative diseases, Parkinson’s disease and depression. After 2010, HA has established a mechanism to commission and review Chinese medicine (CM) research projects. Topics include CM-WM interactions, obesity, traumatic brain injury and insomnia, dysphagia after swallowing, etc.
B. Promoting Evidence-based Practice of CM
Another pillar is at the practice level. The CM Research Practical Training programme was launched to enhance CM Practitioners’ competency and CMCTRs’ capacity for evidence-based practice. Since 2017, CUHK’s Integrative Medicine Clinical Evidence Portal4 offers topractitioners a search engine for evidenced-based CM usage and practice, as Asia’s first CM clinical evidence on-line portal, gathering studies from around the world. Placing CM with WM on the same electronic platform for HA data coding in the Clinical Management Information System (CMIS) using the system from the mainland, it has impacts by contributing significantly in the development of the new electronic version of the 2019 International Classification of Diseases (ICD 11) after being put forward to WHO in 2011.
Details are necessary for safer CM-WM collaboration. A CM Toxicology Laboratory was built in PMH to support or refute diagnosis of herbal toxicity. The HA eKG intranet was enriched with a 'herb-drug interaction database' arising from commissioned scientific reviews. Government in 2011 formed the Committee on Research and Development of Chinese Medicine. ITC seminars in conjunction with HA and DH discussed CMWM CMWM collaboration, exchanging EBM experiences and researches on CM and WM complementarity.
Details are necessary for safer CM-WM collaboration. A CM Toxicology Laboratory was built in PMH to support or refute diagnosis of herbal toxicity. The HA eKG intranet was enriched with a 'herb-drug interaction database' arising from commissioned scientific reviews. Government in 2011 formed the Committee on Research and Development of Chinese Medicine. ITC seminars in conjunction with HA and DH discussed CMWM CMWM collaboration, exchanging EBM experiences and researches on CM and WM complementarity.
C. Opening Wider Perspectives for CM Research
The year 2014 was a special year for IM advancement. HKIIM of CUHK, the ICWM Pilot Programme for HA in-patients, and the CM hospital were started. The Endowed Professor in IM in HKU was established earlier.
Government has reserved a piece of land at Tseung Kwan O for the CM hospital with facilities to support teaching, clinical practice and scientific research of the SCMs under the three Universities.
HKIIM developed a comprehensive platform with research and development, clinical service and teaching. Collaboration between different disciplines and scholars from different areas under models of safe and effective IM treatment is expected to achieve breakthrough results. On common chronic conditions with unmet needs in treatment, including functional gastrointestinal disorder, neurodegenerative disease and palliative medicine, IM clinical trials were initiated. The Analytic and Clinical Cooperative Laboratory for Integrative Medicine (ACCLAIM) is a joint platform for scientists and clinicians in sharing information technology, data analysis, and clinical research for the advancement of evidence-based IM. It has a focus on downstream applied clinical research, with translational deliverables and big-data applications in clinical trials, building on an established international collaboration network.
Government has reserved a piece of land at Tseung Kwan O for the CM hospital with facilities to support teaching, clinical practice and scientific research of the SCMs under the three Universities.
HKIIM developed a comprehensive platform with research and development, clinical service and teaching. Collaboration between different disciplines and scholars from different areas under models of safe and effective IM treatment is expected to achieve breakthrough results. On common chronic conditions with unmet needs in treatment, including functional gastrointestinal disorder, neurodegenerative disease and palliative medicine, IM clinical trials were initiated. The Analytic and Clinical Cooperative Laboratory for Integrative Medicine (ACCLAIM) is a joint platform for scientists and clinicians in sharing information technology, data analysis, and clinical research for the advancement of evidence-based IM. It has a focus on downstream applied clinical research, with translational deliverables and big-data applications in clinical trials, building on an established international collaboration network.
The ICWM Pilot Programme cumulates experience on ICWM in-patient care for realizing a model/ framework at the system level. With protocols for treating defined target patient groups basing on the best available evidence, and with treatment objectives of CM and WM streams defined and complementing each other for patient care, treatment outcomes can be monitored for overall evaluation. A clinical framework was developed to guide disease selection, service scope, clinical management and managing clinical risks. An operation framework functions to guide patient flow, organization of care processes and development of infrastructure systems. Three disease areas including stroke care, low back pain care and cancer palliative care were chosen, being joined by three and later seven public hospitals. The Phase III launched in 2018 additionally includes shoulder and neck pain care. The experiences learnt would be of value for the further development of ICWM in Hong Kong.
D. Supported with Funders
The Innovational and Technology Fund of ITC, the Health and Medical Research Fund (HMRF), and the Research Grants Council (RGC) provide good funding sources. Researches range from studies on attitudes and behaviours towards the use of Traditional CM, integrated approach to treatment using CM and WM for diseases, understanding the mechanism and application of herbs in diseases, and better designs to study the efficacy of CM and IM, and better rehabilitative and palliative management. Another direction is to develop new useful CM products, and finding active ingredients from herbs. Funders would emphasise the purpose of such researches, the basic and clinical research contributions, and the impact to combine the research outputs into practice. The better defined the local needs together with success to advance into international domains will draw better support.
FUTURE: APPLYING IM FOR COMMUNITY USE
While much has been done in public hospitals, it is in the community, where CM can play an advantageous role for chronic diseases, and side by side CM-WM practice can bring people better health. Facilitative details are needed for WM-CM coordination and communication. Since 2015, HKAIM started an Integrative Joint Organisational Platform (IJOP), with the objective to build a conducive environment for CM-WM collaborative practice5. It focuses on using quantitative and qualitative inter-professional approaches as the basis for exchanging experience and ideas to compose good details for collaboration while creating opportunities and avenues of CM-WM collaboration in the community.
HKAIM public education went into the media with RTHK in 2004, with alternating WM and CM experts in programmes on clinical problems. It was restarted as a long series of weekly programmes after 2013, presenting evidenced knowledge of herbal formulae and CM/IM practices to the public, as these capture the interests of WM doctors. An Internet platform eKG for public information, education and research was built by HA in 2011 and revised in 2015.
In Hong Kong, integrating CM and WM is to have the two streams collaborating, by jointly determining the diagnosis and observing clinical management of patients. The purpose is to combine the advantages of the two medical disciplines, strengthen the results of clinical curative effects, and minimise the side effects in the course of medical treatment. Then effective applications may make possible the formulation of a plan that is most suitable for the patient to accelerate recovery.
HKAIM public education went into the media with RTHK in 2004, with alternating WM and CM experts in programmes on clinical problems. It was restarted as a long series of weekly programmes after 2013, presenting evidenced knowledge of herbal formulae and CM/IM practices to the public, as these capture the interests of WM doctors. An Internet platform eKG for public information, education and research was built by HA in 2011 and revised in 2015.
In Hong Kong, integrating CM and WM is to have the two streams collaborating, by jointly determining the diagnosis and observing clinical management of patients. The purpose is to combine the advantages of the two medical disciplines, strengthen the results of clinical curative effects, and minimise the side effects in the course of medical treatment. Then effective applications may make possible the formulation of a plan that is most suitable for the patient to accelerate recovery.
ACKNOWLEDGEMENT
We thank with much appreciation for the help and contributions in writing from Vivian Taam-Wong, Wailun Cheung, Justin Wu, Yi-bin Feng, Zhao-xiang Bian and Shew-ping Chow who provided stimulating informative guides on developments in HA and the Universities.
The author apologies for limitations in embrasure of modernisation of CM and herb-pharmacy, of nursing and paramedical developments, the herbal industry, and other research and funding institutions.
The author apologies for limitations in embrasure of modernisation of CM and herb-pharmacy, of nursing and paramedical developments, the herbal industry, and other research and funding institutions.
(Originally published at The Hong Kong Medical Diary Vol. 23 No. 10 : Integrative Chinese-Western Medicine in Hong Kong)