By Eric Brand, PhD, L.Ac.
Like many of my fellow Chinese medicine practitioners, I have been paying attention to the coronavirus for the past few months. While I’ve been closely following the formula approaches that are being employed in TCM hospitals, much of my focus lately has been concerned with maintaining a stable supply of herbs at this critical time. We’ve been receiving many emails from customers concerned about herbal supply chain disruptions related to the coronavirus, and this update aims to keep practitioners informed on the trends that we are seeing from inside the industry.
Essentially this article explores several different topics: 1) The overall effect of the coronavirus and trade war tariffs on the Chinese herbal supply chain, 2) Clinical trends in China in response to the virus, and 3) Individual herbs that have been experiencing surges and shortages in the industry.
Clinical Trends in China
Many clinicians and scholars in China have written about clinical approaches to the coronavirus. The most comprehensive publication that I have seen so far is this piece, which features bilingual Chinese-English versions of a 131-page text that is dedicated to the current treatment of the coronavirus in China. It has detailed formulas and covers the topic relatively thoroughly.
Chinese medicine is being widely employed in China for the coronavirus. Chinese language publications on current treatment standards from the central government include TCM, with a breakdown of different formulas and stages. Additionally, the National Administration of Traditional Chinese Medicine (often still called the State Administration of TCM or SATCM) has started publishing summaries of treatment statistics from TCM hospitals.
In addition to Chinese language sources, I’ve been closely following the work of some of my friends in China, particularly Shelley Ochs, Thomas Garran, and Suzanne Robidoux. Shelley, Thomas and Suzanne all have a strong clinical focus in addition to a solid background (they all did their PhDs in China, in Chinese, and have cultivated deep cultural and medical connections over many years there), and they translated some of the first solid English summaries that I saw in circulation.
In the translation compiled from Shelley Ochs and Thomas Garran, the formulas summarize the principle formulas used at the epicenter in Hubei and in the early outbreak site in Guangzhou. The links for these papers are here and here.
Another recent paper that has been published in English is titled “Can Chinese Medicine Be Used for Prevention of Corona Virus Disease 2019 (COVID-19)? A Review of Historical Classics, Research Evidence and Current Prevention Programs”. It is available for free as a full-text article.
Since I did my PhD in Hong Kong in the area of Chinese herbal pharmacy and my study habit is supported by having an herbal company, I mostly focus on issues of herbal quality control and materia medica. Accordingly, this blog is not focused on the treatment of the coronavirus, but rather its impact on the supply chain, and useful tips from the perspective of herbal pharmacy.
Supply Chain Impact
Unfortunately, the coronavirus has had a major impact on the Chinese herbal supply in the USA, particularly because it converged with the trade war that Trump initiated with China in a perfect storm of bad timing. Many herbal companies held off on shipments for much of the past year, because Trump’s trade war added extra tariffs of 15-25% on any herbs that were imported prior to February 14th (now the tariffs on most herbs have finally dropped down to “only” an extra 7.5% on top of the original 6.4% tax, while a few herbs such as ginseng remain subject to 25% added tariffs). However, by the time the tariffs came down enough for companies to ship products without crippling taxes, the supply chain was already disrupted by closures from Chinese New Year that were drastically extended by the coronavirus crisis.
As the Chinese economy ground to a standstill, most factories were closed and fewer ships were moving, making it hard to schedule outbound shipments. Now that China is returning to work, the factories and ports are backed up. Delays in shipments leaving China have caused many companies to report shortages, which are becoming more pronounced as practitioners start to stock up on particular herbs.
At Legendary Herbs, we have largely been spared from the worst of the shortages, because we were able to get a large shipment of granules out of Shanghai just in time. At the peak of the crisis, our supplier was commissioned by the Chinese central government to produce a national stockpile of herbal medicines for TCM hospitals throughout China, so no additional orders could be accommodated. Fortunately, we had our next order prepared many months in advance before the crisis hit, and we were simply waiting for the tariffs to drop before shipping so that we could minimize price increases for our customers.
The granules our customers rely on are used at 70% of China’s AAA-tier hospitals, and our supplier is the exclusive supplier designated by the Hong Kong Department of Health for all TCM clinics operating under the Hong Kong Hospital Authority. We were extremely lucky to get our shipment out just in time, and we feel fortunate to have a stable inventory of premium granules despite the crisis.
However, many other herbal companies were not as lucky in getting out their shipments, and widespread shortages and price increases have been reported by many leading companies. Some herbs such as ban lan gen, jin yin hua, and huang qin have become hard to find throughout the country. Around 2008, we experienced a similar trend when virtually the entire national supply of jin yin hua dried up. Even the Dr. Oz episode praising yan hu suo a few years ago stimulated national shortages and higher prices for a brief period.
In the current situation with the coronavirus, many practitioners have been stocking up on some herbs that are not frequently used under normal conditions, including aromatic damp-transforming herbs such as huo xiang and pei lan, due to their frequent appearance in some of the recently published formulas that are being used in China. A few comparatively uncommon herbs such as guan zhong are also experiencing shortages, because they are typically stocked in small quantities and easily sell out when many people start suddenly buying them all at once.
In some cases, even temporary shortages can cause elevated prices that take time to correct, especially for crops that require several years to reach maturity. For example, around the peak of the H1N1 virus, jin yin hua became very scarce and the price went up from about $7 for a 100g bottle of granules to nearly $35 around 2009. We quickly dropped the price back down to $18.90 at Legendary when the raw material costs came down in subsequent years. However, many other companies simply kept their jin yin hua prices at $40 or more for another decade, even though the raw material price had long since dropped back down.
Why have certain individual herbs become so scarce?
In the SARS crisis, as well as in the coronavirus and H1N1 events, many formulas widely used in China have been influenced by wen bing (warm disease) theory. While some formulas that appear in the publications from Hubei are essentially modified classic Shang Han Lun formulas such as ma xing shi gan tang, many of the formulas published in the papers from Hubei and Guangzhou emphasize heat and dampness. An emphasis on heat and dampness is common in wen bing formulas, and not surprisingly we see a run on heat-clearing herbs such as huang qin, jin yin hua, and lian qiao, along with aromatic damp-transforming and exterior-resolving herbs such as huo xiang and pei lan. As in the SARS and H1N1 outbreaks, there is widespread use of ban lan gen, with tremendous demand both domestically in China and in overseas markets.
Historically, the wen bing style emerged in southern Chinese regions in response to epidemic illnesses that circulated during the Qing dynasty. Some formulas from this period, such as Wu Jutong’s yin qiao san, remain in widespread use. Even during normal times, data from Taiwan’s electronic health insurance shows that yin qiao san is one of the most frequently prescribed formulas by Chinese medical doctors in Taiwan (in 2002-2003 for example, it was ranked at #6, with an average of over 25 metric tons of granules used in the local TCM market).
Below are some interesting facts about some of the main herbs that are in short supply at the moment. If all you care about is the core info on the supply chain issues, no need to read further. But if you are an herb nerd that made it this far, here we go:
Huang Qin has been flying off the shelves. Despite its relatively high frequency of use (and comparatively abundant inventory), it has had such a surge that several suppliers have reported shortages.
At Legendary Herbs, we carry huang qin in both unprocessed (sheng) and wine-processed (jiu) forms (our granule line features different processed forms of many herbs, including yi yi ren, da huang, bai zhu, bai shao, ban xia, etc.). Since many Western practitioners are not familiar with the nuances of the different processed forms, we have had huge surges in the sales of unprocessed huang qin. However, in the context of lung heat, the wine-processed form is preferred, and we have plenty of huang qin still available in the “jiu” (wine-processed) form because it is easily overlooked by people that simply seek out “huang qin” (which is the sheng form by default).
The effects of huang qin have long been appreciated in China. It is one of the few herbs that was used historically as a formula all by itself (TCM textbooks regularly list huang qin as an example of dan xing, “going alone” in the seven relationships of Chinese herbs). According to prescribing data from Taiwan, huang qin ranks #7 in frequency when added as a single herb addition to granule formulas, with an average of 7000 kilograms of huang qin granules prescribed per year. When its use in granule formulas is factored in, it is the 8th most frequently prescribed Chinese herb in Taiwan (based on an analysis of two million patient visits).
Traditionally, huang qin is differentiated into two forms based on its growing conditions: old roots are withered in the center and traded under the name ku qin, while young roots are known as zi qin or tiao qin. Old roots are considered to be superior for lung heat, while young roots are traditionally used for damp-heat in the intestines and have a more descending nature. When huang qin is excessively moistened prior to slicing, it causes a greenish hue to appear on the cut surface, which is related to a decline in its baicalin content. Thus, the preferred material has a relatively yellowish appearance with less of the green color present (notably, ku qin appears more porous while tiao qin has a tighter root structure).
In China, the impact of the coronavirus has been most intense in Hubei Province, which strikes a special chord in my heart. Hubei province was the home of Li Shizhen, the author of the Ben Cao Gang Mu, a Ming dynasty text that represents the pinnacle of Chinese materia medica literature. Li Shizhen himself nearly succumbed to a respiratory illness in his childhood, and it was a decoction of huang qin that he credited with saving his life. This episode influenced his choice to study medicine, and today we are blessed with his tremendous works.
A rare 1603 AD print run of the Ben Cao Gang Mu that I found in the British Library during my PhD research
In 2018, I had the honor to attend the 500th anniversary celebration of Li Shizhen’s birth in his hometown of Qichun, where the local government transformed his tomb into a massive lakeside palace/park with a library and museum of Chinese medicine. Over 800 traditional medicine scholars attended the ceremony in Hubei, and celebrations for Li Shizhen were also held in 2018 at the UNESCO center in Paris, as well as in Taipei, Hong Kong, Beijing and Shanghai. I had the rare chance to attend because my PhD supervisor Prof. Zhao Zhongzhen was a keynote speaker at each of the events, and I often find myself thinking about Li Shizhen’s hometown in Hubei, trapped in the midst of this tragic epidemic.
Li Shizhen’s tomb in Qichun, Hubei
Around the same time, a project was launched with the Discovery Channel in Asia to memorialize Li Shizhen in a five-episode TV series. Among the sites filmed was the Kam Wah Chung Museum in John Day, Oregon, which was the former home of a Chinese doctor who moved to the town during the Gold Rush era in the 1860s. Despite extremely high death rates in the surrounding villages, in the village where Ing Hay (“Doc Hay”) practiced Chinese medicine, no patients ever died of the Spanish Flu epidemic of 1918. I had the chance to go through the collection of herbs that has been preserved in Ing Hay’s pharmacy since the 1920s while doing my PhD research, and Dr. Beth Howlett of OCOM initiated a project to analyze his formulas for references to the Spanish Flu epidemic. Notably, many of the same herbs that we use today are still perfectly preserved in Doc Hay’s collection, including his huang qin and excellent quality chuan bei mu.
Chinese herbal pharmacy in the Kam Wah Chung Museum
Jin Yin Hua and Lian Qiao
Lonicera flower (jin yin hua) and forsythia fruit (lian qiao) are often used together, and the two are considered to have a relationship of “mutual need” (xiang xu) according to TCM textbooks. Along with huang qin, both are key ingredients in a prepared formula called shuang huang lian kou fu ye that was widely featured in the media at the beginning of the coronavirus. However, since they are normally not used as frequently as huang qin, both immediately sold out from many suppliers.
The stem of the lonicera plant (ren dong teng) was already listed in the earliest materia medica, the Shen Nong Ben Cao Jing, which dates back about 1800 years to the Han dynasty. However, the flowers (jin yin hua) are a more recent addition to the materia medica. First used externally for sores, it is only during the Qing dynasty that we see the extensive use of jin yin hua in internal formulas.
In the Qing dynasty, the physician Wu Jutong employed jin yin hua in the formula yin qiao san in the text Wen Bing Tiao Bian, where it was prominently paired with lian qiao. Lian qiao is primarily differentiated into only two market forms: qing qiao vs. lao qiao (the former is harvested prior to maturity while the seeds are intact, while the latter is harvested after the fruit splits and the seeds are gone). By contrast, the situation is far more complex for jin yin hua.
In the 1963 edition of the Chinese Pharmacopoeia, Lonicera japonica was the only official species listed as a source of jin yin hua. However, from the 1977 through the 2000 editions of the Chinese Pharmacopoeia, several other species such as Lonicera hypoglauca, L. confusa, and L. dasystyla were included along with L. japonica as official sources of jin yin hua. In 2005, the Chinese Pharmacopoeia separated L. japonica from the other species, and now L. japonica is the only official source of jin yin hua, while the other species are known as shan yin hua.
The cost of L. japonica is relatively high because it forms smaller flower clusters and the flower must be picked during a brief time period, prior to the opening of its petals. By contrast, some of the other species that are now collectively known as shan yin hua form larger flower clusters, and can be harvested more efficiently and sold for much lower prices. During a trip to China, I once even saw a rare shan yin hua variety that had flower buds that did not open; this made it more economical to cultivate and the plant was widely cloned and grown by cell culture. Today, many Chinese herbal markets feature a wide spectrum of grades of shan yin hua and jin yin hua, and the two forms can be easily differentiated based on their morphology with the right training.
On the traditional market, only Lonicera japonica is considered to be the authentic, superior form of jin yin hua, and this is the species that we carry in granule form at Legendary Herbs. At the moment, both jin yin hua and lian qiao are difficult to obtain in large quantities, though we fortunately have secured a stable long-term supply at Legendary.
Check back on our blog for future articles focused on other herbs that are currently experiencing shortages and surging demand, including ban lan gen, chuan bei mu, huo xiang, ban xia, chen pi, and more.