Modernisation and its side effects - an inquiry into the revival and renaissance of herbal medicine in Vietnam and Britain A thesis submitted for the degree of Doctor of Philosophy Ayo Wahlberg Department of Sociology London School of Economics and Political Science October 2006 2 For the Willamos & the Wahlbergs 3 Abstract Herbal medicine has experienced tangible revivals in both Vietnam and the United Kingdom since the mid-20th century, as reflected in sales of herbal medicinal products, numbers of users and the availability of training opportunities for aspiring herbalists. In both countries, this revival came on the back of more or less concerted official efforts to discourage and even ban the practice and use of herbal medicine, by colonial authorities (in Vietnam) or professional medical associations and regulatory bodies (in the UK). Utilising archaeological and genealogical methods as developed by Canguilhem, Foucault and others, this study seeks to account for these revivals by pursuing three particular lines of analysis. Firstly, by describing the formations of power-knowledge relations which have allowed Vietnamese and British herbal medicine to challenge biomedical monopolies in the latter half of the 20th century, it is argued that the ways in which ‘quackery’ is conceptualised and regulated against in both countries today, has undergone substantial transformations. Secondly, by identifying the techniques of truth making which either suggest or contest a superior efficacy (over placebo) for two particular herbal medicines in the treatment of depression (in the UK) and addiction (in Vietnam), the study demonstrates how the concept of ‘efficacy’ not only pertains to bio-physiological effects but also to the symbolic effects of the treatments in question. Finally, by asking what kind of ‘life’ herbal medicine is seen to be affecting, it is suggested that longevity has been joined by quality of life as a separate, yet inherently interlinked, therapeutic site. One of the key conclusions of the dissertation is, that the sub-disciplines of medical anthropology and sociology have played a crucial role in the 20th century births of ‘traditional medicine’ and ‘complementary and alternative medicine’ (as opposed to ‘primitive’ and ‘fringe’ medicine). Firstly, in diagnosing a ‘crisis of modern medicine’ by highlighting its dehumanising and toxifying effects, and secondly, in providing a theory of symbolic efficacy which could help explain the continued importance of what had in the past been written off as ‘esoteric’ or ‘backward’ healing practices. As a consequence, the study describes how an ongoing governmentalisation of human subjectivities has been a requisite side effect of modernisation in the recent revival and renaissance of herbal medicine in Vietnam and the United Kingdom. 4 Table of contents ABSTRACT .................................................................................................................... 4 LIST OF TABLES AND PLATES ............................................................................... 6 ACRONYMS................................................................................................................... 7 PREFACE – KNOWLEDGE AND PRACTICE......................................................... 8 1 MODERN FAILURES, TRADITIONAL REMEDIES........................................ 14 2 HISTORIES OF THE PRESENT........................................................................... 41 3 TRANSFORMATIONS IN QUACKERY ............................................................. 60 4 BIO-POLITICS AND THE NORMALISATION OF HERBAL MEDICINE... 87 5 ABOVE AND BEYOND SUPERSTITION ......................................................... 119 6 PATHWAYS TO PLAUSIBILITY....................................................................... 159 7 PETTY ENGINEERS OF MODERN LIFE ........................................................ 190 8 CONCLUSION ....................................................................................................... 223 REFERENCES ........................................................................................................... 237 5 List of tables and plates TABLE 1: CAM HIERARCHIES ………………………………………………....77 TABLE 2: LEVELS OF EVIDENCE ……………………………………….........142 TABLE 3: RATING SCALES AND DIAGNOSTIC CRITERIA USED IN SJW TRIALS …………………………………………………………………..153 TABLE 4: LOG FOR MONITORING EFFECTS OF ST. JOHN’S WORT ON TARGET SYMPTOMS OF DEPRESSION ……………………….208 TABLE 5: DỰỚNG SINH VITALITY METHOD ……………………………...217 PLATE 1: CLINICAL OUTCOME MEASURES …………………………….. 147 6 Acronyms AMH Association of Master Herbalists BHMA British Herbal Medicine Association BMA British Medical Association CAM complementary and alternative medicine DSM Diagnostic and Statistical Manual of Mental Disorders HAM-D Hamilton Depression Scale HPLC High Pressure Liquid Chromatography ICD International Statistical Classification of Diseases IDQC Institute of Drug Quality Control MHRA Medicines and Healthcare products Agency (previously Medicines Control Agency) NIMH National Institute of Medical Herbalists TLC Thin Layer Chromatography TM traditional medicine TMCAM traditional, complementary and alternative medicine UNDCP United Nations Drug Control Programme UNOPS United Nations Office for Project Services WHO World Health Organization 7 Preface – knowledge and practice “It’s a herbal remedy? Addiction? Yes… Vietnam… Yes… Well, that sounds pretty amazing, how much do we know? Really? Yes, let me call you back.” A Master’s student at the time, I was working a few days a week as an assistant in the information unit of a UN development agency in Copenhagen. My boss called me into her office where she had just finished the telephone conversation I had overheard. I was asked if I wanted to go to Hanoi a few months later in August. The Vietnamese government and the UN Development Programme were about to sign a three-year agreement in June of 1997 for a project on the “International Scientific Development of the Anti-Drug Medication Heantos”. This was a story that would sell itself and the idea was to invite a group of European journalists to meet with the herbalists, scientists, doctors, UN officials and government representatives who had made the project possible. In the field of international development, most stories have to do with a one-way flow of resources, technology, know-how and humanitarian aid from industrialised to developing countries. Here was a story that turned the tables, a herbal remedy from a developing country which could potentially help the industrialised West with one of its fastest growing scourges, namely drug addiction. Before boarding my return flight back home from Hanoi, I bought myself a copy of the 22 September 1997 issue of Time magazine to help pass the hours. A full-page article in the health section was asking whether St. John’s Wort, a folk remedy made from the plant hypericum perforatum , was “Nature’s Prozac?”. Apparently a string of recent clinical trials and pharmacological experiments in Germany were suggesting exactly that, with European sales skyrocketing as a result. I was otherwise busy finalising a degree in social science and international development studies in the middle of a field some thirty kilometres west of Copenhagen. The development studies course at Roskilde University was consistently overbooked. Most of us had travelled the world many times over, enough to realise how much of a luxury shoestring travel was when compared to the misery of the lives of the majority in many of the countries we had travelled in. We were convinced that the time was indeed ripe for alternative thinking in development studies as a new millennium approached; the World Bank, the WTO, the WHO and other international agencies had got it all wrong. An 8 alternative development was needed or even better, alternatives to development. Resistance, emancipation and the subaltern were the orders of the day. At the same time, a few of us at the institute began wondering how we could be so sure in our convictions. Post-lecture discussions turned into weekly ‘grid sessions’, as we called them. Rather than approach underdevelopment as some kind of ontological state or condition (of a continent, country or community), we learned to ask how we might approach it as a problem. What was it that made the alternative so compelling in attempts to address this problem? It was an approach I would pursue intensely in a Master’s thesis about alternative development and one that I continue to pursue with equal intensity in the chapters that follow about alternative medicine. Since the summer of 1997, I have returned to Hanoi for extended stays on three occasions, twice to work as an intern at the Institute of Chemistry (in 1998 and 1999) where herbalists and scientists have been working to further develop Heantos for a decade now, and most recently in the fall of 2004 to do some follow-up fieldwork for this current study. During these stays I had the opportunity to travel throughout the north of Vietnam, meeting and learning from traditional practitioners, users of herbal medicine, doctors, government officials, UN agency representatives and local members of the Communist party in the many towns I visited. I had the chance to visit remote villages where opium cultivation and use have been a practice for centuries, to drive along the treacherously winding roads favoured by traffickers of opium resin, to talk with the addicts whose demographics neatly match the traffickers’