Perspectives on Immunity: Sharon Weizenbaum & Shang Han Lun Theory

As I write this, we are deep into autumn and winter is coming. It’s the time of year when many of us start to think more about how well our immune system is functioning. We hope to be able to avoid more severe courses of the seasonal viruses that will inevitably circulate during the winter months. This year, of course, we not only have colds and influenza to worry about. We continue to be preoccupied with COVID-19, which appears to be surging around the world with the coming of winter to the northern hemisphere. Those of us in the Western United States may wonder, additionally, whether persistent exposure to wildfire smoke (or avoidance of outdoor activity due to smoky air) over the past two months, during this year’s unprecedented fire season, may have impacted our abilities to deal with infections this winter.

In this late autumn context, in the midst of a pandemic, with flu season up on us, I thought it could be useful to talk about immunity.

I’ve been thinking a lot about immunity this year and gotten some interesting perspectives from various teachers of herbal medicine. If time allows, I'd love to present some of these views in upcoming blogposts.

I'll start today with a teaching on immunity that I heard from Sharon Weizenbaum, a long-time herbalist and acupuncturist based in Amherst, Massachusetts, where she directs the White Pine Institute. Dr. Weizenbaum is a scholar of Chinese language and classical Chinese herbalism. She and her students have been leading voices in the discussion of Chinese herbal approaches to COVID-19 in the United States.

In March 2020, as the pandemic arrived in North America, Dr. Weizenbaum and her colleagues were learning about the treatment of COVID-19 in China & beginning to treat COVID patients on the East Coast, using classical Chinese herbal medicine prescriptions. At that time, Dr. Weizenbaum gave a lecture on her interpretation of the Chinese medicine perspective on immunity and the immune system, drawing particularly on the classical Chinese Medicine text, the Discussion of Cold-Induced Disorders, or Shang Han Lun, attributed to the Eastern Han Dynasty physician Zhang Zhong-jing (150-219 CE.)

This lecture was much more theoretical than practical, and did not go into specific herbs and therapies. I found interesting Dr. Weizenbaum's effort to "open the narrative" on immunity, distinguishing between an us-vs-them perspective & a more holistic, integrated view of host and environment.

Opening the “Standard Narrative” on Immunity:

Dr. Weizenbuam begins her lecture by stating that there is a standard narrative on immunity that informs our approach to infectious disease in the modern, western world. It is characterized by a dualistic and militaristic quality, an "us vs them" perspective. It is basically:

• There are bad things out there. They can “get in” and “GET ME.”

• The way to stay healthy is to strengthen my defenses and keep the bad things OUT.

• If they get in, I need to ATTACK them, kill them, and/or get them out.

• My “immune system” keeps things out and helps my body FIGHT BAD THINGS OFF.

Dr. Weizenbaum acknowledges the value of this narrative for some purposes. In the context of the pandemic, the narrative of “there are bad things out there that can get inside of me” forces us to social distance, which in turn slows the spread of the virus and saves lives. 

At the same time, Dr. Weizenbaum states that this narrative of immunity can have some negative outcomes. She seeks to open our understanding of immunity to different narratives.

There is No “One-Size-Fits-All” Approach,

Everyone Needs to be Treated as an Individual:

Dr. Weizenbaum acknowledges that the idea that “there are bad things out there that can get inside of us” created an atmosphere of fear at the onset of the pandemic. Some of us sought protective herbs. Various one-size-fits-all preventive herbal or medicinal formulations got pedaled around the internet. There were recommendations for herbal formulas consisting of cold, bitter “antiviral” herbs; and others for warm, dispersing “protective” herbs. Dr. Weizenbaum points out that herbal prescribing needs to be more nuanced, based on a complex understanding of the natures and qualities of herbs, as well as the synergistic qualities of herbal formulations. It also needs to be based on an understanding of each individual’s specific need as determined by a differential diagnosis of symptom patterns and constitution. If a patient is already cold, they should not take cold, bitter herbs. This could make them worse. If a patient is symptomatic, they should probably not take warming, tonifying herbs. Simplistic one-size-fits-all herbal preventive measures, though attractive in the face of a scary viral pandemic, could be dangerous for certain individuals. 

The Immune System is Not Just One Thing:

Dr. Weizenbaum continues her lecture by broadening our perspective on the immune system. Asking, “How, then, do I help my immune system?”, she notes:

• The “immune system” is none other than the sum-total of the functions of my whole body. Immunity is based on the collective functioning of all body systems: circulatory, digestive, respiratory, nervous, etc.

• If this is true, I should observe: How does my body function? How is my body not functioning optimally? 

• Often one can observe a weak link or two in how our body is functioning. This weak link, she states, is the area that needs strengthening, or optimizing, as we seek to improve our immunity.

For example, if every time I eat, I get bloated, and food moves through my body really slowly, perhaps this inhibits my body’s ability to create healthy cells. So, digestion and assimilation of nutrients is the area that needs attention as I seek to boost my immunity.

Or, if I have asthma and don’t breathe well, then that’s an important area to address, in relation to protecting myself against the virus.

Or if my sleep is poor and I experience excessive stress, then I might address that issue at its root.

Various Historical Approaches to Infectious Disease in Chinese Medicine:

Next in her lecture, Dr. Weizenbaum briefly surveys some of the approaches to infectious disease in various historical periods of the Chinese medicine traditions.  You can find a brief summary of these here, in one of my blog posts from earlier this year.

Dr. Weizenbaum concludes that some of these approaches are still dominated by the narrative of “bad things out there.” For example, she states, the 18th century “Wen Bing” or “Warm Disease” theory, which arose in China in response to the introduction of western viral infections like measles & mumps, is basically restatement of the idea that there are “bad” viral pathogens out there that can get inside of me. In the Wen Bing school of thought, we look at a patient’s symptoms to reveal the “nature of the pathogen.” I.e., if the patient’s tongue has a yellow-greasy coating, then the pathogen must be warm and damp. But what exactly does this mean, that the pathogen is warm-damp? Is there really a pathogen inside of us spreading heat and dampness? What exactly is that pathogen doing in our body? Modern-day practice of Traditional Chinese Medicine continues to follow this pathogen-focused approach: i.e. we have to find, identify and attack the pathogen, using herbs that counter the nature of that pathogen. With the increased influence of western biomedical theory, modern practitioners of TCM seek to add herbs shown to have “antiviral” properties to our armory for treatment and prevention of viral infection.

 

Ultimately, having surveyed these historical Chinese medical schools and trends, Dr. Weizenbaum chooses to be guided by the older classical Shang Han Lun (or Cold-Induced Disorder) laid out in the writings of the Eastern Han Dynasty Physician Zhang Zhong-Jing (150-219 CE,) which she feels is more compatible with an expanded understanding of the human immune system. Again, see my previous blog post for more information on these various historical streams in the Chinese medicine approach to infectious disease.

Eastern Han Dynasty Physician Zhang Zhong-Jing

“This is a Narrative About the World and Life:” A Different Narrative on Immunity

In her understanding of Shang Han Lun theory of diagnosis and herbal treatment, Dr. Weizenbaum sees an understanding of immunity that is wider than the dualistic, militaristic “bad things out there that I need to protect myself against” narrative.

The narrative she seeks to embrace, in her approach to health, healing and immunity, is about the world and life. It involves an understanding that:

• The nature of life is one of interconnection;

• Health is about being in a workable relationship with life;

• Healing is about coming into this workable relationship with life.

The fact is that the novel coronavirus (COVID-19) has become a part of our world. Part of “boosting our immunity” to this virus might be our body making a shift so that we can eventually live with the virus without it causing us problems. Illness or infection with the virus might be perceived as a process of our body shifting, so that we can now live with the virus as part of our world.

Dr. Weizenbaum states that, with this shift in perspective, the question changes from “how do I keep the virus out of me?” (although this is also important at this stage!) to “When I do get sick, how can I help my body process this, so it doesn't hurt me so much? How can I improve my chances of coming through the illness well, and to become able to live with the virus being part of my world?”

Dr. Weizenbaum states that Chinese medicine, and Chinese herbs, have a lot to offer in terms of helping our bodies shift into a workable relationship with the new virus.

What Is COVID-19 then? And how does it relate to our Immune System?

Dr. Weizenbaum states that COVID-19 is something new in our world that we are being forced to come into relationship with. And our immune system, in this narrative, is the sum of all our body functions that help us learn to come into relationship with the outside world. It is our immune system that enables us to learn to live in harmony with the world outside our bodies, which now includes the COVID-19 virus. This view is in contrast to the dualistic, militaristic idea of our immune system “fighting off the virus.”

How Do the Symptoms of COVID-19 Guide Us?

Dr. Weizenbaum tells us that our symptoms, when we contract an illness, tell us two things:

1. The specific ways in which our specific body is having a hard time coming into relationship with this illness, and

2. What demands this new illness is making is making on our individual body as we come into relationship with it. (i.e. we can consider what particular demands this particular virus is making on certain systems of our individual bodies, based on where dysfunction shows up as we encounter the virus.)

As A Healer…

As healers, then, our goal is to help the patient’s body come into relationship with this new virus. (The same can be said for any of us caring for ourselves as we encounter a new challenge.) Our process of diagnosis is to observe where the body is having a hard time in terms of physiological functions (rather than considering the specific nature of the pathogen.) Our treatment is to provide measures to help the body process this new challenge better, and to not let it kill us/the patient.

Seeing the Body as a Circle

Having established a foundational framework that our bodies are part of an interconnected network of life in the world, Dr. Weizenbaum further describes how our bodies relate to and interact with the world. Our bodies, she states, function as a circle. We are constantly taking in life and nature, and giving back to nature. In this way, we live with nature. We are nature.

We take in life/nature in a vertical downward motion, according to natural rhythms, through breath, digestion, our pores, our senses and our hearts. We give back to nature not only through our breath, our pores, our excrement, but also through our actions, our relationships, our creations, our lives.

If we try to keep something out (as in “keep out the virus,”) we are stopping a natural, cyclical process.

So, we are constantly taking in and giving back, in a cyclical manner. We are in a permeable relationship with life. The ability to do this well is the mark of a healthy immune system.

Problems (illness) occur when:

• Our body doesn’t process something well, or

• Something is being demanded of our body that is beyond our body’s ability to process. 

By extension, COVID-19 makes a person very ill or, tragically, kills a person when:

• The person’s body can’t process the virus in some way, and 
• The person’s body does not get the help it needs to process the illness. 

At least in the early stages of the pandemic, western medicine was mostly at a loss in terms of what to offer to help a patient's body process the virus before it became severe or life-threatening. Some interventions might include a humidifier, or over-the-counter medications like robitussin or mucinex. Chinese herbs are another supportive intervention.

COVID-19, Dr. Weizenbaum states, is coming into our world with very particular demands on our bodies. Her application of herbs is to help the body shift in a way to allow the novel virus to move through without hurting us so much. Diagnosis is identifying where in the cyclical process of taking in nature and giving back our bodies need help. The signs and symptoms an individual experiences in the course of a COVID infections give us the answer: where exactly in this cycle does the body need help to process.

I will not go deeply into Shang Han Lun theory here, because that's a more lengthy & complicated discussion. Suffice it to say, Shang Han Lun theory illustrates six places in this this circular cycle where obstruction, insufficiency or dysfunction can occur. (For example, is there a blockage in our body's ability to vent a pathogen at early onset? Is there a blockage in the descension of food and oxygen? Do we lack ability store vital energy? Is our ability to tranform what comes in into vital energy? Etx.) Signs and symptoms are very specifically described in the Shang Han Lun text, which guide diagnosis of these dysfunctions. Herbal formulas aid physiological function by addressing these specific areas of dysfunction.

In conclusion, I thought that this holistic perspective on immunity provides a nice counterpoint to our dominant narrative on host vs pathogen. I see these contending narratives play out in various medical approaches. On one extreme, western medicine devotes itself to understanding the nature of the infectious pathogen and its impact on our bodies in minute biochemical detail, and thereby learning how to fight and kill it. Holistic medicine, by contrast, tends to be more interested in cultivating the host's immune physiology. May the two systems work together, and perhaps the holistic view perspective might help us live in the world with less fear, and more peace and gentleness.

Half a Year into the COVID-19 Pandemic: Some Updates on COVID Research, Thoughts on Collective & Social Immunity, the Epidemic of Fear concept, etc.

As I write this, we are deep into autumn and winter is coming. It’s the time of year when many of us start to think more about how well our immune system is functioning. We hope to be able to avoid more severe courses of the seasonal viruses that will inevitably circulate during the winter months. This year, of course, we not only have colds and influenza to worry about. We continue to be preoccupied with COVID-19. Those of us in the Western United States may wonder, additionally, whether persistent exposure to wildfire smoke (or avoidance of outdoor activity due to smoky air) over the past two months, during this year’s unprecedented fire season, may have impacted our abilities to deal with infections this winter.

I thought I'd take some time to write out some of my musings on the pandemic, having watched in unfold in Berkeley during the past six months:

Western Medical Research & COVID:  A Round-Up of Recent News Articles:

In its approach to COVID-19, the western medical establishment has devoted itself to understanding everything it can about the COVID-19 virus and its transmission at a biochemical level. In the course of treating severely ill COVID patients, researchers and medical professionals are learning more about which medical treatments work and which don’t. Remdesivir, dexamethasone, and monoclonal antibodies all seem to offer some help to COVID patients. Here are a few related news items from the last couple of weeks: 

Here’s an interesting article on emerging evidence of the efficacy of monoclonal antibody treatment in combating COVID-19. Monoclonal antibodies was one of the treatments President Trump received in hospital after contracting the virus.

It seems the jury is still out on the effectiveness of remdesivir, a broad-spectrum antiviral medication which showed promise in the treatment of lower respiratory tract infections related to COVID-19. One study published in the New England Journal of Medicine on Oct 8, 2020, concluded that remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with COVID-19 and having evidence of lower respiratory tract infection. On the other hand, a preliminary report, released a week later, of the World Health Organization (WHO)’s large scale “Solidarity Clinical Trial” for COVID-19 treatments, suggested that remdesivir had no substantial effect on COVID-19 patients’ mortality. 

Public health officials continue to do their best to recommend measures, like masks, social-distancing and handwashing, for slowing the spread. It seems that the ultimate goal of the medical establishment, in its approach to the virus, is the production and dissemination of an effective vaccine. However, it’s unclear how quickly we might really be able to return to “normal life” even after the approval and dissemination of a vaccine, as this interesting New York Times article points out.

Finally, if you need a dose of cautious COVID-related optimism, here's a interview with New York Times Science & Health Reporter Donald McNeil, recorded in the context of the current autumn surge.

How Much Does Western Medicine Consider the Immune System?

Practitioners of holistic/alternative systems of medicine are often quick to point out that, in its search to understand the COVID-19 virus and develop a medical cure and a vaccine, the western medical establishment directs little attention at the body’s innate capacity to resist infection, or to its capacity to successfully fight off the viral infection if a patient is unfortunate enough to contract the virus. That is, the western medical establishment tends to pay a lot less attention to the immune system of the human host in comparison to nature of the pathogen.

What About Our “Collective Immunity” as a Society? Or “Economic Immunity”?

The question of social vulnerability, fortunately, is receiving somewhat more attention from social scientists, public health researchers and journalists. Why have some segments of our society, namely Black, Latino, Native and poor and front-line worker communities, been so disproportionately affected by COVID in comparison to White & affluent folks? At this point, in late 2020, evidence also is also emerging that non-COVID-related death rates among people of color have also increased disproportionately, in relation to white or to total population, this year. You don’t have to search far for analyses of these trends: Here’s one article from Brookings. Here’s another from NPR.

Why has the pandemic had such a devastating effect on our economic systems, with some segments of the economy and workers being much more hard-hit than others?

In addition to taking a holistic approach to augmenting the immunity of our individual bodies, might we not begin to think about a truly inclusive “social immunity,” as we recover and rebuild after this pandemic? Will we institute programs to promote more broad-based economic resilience?

Should We “Fear” the Virus?

President Donald Trump emerged from his own infection with the COVID-19 virus saying, essentially: Don’t fear the virus. It’s no big deal. It’s not worse than the seasonal flu. “Don’t let it disrupt your life.”

Now, I’m going to assume most people reading this will see this merely as part of the ongoing stream of irresponsible, callous and narcissistic gestures that masquerade as leadership from this administration. It is regrettable that this president, who was flown to Walter Reed Hospital in a private helicopter and received every available cutting edge medical therapy, failed to express empathy for the thousands of families who have suffered & lost loved ones to COVID, none of whom had access to the health care services that he did. It is also regrettable that he perpetuated a narrative of toughness and machismo, based on lies and mistruths.

An Epidemic of Fear?

Interestingly, during these pandemic months, I have also occasionally heard this line: “Don’t fear the virus,” coming from some folks of the holistic/alternative health community. Some segments of the holistic health community have tended to downplay concerns about COVID-19, saying something like, “What we are really facing is an epidemic of fear.” We shouldn’t let fear control us.  We should understand that, if we tend to our individual health, our immune systems can be strong enough, tough enough, to “handle” this virus.

On one hand, I resonate with the spirit of this assertion. There truly is a lot we can do to improve our bodies’ capacities to fight off, or process, viral infection (from exercise, to sleep and rest, to eating good foods, to spending time outdoors, to getting acupuncture treatments, to using herbal medicine to fine-tune our body’s physiological function, etc.) See, for example, my article from March 2020, Staying Healthy (and Sane) During the Pandemic. Also, I can acknowledge the subtle & not-so-subtle effects of daily anxiety about the virus in myself and my family, like how hard & scary it becomes to leave the house, and how unnatural human contact feels, after sheltering in place for several weeks at a time.

On the other hand, I feel uncomfortable with this “epidemic of fear” rhetoric. Taken to an extreme, it can make people feel embarrassed and ashamed about taking precautions that are actually life-saveing, like wearing masks, social-distancing, etc. We are not all equally equipped to “handle” this virus. Some of us have pre-existing conditions. Some of us are in high-risk categories. Some of us live with and care for elderly and sick family and community members. The inequities in living conditions and access to health care are deep and multi-generational. It’s just not appropriate for anyone to dictate, or critique, someone else’s response to this virus.

Perhaps some of the best outcomes that we can hope for, once we get on the other side of this pandemic, are, first, that we grieve our losses and the shortcomings of our public responses to the virus, including the lack of national leadership on issues related to the pandemic. Then, perhaps we will learn more about our vulnerabilities as a society, and enact policies and programs, build community networks and organizations, to better equalize the risks we face and support the most vulnerable in our society. Perhaps we can improve our “immune health” collectively, not just individually.

A first step for this moment is to VOTE in the November 2020 election. :-)

Analysis of One Chinese Herb Formula Used to Treat Early-Stage COVID-19 Infection

Chinese herbal medicine has been used effectively in China during the course of the COVID-19 pandemic to prevent infection, mitigate the severity of symptoms and slow disease progression.

One of the best reports I’ve heard has come from US-born herbalist and practitioner of Traditional Chinese Medicine, Thomas Avery Garran, PhD. Garran is currently living in Beijing, pursuing graduate work in pharmacology of herbs. He has been working with a team of translators in China to make available protocols being used in Chinese hospitals for infectious disease management at different stages of the COVID-19 disease progression. I want to share some of what I learned from Mr. Garran through a seminar which took place on April 4, 2020, presented by the good folks at the Oakland-based herbal pharmacy, Five Flavors Herbs.

Please note: I’m sharing these ideas for educational purposes only, to advocate for the skillful application of Chinese medicine. Please do not self-prescribe Chinese herbs unless you are a licensed professional. If you are interested in taking Chinese herbs for a medical condition, please consult with a licensed Traditional Chinese Medicine practitioner.

Chinese herbs are not traditionally selected based on their efficacy in killing viruses. And there is certainly not a one-size-fits-all formula to treat or prevent coronaviruses. Chinese herbal formulas are constructed on the basis of pattern diagnosis, in order to optimize the body’s ability to fight the virus and recover. (For more about the construction of Chinese herbal formulas, click here.)

To construct a formula for a COVID-19 patient, we need to take into account the details of his or her symptoms and select herbs based on the presenting symptom-pattern. So, what symptom-patterns are we seeing in COVID-19 patients?

Damp-Phlegm and Toxic Heat as a Key Diagnostic Features:
Thomas Avery Garran reports from China that the typical symptoms of hospitalized patients in the early stages of infection (pre-pneumonia) in Hubei Province (the Province where Wuhan is located and where COVID-19 originated) are:

• Fever (in some cases, not all)

  

  Image Courtesy of Wikipedia

• Fatigue
• Sore Muscles
• Heavy Feeling in the Body
• Poor Appetite
• Loose Stools
• Cough (most, not all)
• Chest Pressure
• Panting, Urgent Breathing
• Greasy Coating on the Tongue.

In Chinese medicine theory, the dominant pattern in this set of symptoms is Dampness and Phlegm. (I will capitalize words like Dampness, Phlegm, when they represent concepts in Chinese medicine theory.) Dampness & Phlegm account for fatigue, muscle soreness, subjective heavy feeling, poor appetite, loose stools, chest pressure, difficult breathing and a greasy tongue coating.

A further verification of a Phlegm-based diagnosis comes, sadly, from the autopsies of patients who did not survive COVID-19 infection. Garran reports that Chinese physicians, observing the lung tissue of deceased COVID-19 patients, found the alveoli caked with thick phlegm (what is being called ground-glass opacity seen in CT scans of the lungs.) It is this phlegm that causes suffocation during advanced stages of COVID-19 infection, by preventing absorption of oxygen through the lung tissue. Some of the difficulty that has arisen in putting COVID-19 patients on ventilators, in fact, seems to come from this accumulation of phlegm around the alveoli.

Based on these observations, Chinese herbal physicians in China concluded that to mitigate symptoms of COVID-19 and slow disease progression, it was imperative to stop or slow the production of Phlegm in the body. In Chinese medicine theory, Dampness is the result of a weak Spleen (roughly equivalent to poor digestion.) Dampness, especially in the company of Heat, tends to congeal into Phlegm. There is a saying the Dampness (as a pathogenic factor) is produced by the Spleen and stored in the Lung. The treatment principles employed to decrease Dampness are to Support the Spleen and Aromatically Transform Dampness.

The fact that digestive symptoms like poor appetite, loose stools, diarrhea and loss of appetite often accompany the early stages of COVID-19 infection supports the idea that Spleen weakness and Dampness are part of the diagnostic picture of COVID-19, and that support for the Spleen must be part of the treatment.

In addition to supporting the Spleen and transforming Dampness and Phlegm, Garran says, it is important to “give the Phlegm a place to go.” This means we need to use herbs that will loosen the Phlegm in the chest and allow it to be expelled or expectorated.

An important note is that, in early stages of COVID-19 infection, cough should not be suppressed. So we don’t want to use herbal Lung astringents or over-the-counter pharmaceutical cough suppressants. We want to loosen the phlegm in the chest and actually encourage coughing, thereby allowing the phlegm to be coughed out of the lungs. (At later stages of COVID-19, when the patient is more debilitated, however, there may be a need to suppress cough.)

The idea that COVID-19 infections tend to be characterized by Phlegm & Dampness has been a little confusing to western audiences, since many of us have heard that one of the symptoms of the illness is a dry cough. Garran clarifies that even if the cough is dry, there is still a lot of very sticky, difficult-to-expectorate phlegm coating the insides of the lungs. (This appears to be generally true, though individual cases will vary depending on patient’s constitution, surrounding climate, etc.)

In addition to Dampness & Phlegm, Garran states that Toxic /Pathogenic Heat is also a diagnostic pattern typically seen in COVID-19 patients in China (as opposed to cold damp-phlegm.)

Finally, in terms of Chinese medicine theory, Garran observes that the COVID-19 virus is very aggressive and quick-moving. Symptoms of infection change rapidly. From a Chinese Medicine "levels-of-infection" perspective (more about that in this article), the virus is said to initially penetrate the exterior defenses or Wei Qi, then move to the organ level where it constrains the Lung and what we call the Middle Burner (or the Spleen/Stomach/digestive organs.) This is where the skillful application of herbs comes in: to slow the progression of the virus from initial to more severe stages.

Herbal Formula for Initial-Onset Stage of COVID-19 Infection from Hubei Province, China:
To illustrate how Chinese herbs are used to combat COVID-19, I’ll share an analysis of a formula being used in hospitals in Hubei Province, China, to treat patients at the early-onset stage of infection. I do this to share information about the beauty and sophistication of Chinese herbal medicine. Again, if you are not a trained herbalist, please do not self-prescribe. Please consult with a licensed practitioner if you’re interested in herbs for prevention or treatment.

A typical pattern observed in Hubei Province in early-stage COVID-19 patients has been Pathogenic Heat Toxin Penetrating the Exterior and Entering the Lung. As it attacks the Lung, the the pathogenic toxin has qualities of heat and constraint, i.e. it hampers free circulation of Qi. The formula being applied for this condition is a modification of a classic formula called Chai Ge Jie Ji Tang, or “Bupleurum and Kudzu Decoction to Release the Muscle Layer.” The formula has its origins in the Shang Han Lun, or Treatise on Cold-Induced Disorders, compiled during a period of frequent epidemics in the the Late Han Dynasty period in China. (For more information, click here.)

The herbs used in this formula modification are:

(I will list both the Chinese pin yin name and the Latin or common botanical name.)

• Chai hu / bupleurum root
• Ge gen /puerariae root (aka kudzu)
• Qiang huo / Notopterygii root & rhizome
• Du huo / Angelicae pubescentis rhizome
• Gan cao / Radix glycyrrhizae Uralensis (aka raw licorice root)
• Shi gao / gypsum (calcium sulfate)
• Lian qiao / forsythia fruit
• Ban lan gen / isatis root
• Huang qin / Scutellariae baicalensis root
• Xuan shen / Scrophulariae ningpoensis root
• Bai shao / white peony root

Bupleurum Root
Photo Credit: Sacred Lotus Chinese Herbs

There is a Chinese medicine tradition of pairing herbs (known in Chinese as "dui yao") whose qualities work well in synergy and balance one another. This formula is an excellent example of this type of pairing. I'll analyze the herbal constituents in pairs.

First, let’s look at the the two chief ingredients in the formula: bupleurum and pueraria roots. Both of these herbs are employed in the treatment of colds and flus, at the stage when the pathogen is considered to be at the defensive surface (the Wei level) of the body. Together they open constraints at the surface. They “open the doors,” so to speak, so the pathogen can be kicked out. Both of these ingredients are cool in nature (as opposed to warm herbs that open the surface, like ginger or cinnamon.) They are are used because the COVID-19 virus quickly manifests with heat signs and symptoms. Pueraria’s special quality is that it relieves muscle aches, headache, and back/neck stiffness related to early-stage viral infection. Both herbs relieve fever. Bupleurum particularly addresses alternating fever and chills. As opposed to suppressing fever or suppressing the body’s natural immunity, they open the surface to clear the invading pathogen through the surface level. (In western herbal theory, these herbs would be considered diaphoretics.)

Pueraria Root
Photo Credit: Little Flowers

The next pair of herbs to consider are Notopterygii and Angelicae pubescentis roots. These two herbs are especially effective together for pushing out Dampness. Like bupleurum and pueraria, notopterygii and Angelica pubescentis work at the surface/exterior defensive level of the body, but unlike the former two, notopterygii and angelica are warm to effectively dispel cold-dampness. They also helps relieve symptoms like headache, body aches, chills, fever, along with fatigue and a subjective heavy feeling, as is commonly seen in the early stages of COVID-19 infection.

So far we have bupleurum and pueraria, which are cool and open the surface to expel heat-pathogen. And we have notopterygii and Angelica pubescentis which are chase out dampness. These four herbs work on the surface, defensive layer of the body, opening the doors and expeling damp-pathogen.

Notopterygii
Photo Credit: Sacred Lotus

Because the typical COVID-19 progression is to move from the surface level of the body into the interior, and specifically to attack the Lung and Stomach organs, creating a “constrained heat” quality around the Lung (difficult breathing, wheezing, cough, etc.) and interfering with the digestive process, the next two herbs specifically address heat at the level of the Lung and Stomach organs (no longer at the surface level.) These are gypsum and raw licorice root.

Gypsum (which is a mineral and has to be cooked longer than the other herbs,) clears Heat from the Lungs and Stomach. It particularly addresses cough and wheezing with fever and thick, viscous Phlegm in the Lungs. Raw licorice is most often used in formulations as a Spleen Qi tonic. But here it is used clear heat toxin from the Lungs, stop cough and wheezing.

Raw Licorice Root
Photo Credit: Shen Clinic

The next pair of herbs, forsythia fruit and isatis root, have yet another function. According to their Chinese medicine classification, these herbs “Clear Toxic Heat.” They are known to have constituents that are particularly effective in fighting virus. ("Anti-viral" is not a particularly traditional consideration in Chinese herbalism, but a nod to modern pharmacological considerations and the virulent nature of the COVID-19 virus.)

Coming to the end of this list of herbs, Radix Scutellariae Baicalensis also has an affinity for the Lung and Stomach organs. It’s function is to Clear Heat and Dry Dampness. It treats high fever, irritability, thirst, and cough with thick yellow Phlegm, as well as diarrhea or stomach upset due to toxic infection. Scrophularia helps clear Toxic Heat and Transform Phlegm in the Lungs. Scrophularia has a unique quality that while it helps clear Toxic Heat infection, it also has the capacity to nourish Yin. The idea here is that it may help soften and loosen the thick, viscous Phlegm coating the lung surfaces, making the Phlegm easier to expectorate.

Gypsum
Photo Credit: Herbal Shop

The final group of herbs, white peony root, together with the already mentioned Scrophularia and raw licorice, have a forward-looking quality. Each of these three have a quality of nourishing and moistening. Peony root protects the Yin and Blood of the Liver. Scrophylaria nourishes Yin. Raw licorice moistens tissues, tonifies Qi, harmonizes the herbs in a formula and moderates the harsh effects of other herbs. The primary herbs in this formula have strong anti-infectious, heat-clearing qualities. They are generally meant to be taken short term because they can deplete energies of the body. Also, viral infection tends to damage the Yin and Qi of the body. Fever, while it helps clear infection, can result in lingering dryness, irritability, constipation, etc. The final three herbs help mitigate these negatives to promote long-term recovery.

Forsythia Fruit
Photo Credit: Sacred Lotus

On a final note, the traditional form of this formula, Chai Ge Jie Ji Tang, contains Jie geng, or Radix Platycodi Grandiflori as a significant ingredient. Platycodon root is regularly used in Chinese medicine to open the Lung, treat cough and clear Phlegm. Why is it not favored in treating early-stage COVID-19 patients? Thomas Avery Garran proposes that it is not used because it suppresses cough. As mentioned before, we do not want to suppress cough, rather we want to open the Lung, loosen Phlegm and allow it to be coughed out.

Keep in mind that this is only one of many formulas being used to treat COVID-19 patients, in China, at an early stage. I wanted to describe it as an example of the nuanced way Chinese herbs are used in formulas. If you are interested in using Chinese herbs in the context of the pandemic, please consult a licensed Chinese herbalist.

If time allows, in the coming days, I'll share some notes about formulas for prevention of COVID-19 infection, as well as for later stages of infection and recovery phase. In the mean time: Stay safe! Stay healthy! Let's get through this!

How Herbal Formulas are Built in Traditional Chinese Medicine

I want to share a bit about some of the traditional Chinese herbal formulas being used to treat COVID-19 patients. But before I do that, I'd like to provide a little insight into how herbs are selected and combined to make formulas in Traditional Chinese Medicine.

In both eastern and western herbal medicine systems, it’s fairly rare for an herbalist to prescribe only one herb at a time (except under very particular circumstances.) Herbs are generally considered to work most effectively in synergy, i.e. in combination with other herbs.

In the course of the 2000+ year evolution of traditional Chinese herbalism, practitioners have developed a sophisticated system for combining herbs into formulas.

Herbal Formulas Based On Pattern Diagnosis:

One feature of Chinese herbal formula-construction is that it is based on Chinese medicine’s unique system of diagnosis. In Chinese medicine, patients are diagnosed based on constitutional tendencies and symptom patterns. Treatment methods and strategies are based on traditional descriptions of symptom patterns. Herbal choices and formula combinations are, in turn, based on this pattern-based differential diagnosis.

One thing this means is that herbs are generally not selected to chase symptoms. In an infectious disease scenario, herbs are not selected primarily with the intent to “kill the virus.” Rather herbal combinations are used to optimize a patient’s physiological function and improve their ability to rid the virus from their body.

"Hierarchy" of Ingredients:

Another special feature of Chinese herbal formulas is that the herbal constituents, rather than being thrown together together haphazardly, are organized according to particular organizing principles. The metaphoric for an herbal is the imperial court (a relevant metaphor in ancient Chinese society.) Each herb in a formula falls into one of four categories symbolizing members of the court:

1. The Chief Herb (aka the king or emperor): This is the ingredient that is directed against, or has the greatest effect on, the patient’s principal pattern or disease. This ingredient is indispensable to the formula.
2. The Deputy Herb(s) (aka, minister or associate): This ingredient can have one of two functions: 1) aids the chief ingredient in treating the principal pattern or disease; or 2) serves as the main ingredient directed against a co-existing pattern or disease.
3. The Assistant Herb(s): This ingredient can have one of three different functions: 1) reinforces the effect of the chief or deputy ingredients, or directly treats a less important aspect of the pattern or disease; 2) moderates or eliminates the toxicity of other ingredients or moderates their harsh properties; or 3) has an effect that is opposite of that of the chief ingredient and is used in very serious and complex disorders.
4. The Enjoy Herb(s) (aka messenger or guide): Can have one of two different functions: 1) focuses the actions of the formula on a certain channel or area of the body; or 2) harmonizes and integrates the actions of the other ingredients.

Source: Bensky, Dan and Barolet, Randall. Chinese Herbal Medicine: Formulas & Strategies.

Roots of Chinese Medicine Strategies for the Treatment of Infectious Disease

Physician Zhang Zhong-Jing
Photo CreditWikipedia

Chinese medicine is a valuable resource in context of the COVID-19 pandemic. Herbal strategies for addressing infectious disease have been refined over the course of 2000 years, and have been particularly influenced by historical epidemics.

The first significant textbook of herbal formulas was written by the famous doctor Zhang Zhong-Jing (150-219 CE.) Zhang lived during the final years of the Eastern Han Dynasty, when continual war and strife led to the outbreak of many epidemics. Zhang lost two-thirds of his family members, the majority of them to infectious diseases. He dedicated his life to distilling a formulary for every stage of infectious disease. These formulas are detailed in the classic Chinese medicine text Discussion of Cold-Induced Disorders, or Shang Han Lun.

Later, in the Ming Dynasty (14th-19th centuries,) the introduction of western diseases such as mumps and measles was a catalyst to revising Zhang’s formulas to effectively treat these new epidemics. The foremost physicians credited with these revisions were early 18th century physician Ye Tian-Shi, and late 18th century physician Wu Ju-Tong, whose work culminated in the medical text Systemic Differentiation of Warm Diseases, or Wen Bing Tiao Bian.

Ming Dynasty Physician Ye Tian-Shi
Photo Credit http://www.itmonline.org/

Modern-day practitioners of Chinese herbal medicine draw heavily on theories laid out in both the Shang Han Lun and the Wen Bing when treating colds, flus and epidemics, including the earlier coronaviruses SARS and MERS.

One notable feature of these texts is that they both outline a specific progression of stages by which infectious disease enters and overtakes the human body. In the case of the earlier Shang Han, or cold-induced disorders, infection was considered to progress through six stages: three external (or yang) stages and three internal (or yin) stages. Specific formulas (or formula variations) are employed at each level, with the goal of keeping the infection on the outside (yang, energetic, defensive or muscular) of the body and preventing it from becoming more serious and penetrating to the interior (yin organs). Similarly, later in history, the Wen Bing, or warm disease school, built on earlier ideas and outlined a four-stage progression whereby infectious disease progresses from exterior to deeper layers of the body. The Wen Bing school, in the 18th century, was also the first in China to clarify an understanding that infectious disease pathogens spread from person to person.

In the United States, obviously, patients in advanced, severe stages of COVID-19 infection are treated in the hospital for pneumonia, put on ventilators, etc. These patients are generally not receiving herbal treatment. However, Chinese herbalists in the United States can draw on the rich formulary developed over 2,000 years to effectively prevent viral infection and mitigate symptoms during earlier stages of infection.

Sources:
Bensky, Dan & Barolet, Randall. Chinese Herbal Medicine: Formulas & Strategies.

Mitchell, Craig; Ye, Feng & Wiseman, Nigel, ed. Shang Han Lun: On Cold Damage, Translation & Commentaries.