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SARS AND CHINESE MEDICINE
How the Chinese People and Institutions Responded with Herbs
Note: At the time of this writing, the SARS epidemic was largely under control outside of China and Taiwan. Unless the epidemic unexpectedly springs up again, there will be relatively little concern outside China about using herbal therapies to prevent or treat it; there are reasonable expectations that modern medical interventions, such as antivirals and immunizations, will be ready within a year. Nonetheless, it is of interest to see what herbs the Chinese people turned to first, to understand how Chinese herbs are utilized in their native land to prevent and treat infectious diseases. It is one thing to recite the theories of traditional Chinese medicine and to go through the list of traditional remedies published in textbooks, and another to learn about the actual response, which may be different. By examining this response, including institutional reactions to the situation, it may be possible to gain new perspectives on Chinese views of herbs and their effects.
SARS (Severe Acute Respiratory Syndrome) appeared suddenly in the news during March 2003, but cases of the syndrome had been observed at least five months earlier as an unusual type of pneumonia described in Guangdong province, China. In December, health workers there had relayed their worries about this disease to authorities who, unfortunately, did not respond effectively. The first official case, with the disease being named SARS, was described later by a visiting Italian doctor in Vietnam. On February 26th, a man was admitted to a hospital in Hanoi with high fever, dry cough, muscle soreness, and mild sore throat. Over the next four days, he developed increasing breathing difficulties, severe thrombocytopenia (low platelet count) and signs of respiratory distress syndrome requiring ventilator support.
By March 18, over 200 cases and 4 deaths had been reported. During a period of just three weeks afterward, the number of SARS cases soared to over 2,000, with about 75 deaths, which triggered the alarms worldwide. The spread of the disease then slowed from this exponential growth rate seen in March and early April, to a linear rate of nearly 1,000 new cases per week until mid-May while frantic steps were taken to inhibit its spread. The disease was then largely confined to China (including Hong Kong and Taiwan), where the infection rate has since slowed further to about 600/week. At the time of this writing (end of May 2003), the World Health Organization cites about 8,300 cumulative cases worldwide, most of them in China, Hong Kong, and Taiwan, with about 750 deaths (about 9% of those infected); the rate of new cases has declined dramatically to less than 300 per week.
The elderly and those with other health problems are at highest risk of fatality from SARS. Most people recover from the disease, though it may take several weeks to do so, and the number of SARS cases reported in the media refers to the cumulative total, not the number of people who are sick at any one time. There have been tentative reports of relapses in those who recovered, though these appear to be other ailments, not recurrence; most people recover completely.
The main effective preventive measure for SARS is to quarantine those already infected (or likely to have been infected) coupled with actions that reduce the spread of the disease that could occur with crowding (e.g., cancellation of school classes and business meetings, reduced air travel between the main disease areas and the rest of the world). Beijing, which has been hard hit by the disease, had to take extraordinary measures, stopping most gatherings of people to minimize the chance of spread of the disease in crowds and restricting travel in and out of the city. Depending on where infected people now are, the disease may remain reasonably contained or may again spread rapidly. It was reported that there are cases of SARS suspected in some remote areas of China, which indicates a potential for a sudden spread due to inability to effectively quarantine people in these areas.
A problem with SARS control, which may also be the key to preventing its further spread, is that there appear to be a small number of individuals who become "superspreaders:" one person infects many others. For example, the epidemic in Toronto that led to the city being temporarily put on the WHO list of places to avoid, was generated by a single "superspreader." The infection came into the city just once; from Toronto, the disease was spread to the Philippines by a single traveler; the disease reappeared in Toronto at the end of May after several weeks of apparent successful control, the result of one lingering case causing 35 suspected new cases. Preventing a few superspreaders from contact with others and from traveling to uninfected areas during the time they are contagious could greatly limit the epidemic. The disease also may have a seasonal aspect, flaring up during the usual cold/flu season, and then fading during the summer.
It was quickly understood that SARS is due to a coronavirus (illustrated below, named for the array of projections), and this one was genetically mapped following three weeks of day and night work by Canadian researchers. SARS has been renamed Corona Virus Pneumonia (CVP), but the original term is still used. Other coronaviruses are a common cause of mild to moderate upper-respiratory illness in humans; they are associated with respiratory diseases in animals; animals may also experience gastrointestinal, liver, and neurologic diseases from coronaviruses. These viruses are known to survive in the environment for as long as three hours, but with SARS, there is evidence already that it can remain in the environment for longer under optimal conditions. For example, it was found to survive for two days on plastic at room temperature. The virus is excreted in urine and feces and may remain in sewage for days; a major outbreak in a Hong Kong apartment complex was traced to a leaky sewage pipe.
The origin of the disease is believed to be a virus in an animal or group of animals that was brought into Guangdong province of China and transmitted to a person or group of people, who then spread it to other people. Guangdong is a crowded province with much intermingling of human and animal populations, especially with chickens and pigs. A likely explanation for the origin of the current epidemic is that a wild animal from a remote forest was brought into a Guangdong meat market, and the virus was transmitted during handling. It was noted that an unusually high number of food handlers were among the first people infected by the virus (about 5% of the first 900 patients diagnosed), giving some support to the idea that contact with an animal to be used as food was the starting point. Researchers have suggested that the animal that originally transmitted the disease was a type of mongoose called a "civet cat" (which is not related to cats, but has a cat-like appearance). This is a delicacy in Guangdong; a civet cat seller was among the first to get SARS in China last December.
Elisabeth Rosenthal, writing for the New York Times News Service, described a potential starting point for the disease, in the Dongyuan animal market, an hour south of Canton (Guangzhou, the main city):
In hundreds of cramped stalls that stink of blood and guts, wholesale food vendors tend to veritable zoos that will grace Guangdong province's tables: snakes, chickens, cats, turtles, badgers, frogs. They are stacked, one on top of another, in cages that in turn serve as seats, card tables, and dining quarters for the poor migrants who work there….For a corona virus, like the one that causes SARS, it would be easy to move from animals to humans in the kitchens and food stalls of Guangdong, a province known for exotic cuisine prepared with freshly killed beasts.
She relays some of the early cases:
One of the earliest victims, in December, was a seller of snakes and birds in the area who died of severe pneumonia at Shunde's First People's Hospital. His wife and several members of the hospital staff contracted it as well, setting off an outbreak that now sounds eerily familiar....Around the same time in December, Huang Xinchu, a chef, was admitted to the Heyuan People's Hospital, 100 miles to the north, ultimately infecting eight doctors there. On January 2, another desperately ill chef was hospitalized in the city of Zhongshan, south of Shunde, setting off an outbreak....Thirteen medical workers were infected, who in turn infected 15 others.
This scenario was repeated several times in January and February, at which point the epidemic was already out of the range of easy control. People leaving the area to visit other parts of China, or other parts of the world, were taking the disease with them. For example, as Rosenthal related:
On February 21, Dr. Liu Jianlu, a 64-year-old lung specialist from the Zhongshan hospital, attended his nephew's wedding in Hong Kong, even though he was running a fever. At the Metropole Hotel, where he stayed, he passed SARS to a number of other guests, including two Canadians, an American, and a man and three women in Hong Kong."
The disease began its rapid spread from that hotel, setting off a panic in that city.
The health departments in Sunde, Heyuan, and Zhongshan reported the rapidly spreading acute pneumonia to Guangdong authorities in early January. However, the messages seems to have gotten stuck there, or were considered inconsequential, as it was not until the Hanoi case of the disease was announced that the Chinese government realized what they had been experiencing for about three months. Other slow reactions, particularly in Beijing, led to disastrous consequences, as the disease appeared out of control in that city; the health minister and mayor in Beijing were dismissed for their reticence to acknowledge the extent of the disease and accompanying failure to mount an adequate defense against its spread in the early stages. In April, the central government of China ordered immediate construction of new hospitals for the sole purpose of handling SARS patients (and avoiding having these patients at other hospitals).
There are no established treatments for the SARS virus other than palliative measures (which probably save lives; in the U.S., for example, there have been no reported deaths due to SARS), but several antiviral drugs (such as Ribavirin that is used routinely for hepatitis C) have been utilized and a number of others are being tried. Since the main center of the infection has been in Southeast Asia, where herbal medicine is still a vital part of the health care system, Chinese herbs have been administered to some of the patients with SARS. But, herbs are mostly being taken by many who fear getting SARS. The results of these herbal preventative strategies are unknown. Following are news reports relaying some of these efforts, with explanations of the herbs and the traditional medicine concepts behind their selection (some information about exact case numbers at the time of the report have been edited out, as it is not relevant to the matter at hand).
Many Asians Turn to Traditional Medicine
SINGAPORE (AP) - Ginseng, chrysanthemum, white fungus [tremella] and all manner of herbal remedies are selling fast across Asia as people seek ways to ward off severe acute respiratory syndrome, the deadly flu-like disease with no proven cure.
In Singapore, where four people have died and 100 are sickened with SARS, customer Tan Ai Bee is confident she has the stuff to ward it off-five large packets of Chinese herbs and roots meant to boost immunity. "These are for fever and flu. They can help prevent the SARS virus," said Tan. "I have been taking Chinese medicines for a long time; there is no reason to lose faith in them now."
Singapore's government and others across Asia have appealed to people with sudden high fever or difficulty breathing to see a doctor. But many are self-medicating with herbal remedies, traditional medicines regarded in Asia as a reliable way to get well and stay well. Frankie Lew, a consultant physician at the Meiseido Chinese Medical Treatment Center in Singapore, said some might find comfort in the medicines, fearing that they will be quarantined if they go to a hospital.
"Some may not want to be isolated, so they come to us for cures," said Lew, consultant physician at the upscale Meiseido Chinese Medical Treatment center. Lew said many patients came to the center last week seeking herbal medicine for flu and pneumonia. No one said they had SARS, he said. Some people asked for a simple herbal soup mix of ginseng, roots, and leaves to treat pneumonia, Lew said. The herbal cocktail costs $1.13.
Items like ginseng, chrysanthemum and white fungus are selling fast, said Chiang Pin Pin, a marketing executive with Yue Hwa Chinese Products. Another hot seller is Pientzehuang-green chiretta [Pientzehuang is the brand name; andrographis is the green chiretta, called chuanxinlian in Chinese; there is also an expensive patent medicine called pientzehuang that was being recommended and may be confused here] tablets from China that are believed to reduce the chance of infections. They're almost sold out with no sign of being restocked, Chiang said. "Our suppliers in China are running out of stocks because people are rushing for the same items," said Chiang.
Ginseng is mentioned here because it is relied upon to protect a person from disease; it is also considered important in treating serious lung diseases. White fungus is a tonic that is considered beneficial as a food to prevent illness and is also commonly used to resolve lung ailments. Chrysanthemum is used to treat "wind-heat" syndromes, such as influenza, with symptoms of fever, sore throat, and cough, somewhat like what is experienced with early stage of SARS. Andrographis is a potent bitter herb that is used to treat infections; it has become a popular remedy for common cold and flu. Andrographis is classified in the Chinese system as an anti-toxin herb, where a toxin can refer to an infectious organism (pathogen). Suppliers of Chinese herbs are running low on andrographis because so many people are worried about SARS and rushing to get preventive health care products and just-in-case remedies to have at home.
From the TCM perspective, prevention of illness is usually a matter of nourishing the body to enhance its resistance to the invasion of foreign influences; for this, tonic herbs are used as one strategy. At the first stage of an infectious disease with fever, like SARS, herbs for dispelling wind-heat are given, in an effort to repel the invading pathogen and halt the disease before it takes up residence in the body. If the disease takes hold, anti-toxin herbs are then employed. Once a person becomes quite ill and debilitated by the disease, it may be time to bring in the tonics again, this time to help preserve the life of a patient who is suffering from the infection's damaging effects.
|Tremella (Tremella fuciformis; white fungus; silver ear). It is used to nourish the yin, tonify the lung, eliminate sputum, relieve cough, and calm the mind.
|Ginseng (Panax ginseng). It is used to tonify the qi, improve digestion, strengthen the lungs, alleviate coughing, and calm the mind. Substitutes include codonopsis (C. pilosula) and pseudostellaria (P. heterophylla).
|Andrographis (Andrographis peniculata; green chiretta). It is used to treat toxic heat syndromes, with the effect of alleviating fever, cough, and sore throat.
|Chrysanthemum (Chrysanthemum morifolium). It is used to dispel wind-heat, applied in early stage of febrile diseases. Some people prefer to use wild chrysanthemum (C. indicum), which has a smaller white flower.
In another story about Chinese herbs for SARS, isatis root (banlangen), which is also an anti-toxin herb used like andrographis, is featured:
Hong Kongers Throng Herb Stores as Virus Spreads
HONG KONG - Panic-stricken Hong Kong residents are crowding into Chinese medicine shops to buy herbs they hope will ward off or even cure a deadly pneumonia epidemic that is believed to have killed more than 80 people worldwide.
"Many more people are buying Chinese herbs for pneumonia these days than before. All Chinese medicine stores are very busy," said Chinese medicine practitioner Michael Pang. "There has been talk that certain prescriptions can cure atypical pneumonia and many people are buying herbs listed on those prescriptions," he added.
Doctors in hospitals have had some success treating patients using anti-viral drugs and steroids, but scientists have yet to find a specific cure for the highly infectious disease.
Though the virus is believed to be a new one, many Chinese are turning to traditional remedies, based more on centuries of experience than scientific foundation. "I'm buying this banlangen for the first time. People say it can treat atypical pneumonia," said an elderly woman, picking a pack of herbs from a shelf.
Rumors have been swirling that tea made with banlangen, a kind of dried plant root which is often used to treat problems like flu and sore throat, can cure the new disease.
But some Chinese herbalists have misgivings. "You cannot rule out its function altogether, it has worked on flu and pneumonia, but we can't say it's a specific cure for this atypical pneumonia because we don't even know what virus is causing the disease," Pang said.
Wu King-shing, another Chinese medicine practitioner, was prescribing another plant root believed to be able to fight a wide range of viruses. "I'd treat the disease with huzhang [Polygonum cuspidatum]. It can suppress many kinds of viruses, including flu virus and coronavirus and has showed very satisfactory results," Wu said. "And there is no side effect." Some Hong Kong scientists believe a new strain of coronavirus, which causes the common cold, is the primary cause for the disease. "I drink the tea every other day myself," Wu said, eagerly writing a prescription for a prospective client....
Isatis root (Isatis tinctoria; banlangen)
Polygonum cuspidatum (huzhang)
|Both herbs shown here are commonly used as broad spectrum antiviral agents.
In Hong Kong, herbs are used extensively; they are prescribed by individual herbalists or bought over the counter; however, they are not utilized in any of the modern, Western style, hospitals. An exception was made for SARS:
Hong Kong Allows Hospitals to Try Chinese Herbs for SARS
HONG KONG - Desperately searching for a cure for SARS, Hong Kong's hospitals will allow the use of traditional Chinese medicine for the first time since World War II, the city's health authority said on Monday.
The surprise move came after Hong Kong announced another six deaths from severe acute respiratory syndrome (SARS), and as more physicians and nurses in the territory began taking Chinese herbs to protect themselves against the disease. "We are open to the use of Chinese medicine," said Liu Shao-haei, senior executive manager of the Hospital Authority. "But we will see if the patient wants it, how it is to be applied and if the patient's condition allows for such alternative types of treatment," he told a news conference.
Hospitals in the city have not used traditional Chinese medicine for treatment since the Japanese occupation in the early 1940s. But the medicines, mostly derived plants, are extremely popular in the city of seven million. Since the outbreak of SARS in February, hundreds of thousands of people are using traditional recipes to ward off the disease.
Some physicians and relatives of patients in Hong Kong have been lobbying for the use of Chinese herbs to treat SARS, especially after officials recently said a cocktail of the anti-viral drug, ribavirin, and steroids was not working for a small but growing number of patients.
A team of Chinese medicine experts at Hong Kong's Chinese University put together a recipe in mid-April as part of an urgent effort to bring down the rate of infection among front-line medical staff.
Front-line healthcare workers are especially vulnerable to SARS and up to a quarter of people infected in Hong Kong are doctors and nurses who had attended to severely ill SARS patients. "Chinese medicine is most suitable for prevention of the illness and for treatment in the initial and middle stages of the illness," Dr. Cen Ze-bo, from the School of Chinese Medicine at the Chinese University, said.
Healthcare workers at the Prince of Wales Hospital, site of Hong Kong's first SARS outbreak, have been taking herbs in a granulated form, since mid-April [see below for details] The granules are dissolved in hot water and the mixture is then consumed once or twice daily. Some of its main ingredients are wild barley [coix] and banlangen [isatis root], a dried plant root [this formula is described on the next page]. Cen said the recipe was similar to those used in hospitals in China's southern province of Guangdong, where the disease first emerged in November before spreading to more than 20 countries in the last 6 weeks.
"We will need maybe a month to see how effective it is in controlling the infection rate among hospital staff," he said. Hospitals in Guangdong are using a mixture of both western and Chinese medicine to fight the epidemic, Cen noted.
"Wild barley" refers to coix (from Coix lacryma-jobi), which is mentioned in other formulations for SARS prevention. This herb, for which the grain is the part used, appears similar to barley and is sometimes called pearl barley. It contains coixenolide, a compound being researched for antiviral and anticancer effects. Coix was traditionally used for "damp-heat" problems, as occur in some cases of diarrhea and arthralgia, but it has been developed as a therapy for many other diseases in recent decades.
The granules mentioned in the article were described in this announcement:
Powdered Granules to be Delivered to Thousands of Medical Personnel
The chairman of the Administrative Committee of the Research Center of Hong Kong Chinese University, Liang Bing Zhong, yesterday revealed the ancient herbal formulae that they are manufacturing as powdered-granules. There are mainly two ancient formulae-Sang Ju Yin [Morus and Chrysanthemum Combination] and Yu Ping Feng San [Jade Screen Formula], which will include herbal ingredients that have been clinically proven to be effective for anti-viral effects [for example, isatis]. He predicted that within five days time, they can be distributed to medical personnel for their use. The prescribed herbal formula has to be taken continuously for 14 days. Hence, the research center is manufacturing the initial batch of 40,000 packets of these powdered granules (which can be consumed within 10 days). The committee is planning to provide for medical personnel first and then subsequently they can be made available to the people of Hong Kong in general.
Sang Ju Yin (made with chrysanthemum, mulberry leaf, and 6 other herbs) is well-known in China as a therapy for the early stages of common cold and influenza. Yu Ping Feng San (made of three herbs: astragalus, siler, and atractylodes) is a common therapy to prevent illness, its name indicating that it provides protection-like a screen of jade-against invaders.
Already in February, TCM doctors had publicized potential Chinese food therapies and herb therapies for preventing SARS, some of which became quite popular; as examples:
Preventative Food Recipes
Herbs for Prevention
The frequent reference to dryopteris (guanzhong) is actually to two ferns commonly used as anti-infection agents, especially for common cold and flu: Dryopteris crassirhizoma (pictured left, below) and Osmunda japonica (pictured right). Guanzhong is usually combined with other anti-infection herbs, like isatis, and provided in prepared remedies for both treating and preventing respiratory tract infections. For example, a folk practice in southern China is to treat drinking water with this herb to ward off common cold. Disease spread is also prevented by burning guanzhong with moxa (Artemisia argyi) as a fumigant. Dryopteris crassirhizoma has to be used with care, as it is toxic; Osmunda japonica is less toxic.
The main research center for Chinese herbs in Hong Kong is at the University of Hong Kong. Researchers there, utilizing traditional Chinese prescribing principles and modern research on effects of herbs, designed other formulas for use:
SARS: Chinese Herbal Medicine Prevention Prescriptions
The University of Hong Kong, School of Chinese Medicine, has devised two herbal formulas for prevention of SARS (severe acute respiratory syndrome). They say the staff at their clinics have been taking these herbal teas for more than a month and so far, none has been infected.
|SARS prevention for general use:
|SARS prevention for those of weak constitution with dampness:
The inclusion of atractylodes and pseudostellaria in both formulas reflects the idea that the pathogenic influence involved with SARS is one of "damp-heat" that damages qi and yin, causing weakness, fever, and dryness. Atractylodes addresses the damp syndrome and the antitoxin herbs (e.g., lonicera, forsythia, and isatis) address the heat syndrome; pseudostellaria (pictured right) is considered an ideal herb for tonifying qi and replenishing yin, somewhat like tremella. The original places where SARS occurred (Guangdong, Vietnam, and Singapore) have a climate that is usually hot and damp. The climate is thought to be the root of many diseases; from the modern perspective, it is the crowded conditions that most encourages spread of respiratory viruses.
On April 29, a story appeared about people lining up in Beijing to buy herbs to prevent SARS, it starts:
Chinese Turn to Herbs Against SARS
BEIJING (AP) - The chunks of brown bark, yellowish slivers of roots and dried light-green flower buds look more like garden mulch than medicine. But millions of Chinese believe this traditional herbal remedy--"Ba Wei," or "Eight Ingredients"--offers some of the best protection against the SARS virus, which has infected thousands and killed at least 148 in China, and for which there still is no cure.
Before 8 a.m., people form long lines outside one of Beijing's most famous drugstores, Tong Ren Tang, to buy doses of the herbs and roots wrapped up in white paper packets. They believe the medicine-which includes dried honeysuckle and wild chrysanthemum-helps to boost their resistance and ward off SARS, or severe acute respiratory syndrome.
"I'm buying some for my son because he's a businessman who's always out visiting customers. I'm worried about him," said Long Wenjun, a retired store clerk standing outside the store's Chinese facade with red columns, gold dragons and lanterns with red tassels.
Tong Ren Tang is China's oldest herbal drug manufacturing and retailing enterprise, dating back to 1669, with service to the Qing Dynasty Emperors. It has a reputation of always being there as a service to people during epidemics, providing huge quantities of remedies at reasonable prices. The remedy referred to here as Ba Wei might be inadvertently confused with Ba Wei Di Huang Wan, which is not related (both formulas have eight ingredients). Ba Wei is a preparation of Tong Ren Tang that is used for treating initial stage of cold and flu. The main ingredients, lonicera (honeysuckle) and wild chrysanthemum (Chrysanthemum indicum) are like those of the well-known "double stuff" tea made from lonicera and chrysanthemum flowers and used as a "detoxicant," a preventive and remedy for feverish ailments. This combination is widely appreciated. Fu Kezhi, the Director of ITM's China office, relayed his own use of herbs for this purpose, also on April 29:
A good many Chinese people are accustomed to using of some herbs such as lonicera and wild chrysanthemum flowers or certain herbal formulas for clearing heat and cleaning toxins, to get a good result. But, if there is no fever at the time, I would like to drink green tea plus Hangzhou white chrysanthemum flower together, about 6-9 grams a time, 2-3 times daily with around 1.5 liters of boiled water, drinking it frequently all the day, even at night. This might have a nice effect for taking precautions against catching cold, and maybe effective to prevent certain epidemic evils; I have not had the problem of catching cold in recent years.
Recently, the following six Chinese herbal prescriptions were recommended to the Chinese population for preventing SARS. The recommendations (including the detailed instructions provided here after the formula listings) are based on an intensive discussion by a group of Chinese medical experts invited by the China National Administration of Traditional Chinese Medicine. Their suggestions were published in The Global Times in Beijing (April 25, 2003). The report advised that those working to prevent SARS must guard against abusing Chinese medicinal herbs (e.g., taking too much, using them indiscriminately). When possible, the formulas should be prescribed according to individual conditions. When talking about "preventing SARS" in this context, the implication is that one would take these herbs if there has been suspected contact with a SARS-infected person, or if there are initial symptoms of a SARS-like disease. In other words, these formulas are used when it is believed that a person might have the corona virus already but has not yet developed the syndrome; so they are intended to prevent the full syndrome, SARS, from developing from the initial exposure to the virus.
Isatis leaf (daqingye)
Perilla leaf (zisuye)
|benefit qi, remove moisture, clear heat, clean toxin
|clear heat, clean toxins, resolve turbidity
|clear heat, clean toxin, dispel wind, expel pathogens
Red Atractylodes (cangzhu)
Isatis leaf (daqingye)
Perilla leaf (zisuye)
Red Atractylodes (cangzhu)
|clear heat, dispel wind-chill, expel pathogens
|strengthen spleen, benefit qi, resolve damp, clean toxins
|benefit qi, disperse pathogens, clean toxins, remove moisture
Individual herb doses within a formula: Usually 6-10 grams for each herb, except 15 grams when using astragalus, pseudostellaria, phragmites, taraxacum, houttuynia, capillaris, patrinia, or coix; for licorice (raw), use only 5 grams. Specific dosages were provided by the Administration as an example for each formulation.
Methods for drinking and decocting: Use earthenware or a glass pot; add water to one batch of the herbs sufficient to cover with about 2-3 cm (1 inch) of water above the herbs; heat to boiling with moderate heat, then continuously heat with gentle heat about 15-20 minutes. The aromatic herbs, such as mentha, pogostemon, and perilla leaf, ought to put in only after the water has already started boiling to ensure potency. Each batch of the herbs is decocted twice; mix the two shares of the decoction together, then divide into two portions to take twice a day, warm, after meals. The volume taken each time should not be over 200 ml (about 7 fl. oz.).
Optimum conditions for use and precautions: During administration of the formulas, consume light meals, avoid greasy and strong flavored dishes, maintain a regular schedule of daily activities, and pay attention to having a rest. For those formulas that contain chiefly heat clearing and toxin cleaning herbs, persons with weakness of the digestive system, pregnant woman, and woman who are menstruating should not use the formula. For the elderly, children, or persons with very weak condition, the dose of the herbs should be decreased appropriately.
The advisory also mentions patent medicines, which can be used as an alternative to the decoctions, and their selection will depend on the individual symptoms and signs and the climate conditions. Thus, during the spring when the weather is becoming both damp and warm, the patents selected will usually have the function of dispersing wind-heat, resolving dampness, and removing turbidity. As an example, Shuang Huang Lian (comprised of three herbs: lonicera, scute and forsythia, and known as an anti-viral, especially for respiratory tract infections) combined with Huo Xiang Zheng Qi Pian (Pogostemon Formula, used for "summer heat" or damp-heat) is a suitable selection. The advisory group also suggests relying on the traditional diagnostic method of observing the tongue coating. For example, if the tongue looks white and greasy, Bao He Wan (Citrus and Crataegus Formula; which promotes digestion and clears accumulation) and Huo Xiang Zheng Qi Pian can be applied as a preventive remedy. It is expected that early stage of an acute illness, especially one marked by dampness, will reveal itself with a thick tongue coating.
In the institutional recommendations from China (including the Hong Kong research center) lonicera is frequently mentioned (it also appeared in some of the popular remedies). Lonicera has these advantages:
gentle on the digestive system;
SARS came on suddenly, and presented a terrifying specter: within days of the first signs of infection, the person could be laid up in the hospital with a severe pneumonia-like respiratory illness, that could suddenly turn for the worse and become fatal. Catching the disease appeared as easy as catching the common cold or flu, just by being in the same room as an infected person. Effective treatment was not available. Thus, there was an immediate need to find methods of protection.
Modern medicine quickly determined the causative agent, and could recommend severe quarantine measures as a means of effective control. Patients were treated with a variety of drugs that were thought to be of potential benefit: initially, antibiotics, later antivirals, steroids, and others. The use of the latest technology determined the viral genetic code and is being applied to developing a vaccine as well as quicker test methods for detecting an infection in an individual with suspect symptoms.
Conditions in China worked against effective quarantine. Some members of the government chose to downplay the epidemic, perhaps as the result of patterns of response ingrained over the past several decades of strict controls on information. Some people, fearing quarantine measures, avoided going to hospitals or fled from the cities where infection rates were notable, thus spreading the disease.
Many people in China are used to relying on herbal therapies, and turned to their traditional methods, just as doctors initially turned to their standard drugs. Herbs and foods that were understood to prevent illness, particularly illnesses like common cold, influenza, and bronchitis, were thought of immediately. Herb therapies that had a reputation for preventing disease generally and herbs specifically known to inhibit viruses became the main focus of attention.
Isatis (root and leaf) and lonicera (flower) are antiviral herbs that had been widely used for centuries and now seized upon as likely to be most effective for inhibiting the early stage of the disease. This response is no doubt based on a combination of cultural experience with the herbs and modern research, which has focused on them, as well as hu-zhang, andrographis, forsythia, coix, and dryopteris, as promising antivirals. The combination of forsythia and lonicera is routinely used for treating infections, and is the principle component of the famous remedy Yinqiao Jiedu Pian, used to treat influenza and common cold.
The food therapies (e.g., radish, scallion, and garlic), common tea ingredients (e.g., the popular "double stuff" with chrysanthemum and lonicera flowers), and traditional and patent herb prescriptions (such as Sang Ju Yin, Yu Ping Feng San, Huoxiang Zhengqi Pian and Shuang Huang Lian) are consistent with Chinese recommendations that should be learned by students of Chinese medicine in the West. Yet, some of these may fall out of the standard curriculum.
For people in China who have faith in their traditional medicine system, the question that arises is: can I get the foods and herbs that are recommended? By April, many of the desired items, such as recommended patent medicines and isatis roots, were hard to get because the supply chain could not readily meet the demand. For others who are uncertain about using Chinese herbs, the key question is not so much, can I get the materials, as: do they work? With a new disease like SARS, it is almost impossible to know if the herbs that may have prevented or treated a similar disease will be effective for this one. Still, the China National Administration of Traditional Chinese Medicine, the Research Center of Hong Kong Chinese University, and other agencies concluded that measures agreed upon by herb authorities ought to be tried, given the seriousness of the disease and lack of a known effective treatment. It would be helpful, however, if herbs such as those suggested here (e.g., isatis, hu-zhang, andrographis, lonicera, dryopteris, etc.) had been more fully researched so that their range of actions would have been better understood at the beginning. Considerable investigation of these herbs has been undertaken in recent decades, but not at a level of sophistication that would be desired.
While it seems reasonable for people already interested in Chinese medicine to make use of these herbs, the lack of evidence for their efficacy means that it would not be appropriate to recommend them to others. The food therapies, herbs, and herbal formulas mentioned in this article are presented to convey what the Chinese have used. Those involved with Chinese herbs generally like to take these sorts of herbs both for preventive health care and treatment of various ailments. For them, the main question is not whether to use the herbs, but rather which herbs one should choose out of the many available when confronted with certain general categories of disease. The principles of therapy guiding those selections (without proof of efficacy) have been roughly outlined here; they would apply to any respiratory system infection due to a virus, especially one that involved the Chinese category of "damp-heat" as a contributing factor.
At the end of the 19th century, traditional Chinese medicine was eclipsed by the profound effect of Western medicine on another epidemic that swept through China. The main western method was quarantine. Today, quarantine along with biological testing and rapid drug and vaccine development are clearly in the forefront. Yet, Chinese medicine has played a role, at least to the extent of providing some action that millions of worried people in China could take while awaiting the progress of modern medical methods. As a result of this SARS experience, more research into the effects of Chinese herbs is likely to focus on the actual clinical responses to antiviral herbs. China has developed remedies for many viral infections, including hepatitis, influenza, viral myocarditis, and viral encephalitis; the population there relies on the herbs. This is not the first time that a new epidemic has raised questions about what Chinese herbs might contribute. In the U.S., practitioners who routinely prescribe Chinese herbs have been asked about providing herbal assistance for HIV infection, West Nile Virus, Hepatitis C, and Lyme disease, to name a few. Perhaps the Chinese government and private enterprises will be encouraged by this experience to more carefully evaluate the herb effects and make sure that they are better understood so that they can promptly be utilized when needed.