Prof Bin Jiang Wu, R.Ac, R.TCMP
President-Ontario College of Traditional Chinese Medicine (Canada)
Vice President-The World Federation of Chinese Medicine Societies (WFCMS)

Executive Committee-The World Federation of Acupuncture & Moxibustion Societies (WFAS)

The Chairman of The Board of TCM Acupuncture Inheritance Committee (WFAS)

Since the 1972 resumption of diplomatic relationship between China and the United States, Acupuncture have been spreading around the world extensively for 40 some year. This is the largest cultural export in the history of China.  At the end of the 20th century and the beginning of 21st century, the United States, Canada, Britain, Australia, and other developed countries have been enacting regulations and policies for Acupuncture and Traditional Chinese Medicine.  In the next several years, more countries will be establishing legislation, giving Acupuncture and Traditional Chinese Medicine its legal status. Internationalization of Acupuncture and Chinese Medicine become the developing trend of this century. Grasp the pace of historical development of the next century, integrating the strength of Acupuncture and Chinese Medicine in the international community has unprecedented opportunities, but also faces many new issuesand challenges. 

1 Regulation as the trend in the development of internationalization of Chinese Medicine and Acupuncture

The development of overseas Acupuncture and Chinese Medicine, just like process of plantation, has gone through 3 historical stages from germination, growth to maturation; having regulation of Chinese Medicine indicate a symbol of maturation in the field of any country. United States, Australia, Canada and other immigration nations are leaders in this act and are the first among to regulate Acupuncture and Chinese Medicine at the end of last century. It is predicated that the wave of regulation of Acupuncture and Chinese Medicine will continue through the mid and towards the end of this century. From seeking regulation to enforcement is a long and arduous road, which require efforts from not only one generations, and internationalization of Acupuncture and Chinese Medicine, is an inevitable trend.  

2 The reform in the theory of Chinese Medicine, Herbal Formulas, and Clinical Study is the trend in the internationalization of Traditional Chinese Medicine

1）Theoretical Aspect of Chinese Medicine:

The theory of Chinese Medicine must be adapted to cultural contexts.  For example, a light redcolor tongue with a thin white coating is considered to be a normal human tongue in the Chinese population. However, for most of the African population, the color of a normal tongue is pink. How to determine a normal frame of reference for tongue diagnosis amongst different populations will be one issue in the future studies of Traditional Chinese Medical theory. 

2）The Alternatives to Chinese Medicine Herbal Formulas:

Due to the unique Chinese cultural background and dietary habits, most Chinese people from childhood know that leaves, grasses, worms, and minerals can be used as a medication, and they are used to take in the herbal formulas. However when Traditional Chinese Medicine came abroad, it conflicted with cultural differences in eating habits of the western world. When people see the grass-roots, bark, insects, and minerals in Chinese medicine, it is difficult to accept and swallow them. Decocting and processing of Chinese herbs is also a challenge for most people due to the strong smell, which easily leads to complaints from the family and neighbors.  Alternatives to the Traditional Chinese Medicine formulas is one of the key point in the reform of internationalization of Chinese Medicine, using concentrated powder for example, is the solution to the beginning of transformation.  

3）The clinical aspects:

In China, routine treatment with Acupuncture of once a day, for ten times has become a standard course of treatment.  However in overseas, due to time and financial reasons, many patients can only come for treatment one to three times per week.  We can compare this to the concept of “blood drug concentration” when taking western medication.  In order to be able to achieve the maximum pharmaceutical effect, medications must be taken on time (every 8h or 24h) repeatedly.  How long of an interval between Acupuncture treatments is appropriate to maintain the sustainability of the "effect of Acupuncture in body” will be an interesting topic to study. The application of alternative auricular or skin micro-needles treatment instead of body Acupuncture to supplement for the lack of regular treatment is also a research topic in the clinical study of Chinese Medicine. 

3．Standardization is the trend in the development of globalization, achieved on the basis of co-existing commonality and differences  

With the development and process of standardization of Chinese Medicine, the standardization of Acupuncture and Chinese Medicine have also been brought up to the agenda.  On June 7-8th of 2010, the “1st Plenary Session of International Chinese Medicine Standardization” was held in Beijing organized by International Organization of Standardization (ISO), there are representatives coming from 15 different countries and 3 international organizations that have participated in the conference.   

Standardization of Acupuncture, Chinese herbs, and Chinese Medicine is a tremendous project that requires very detailed work and frequent knowledge exchanges between members of different countries. Due to different national interests and political framework, there may be serious differences inview of standardization. Whereas working on a ground where commonality and differences co-exist is the strategy for international cooperation. There still is a long road ahead for the international standardization of Chinese Medicine; the process will walk through the beginning and even midway of the 21st century.   On November 6, 2010, the United Nations Educational, Scientific and Culture Organization (UNESCO) have approved “Acupuncture and Chinese Medicine” as the world’s intangible cultural heritage, this inevitably will help push forward the process of internationalization and international standardization of Chinese Medicine.  

4.The formation and advancement of overseas TCM entities

Historically, there are five frameworks that have brought the practice of TCM overseas. 

First, is family-based early immigrant's practice of "Ancestral Chinese Medicine". Most of them are non-medical professionals and workers, and learned TCM by apprenticeship.

Second, in the 1980's, Western Medical trained Physicians from mainland China traveled around the world, and they have been practicing Acupuncture and TCM during their stay aboard.  

Third, in the 1980's, 90's and the beginning of this century, large numbers of graduates from Chinese Medicine colleges in mainland China traveled abroad practicing TCM.

Fourth, as a result of restrictions on domestic legislation the practitioners from South Korea, Japan and other countries who completedtheir TCM training in China, came to Canada, the United States, Australia, Britain, Germany and other overseas locations. This group also includes the trained TCM practitioners from Taiwan, Hong Kong, South Korea, Japan and other countries.

Fifth, TCM Education in Canada, Australia, Europe and the United States has decades of history. The TCM training started in the industry (night) training schools from the 1970's to the early 1980's. After the 1990s, with internationalization of Acupuncture and Chinese Medicine, several groups of TCM institutions, colleges,

Due to local government legislation of Acupuncture and Chinese Medicine, graduates from domestic Chinese Medicine colleges possess language advantages and social background and will become the mainstream of the field of Acupuncture and Chinese Medicine, and as well the main force of the development of overseas Chinese Medicine. This group of professional will gradually change the composition and lifting the face of overseas Chinese Medicine. With that said above analysis should first occur in countries where there is long history of immigration such as United States, Canada, Australia and England.

5 The Integration and expansion of Overseas TCM institutions

The current status of overseas TCM practice is similar to the situation in the 1940's in mainland China.  Most of them are self-employed in a private clinic situation; few are working in local hospitals. It is very rare to see a complex TCM hospital or health center. The law of economic development tells us that if you want develop any further; you have to integrate the advantages, which require that these overseas Doctors have financial resources, as well as humanand intellectual advantages. 

6 Chinese Medicine and Acupuncture protection of intellectual property will be taken seriously

The Chinese government should enhance the protection for intellectual property in the field of TCM and Acupuncture in order to guard and cherish the precious value of this thousand-year0old linage. Chinese Traditional Medicine has experienced thousands of years; it is the only original wealth with its own Intellectual Property Right attached to it. However, we lack the sense of protection when it comes down to foreign knowledge exchange. Although TCM and Acupuncture is widely accepted, does not mean it automatically owns the Intellectual Property Right of that specific country. Trade-mark, patent, and copyright must require application in accordance with the laws locally.
The internationalization of TCM will benefit people all around the world. At the same time when TCM is being popularized, we must take control the rules of internationalization in order to reduce the segmentation of intellectual property right. It is truly unfortunate that Chinese scientist Youyou Tu’s achieved the Nobel Prize but failed to protect her intellectual property rights on her discovery. Cherish and protect the original wealth of the Chinese heritage that came through the history in thousands of years and carry forward the benefits worldwide. 

7  Diverse development of oversea TCM acupuncture education

7.1 Current situation of overseas TCM acupuncture Education

The Lack of clinical internship and residency training are the bottleneck problem of Overseas Acupuncture and TCM education. Graduates of Chinese Medicine in China will typically be working in provincial, municipal or regional hospitals; very few will start their own business. Overseas graduates of Chinese Medicine can only open their own business, or at earlier stage after graduation to work at a clinic to accumulate experiences, eventually is to open their own practice. Therefore opening and operating the business is a realistic problem where every Acupuncture and Chinese Medicine practitioner faces. Marketing and management in the business of Chinese Medicine, the non-shared knowledge thus become a compulsory course in the component of overseas Chinese Medicine education.  Although practitioners graduated from Chinese Medicine schools in China possess strong advantage in technical skills, but lack of education and training in the aspects of business operation, it is difficult to put their skills in practice in short time after they expand abroad, and they need to spend lots of their time and costing them much to make this lesson in gaining the valuable experiences. In the process of internationalization of Acupuncture and Chinese Medicine, reform of education live up to the international standards is an aspect worth considering and putting thoughts into.

7.2 Apprenticeship
Apprenticeship is the shortcut in improvement of clinical experiences, forming genuine Traditional Chinese Medicine.
Traditional Chinese Medicine is a subject that closely combines theory and practice together, theoretical knowledge is obtained from texts and apprenticeship with mentor is the key to learning skills and experiences. This is the characteristics for all traditional culturesto exist and passing down through generations. To take Chinese Kong Fu for example, there are scripts and diagrams that illustrate the key to movements; however no one has ever achieved any style of movement barely by learning from books alone.  The same concept exists in learning Traditional Chinese Medicine, whereas the mentor/master is the carrier of technical skills and clinical experiences.

8 The non-substitutability of the inheritance of TCM acupuncture manipulation techniques

8.1 The specialty of TCM acupuncture manipulation techniques: According to professor Jin Zhang, the representative inheritor of Intangible Cultural Heritage TCM Acupuncture “Acupuncture is a science combined with knowledge and technique. If booking be the carrier for knowledges, while rotors are for techniques, acupuncture manipulation is the integration of both.” [3]Professions that contain highly skilled practices are called craftsmanship (Shou Yi) in China, and the person who inherited this craftsmanship is called craftsman (Shou Yi Ren). TCM manipulation technique that requires highly skilled training and practices is one the main differences between traditional Chinese medicine and other medical systems such as western medicine. The skill level of the manipulation technique is the key to improve curative results in TCM treatment.

Acupuncture manipulation technique is an important means of the subject of traditional Chinese medicine; it is an important part to the human intangible cultural heritage acupuncture for its inheritable specialties. 

8.2The non-substitutability of TCM acupuncture manipulation techniques

Even with the rapid development of the contemporory world , acupuncture techniques still need to be taught and inherited through face-to-face instruction due to its special nature of inheritance. The crasmanship of acupuncture techniques grew more and more precious after time.

Some acupuncture techniques have faded with the demise of the inventors or inheritors; therefore, the UNESCO has started protecting Intangible Cultural Heritage like acupuncture in order to better preserve the essence of these skill-based venerable practices.

On November 16, 2010, the UNESCO recognized TCM Acupuncture as Intangible Cultural Heritage and confirmed the names of the 4 representative inheritors: Cheng XInnong, He Puren, Guo Chengjie, and Zhang Jin. [4]

It is predictable that the learning period will be shortened in the future for University studies that is based on theoretical knowledge due to the change of learning styles and methods. Online learning will become more practice and popular with the sharing of educational resources. However, for disciplines that require high-levels of skill training such as traditional Chinese medicine, the practical trainings will still be addressed since the craftsmanship cannot be replaced with only theoretical knowledge.

8.3 The emphasis of essential technique training and face-to-face mentoring in the inheritance of TCM and acupuncture:

Professor Zhang Jin, the representative inheritor of Intangible Cultural Heritage TCM and acupuncture stated, “There is no craftsmanship that doesn’t emphasize the basic technique training. One can only improve once solid basic knowledge is acquired.”In the history, needle techniques are separated from acupuncture theories in China. Acupoints, meridians, and treatment for diseases are only discussed on literatures, while the practical trainings were only enforced through face-to-face mentoring; therefore, there were very few records of essential technique training on literatures. [5] Acupuncture manipulation has a very specific focus on craftsmanship skills and techniques; it heavily relies on essential technique training and face-to-face mentoring.  

9. The role of the Internet, digital media technologies, and risk investment in the globalization process of TCM and acupuncture.

9.1 Knowledge acquisition in the digital era:

Digital technologies such as remote diagnosis and online learning will further augment the progress of TCM acupuncture globalization. Internet and the application of high-tech Speed up Internationalization of TCM With the rapid development of Internet around the world, it removes the barriers between different regions and countries. For countries in North America occupying vast land space with scattered population settlement, it will realize the sharing of resource in TCM theory over the internet for people that hoping to acquire the knowledge of TCM and Acupuncture. As the development of IT matures down the road, instantaneous online translation in various different languages of material will be other practical methods of learning, people in different countries can now learn from well-known TCM professionals over long distance.  Remote TCM diagnosis and treatment through the Internet will soon be implemented with the advancement of image recognition and wearable devices; online diagnosis and therapy will soon have an essential impact on treatment for sub-healthy disorders and anti-aging preventions.

We chat groups nowadays have become a new popular way for people to communicate and exchange knowledge. “Cloud lecture” provides the freedom in terms of time and pace for TCM continuing education. “Walk the Internet miles and review the digital knowledge” has become a necessity in advanced TCM training overseas.

9.2 Intervention of risk investment and financial planning accelerates the development of TCM acupuncture globalization chain industry.

TCM acupuncture has evolved to fulfill the requirements of composing a global chain industry, as soon as the financial branch and risk investment segment accompanies. TCM acupuncture had always been constituted as private sector in the past century overseas, the requirement for investment is relatively low and not enough attention was paid on risk investment and financial planning, especially with the limited development space caused by the unachieved legislation.

Nowadays, as the completion of legislation, the market for TCM in the US, Canada,and Australia is expanded due to the development of insurance coverage systems. With the intervention of financial planning and risk investment, plus strong organizational structures, individual private clinics with good reputation can be integrated as one chain industry. Initial formation of these chain industries will be constructed in approximately 5 to 8 years and the completion of this industry will be achieved in 10 to 15 years. 

10. China as the cradle of Acupuncture and Chinese Medicine boosts the globalization process of TCM acupuncture.

European Union’s (EU) Traditional Herbal Medicinal Product Directives (THMPD) is in effect officially commencing May 1st, 2011. Any unregistered natural herbs including most of the Chinese herbal remedies are banned and restricted from market and to be used.  This is astonishing news to the field of Chinese Medicine around the world. 

There are two analyses can be provided: 1. the application procedure do not match the formulas of the Chinese herbal remedy; 2. registration lead to enormous costs.Overseas Acupuncture and Traditional Chinese Medicine mostly exist on the basis of individual practice. Although there are academic and professional organizations, they do not form a strong enough force to initiate negotiation with organization like EU. Individual based practices do not have such financial supports to apply for the “Registration”. Practitioners therefore can only take on the role of audience and in the end lost the strategic opportunity.

In this century of internationalization of Chinese Medicine, there will encounter similar issues in the future ninety some years.  Learning the experience from previous lessons and not miss another opportunity, drive the force in leading the trend of historical development is what need to be putin perspective .China, as the cradle of Acupuncture and Chinese Medicine is actively engaged in international affairs; the national force from officials, semi-officials, and non-government organizations (NGO) level is able to initiate dialogues with related official governments and NGOs. Increase mutual knowledge and understanding, reduce resistance and actively promote the progress of internationalization of Chinese Medicine. 

The development of internationalization of Chinese Medicines is a typical liberal economic module; it is directed by the market demand of health care needs of any particular country. Acupuncture being the pioneer, followed by Chinese Medicine and herbal medicine. At earlier stage in time, Acupuncture and Chinese Medicine is a tool for merely survival; presently, it is been included in the regulatory system of health care within any country, Acupuncture and Chinese Medicine practitioners is beginning to earn its social status and becoming a respected profession.  Internationalization of Acupuncture and Chinese Medicine is becoming the trend in this century; therefore it’s also brought barriers and problems in many perspectives. Integrating the forces of international Acupuncture and Chinese Medicine, grasping the progress of historical development, and facing new challenges ahead is the common goal of all fellows in the field of Acupuncture and Chinese Medicine around the world.

This article was published in the 《World Journal of Acupuncture-Moxibustion》（English Version）Vol.4,2016