By Eric Brand

As many regular readers know, authentication and quality discernment of medicinals is a topic that I find fascinating. I originally discovered this nerdy fascination when I was still in school for Chinese medicine, and it has only grown since then. I was studying outside of school by filling formulas in a traditional pharmacy that was run by one of my first close Chinese teachers, a lineage-trained pharmacist in San Diego named Guo Nan-Yu. At the pharmacy, I learned a lot about quality discernment and I was also exposed to the topic of genuine items vs. adulterants.

Follow up:

After I graduated school, I lived in Taiwan for many years and constantly traveled between the USA, Taiwan, and mainland China. My interest in herbal quality discernment only increased over time, and I developed a deep interest in learning about adulterants, counterfeits, misidentified medicinals, and, in particular, the different grades and quality discernment issues related to ginseng.

Over time, I naturally gravitated towards teachers that were knowledgeable in such issues, and I was fortunate to form a good relationship with some of the top Chinese experts in the field, including Dr. Chang Hsien-Cheh and Dr. Chang Yung-Hsiun at China Medical University in Taichung, and Dr. Zhao Zhong-Zhen of Hong Kong Baptist University. These people are inspirational figures for me, as they have all achieved an unprecedented mastery in their respective disciplines and they are all fantastic teachers and human beings in addition to being living legends in Chinese medicine. Studying with them and memorizing the details of their publications has allowed me to cultivate the knowledge base that I’ve always craved, and I’ve been enjoying trying to raise awareness of these critical issues here in the West.

Now that I am back in the USA most of the time, I pay particular attention to the quality discernment and authentication issues that affect TCM pharmacies in the States. I often travel to various schools around the country to give lectures or visit with faculty, and I also teach a class on GMP issues and safe herbal compounding. This gives me the opportunity to see many school pharmacies, which are excellent examples of the state of awareness in our field on issues such as herbal authentication.

Herbal pharmacy and clinical medicine are separate branches in the field of Chinese medicine. Authentication issues exist throughout Chinese society as well as the West, and one can see many misidentified medicinals in the herbal markets of places like Taiwan and Hong Kong. In Asia, doctors are not responsible for understanding all the ins and outs of pharmacy because there are experts in herbal pharmacy that are responsible for understanding the issues involved. In the West, our profession has not yet developed all of the specialty fields seen in Asia, so the individual practitioner is expected to be a jack-of-all-trades. Many practitioners work simultaneously in the role of doctor, pharmacist, tui na practitioner, and clinic manager, so it is understandable that some of the advanced aspects of disciplines like herbal pharmacy and tui na are not fully mastered by most.

Given that our training is primarily focused on clinical medicine, most Chinese teachers in the USA are doctors, i.e., experts of clinical medicine rather than herbal pharmacy. In China, doctors need to know what to prescribe to their patients, but they don’t need to know the fine details of things like the production region of the rehmannia they are dispensing. Consequently, even most of the faculty in the USA is unable to effectively answer all of the advanced questions that come up in the field of herbal authentication. At present, very few schools include classes or training in herbal pharmacy and identification issues, and in many places such classes would be difficult to organize because local experts are scarce.

The arrival of the discipline of herbal authentication is in its infancy in the USA, and nearly every school in the country has items on the clinic shelf that differ from the official product in the Chinese pharmacopoeia. In many instances, the incorrectly identified medicinals are regional substitutes, some of which are doubtless safe and effective. Many of these items have been used as a regional variant of the authentic medicinal for hundreds of years, but they remain relatively poorly characterized because all the scientific research is done with the authentic items rather than their regional substitutes.

In some instances, the substitute medicinals have equivalent medicinal effects; an example of this is the interchangeable use of “Southern” Ban Lan Gen (baphicacanthus) and “Northern” Ban Lan Gen (isatis) or the use of Hong Qi (hedysarum) instead of Huang Qi (astragalus). In other instances, the regional substitute is traditionally thought to be the same but has been subjected to minimal study and scrutiny (as in the case of the various substitutes for Wang Bu Liu Xing, for more also click here and here). Still other cases have differences in the traditional actions of the primary medicinal and the substitute medicinal (as in the case of Ji Xue Teng or Sheng Ma). Finally, some products have dangerous substitutes that present a true risk of adverse events (such as San Qi or Fang Ji). Read more about substitutes here

When taken as a whole, improved understanding of identification issues can be said to be a critical issue for the field. Adverse events stemming from improper substitution could be devastating for the public image of Chinese medicine and could be ruinous to institutions and individual practitioners. Consequently, it is essential that our community understands the issues of herbal authentication and it is essential that we implement academic and trade standards that support the use of correctly identified medicinals.

Educational institutions of Chinese medicine are in an excellent position to provide training to students in the issues of herbal pharmacy. At present, many schools still have items on the shelf that are not the correct specimens. These errors should be corrected so that students have the correct herbs available for educational and clinical purposes. While many schools have a significant awareness of these issues, true expertise remains hard to find and perfect collections of medicinals without adulterants remain the exception rather than the norm.

In light of this, I’d like to commend some of the clinic directors of institutions that have been particularly proactive and responsive to these issues. Of particular note are Micaela Angle of NCNM in Portland and Greg Sperber of PCOM in San Diego. While there are certainly many excellent clinic managers across the country, both of these individuals have demonstrated true leadership when it comes to issues of responsible clinic management. They are very well-educated in the issues involved, and their awareness has led to significant improvements in each of their respective clinics.

For example, Micaela Angle at NCNM recently joined several other clinic directors at a seminar in GMP issues and safe herbal compounding practices. After the training, she then took it a step further by arranging for a site visit of the NCNM pharmacy to seek advice on all the complex issues of correct identification and effective procedures for compounding and record-keeping (as an aside, the NCNM pharmacy is particularly interesting because it has both Western herbs and Chinese herbs, so one gets to see a much more diverse range of preparations that we typically have available). At any rate, I was extremely impressed with Micaela’s knowledge of the issues involved. In particular, she was very well-informed on topics such as medicinals that can pose risks with aristolochic acid, with a thorough understanding of the situation with items such as Xi Xin (root versus the aerial portions) and Fang Ji (Han Fang Ji vs. Guang Fang Ji), etc.

As for Greg Sperber at the PCOM San Diego clinic, Greg was fortunate to inherit a raw herb pharmacy that had largely had its identification issues sorted out over the past few years, with the guidance of supervisors such as Bob Damone and other experts. However, Greg propelled the clinic forward by making some excellent changes to the granule situation. Since the school uses a mathematical method of converting the raw herb dose weights to granule dose weights, Greg identified early on that they needed to use a granule supplier that offered transparency into the issue of concentration ratios. After all, the validity of a mathematical equation depends on the accuracy of the starting data, and Greg recognized that a superior method of accurate dosage calculation could be achieved by transitioning the pharmacy to a supplier that openly specified the concentration ratios of the products in use.

In both of these situations, the managers of the clinics at NCNM and PCOM-SD have demonstrated true leadership in the profession. Their research, knowledge base, and management strategies are a model for clinics everywhere, and I think they have done a great service to their respective institutions, students, and patients. My hat goes off to these two individuals for their service to the profession!