BEIJING (BLOOMBERG) - As Hong Kong's outbreak became the deadliest in the world, among the aid Beijing sent to the financial hub were 1 million packets of honeysuckle, rhubarb root, sweet wormwood herb and other natural ingredients, all mixed according to principles of traditional Chinese medicine.

Practitioners of the centuries-old medicinal system argue such herbal combinations can be just as effective as antiviral pills like Pfizer Inc's Paxlovid.

"Unlike Western medicine that targets the virus itself, the way TCM works against Covid is to first effect change in the environment of our human body," said Dr Liu Qingquan, dean of Beijing Hospital of Traditional Chinese Medicine. "Once the environment changes, the virus can no longer survive."

President Xi Jinping wants other countries to give China's herbal cures a chance. His government is promoting TCM to allies worldwide, sending traditional medicine specialists to Cambodia and supporting clinical trials in Pakistan, both countries that rely heavily on Chinese aid.

Russia in 2020 allowed pharmacies to sell Lianhua Qingwen, one of the most popular types of TCM used to treat Covid patients, and the government of another leader, Belarusian President Alexander Lukashenko, agreed last year to establish a centre to produce TCM near Minsk.

Making TCM globally acceptable as a treatment option for Covid is an important part of Mr Xi's strategy to use the pandemic to elevate Chinese innovations and inventions.

China has still not approved widely used vaccines from AstraZeneca Plc and Pfizer, instead developing its own vaccines and making them easily available worldwide.

To advance its soft-power goals, China needs locally developed vaccines and treatments, says Mr Michael Shoebridge, director of defence, strategy and national security at the Australian Strategic Policy Institute, a think tank in Canberra.

"This is part of creating a Sino-centered world," he says. "It's a door opener."

Active ingredients

China is struggling to persuade sceptics to put aside doubts about medication that hasn't gone through the large, standardised clinical trials required by regulators with global credibility like the US Food and Drug Administration or the European Medicines Agency.

Western medicine explicitly explains how the active ingredients of a drug are processed in the body, but TCM's proponents face challenges showing how the various components in a concoction work.

While studies done in China claim TCM has benefits for Covid patients, critics say there are problems in the way the trials are designed and executed, and these prevent researchers from reaching unbiased and convincing conclusions.

Even Singapore, with a large ethnic-Chinese population accustomed to traditional medicines, has warned citizens not to take Lianhua Qingwen as a Covid treatment.

"To date, there is no scientific evidence from randomised clinical trials to show that any herbal product, including Lianhua Qingwen products, can be used to prevent or treat Covid-19," Singapore's Health Sciences Authority said on Nov 17. "We strongly advise members of the public not to fall prey to unsubstantiated claims or spread unfounded rumours that herbal products can be used to prevent or treat Covid-19."

The US FDA in 2020 sent at least six warning letters to companies selling Lianhua Qingwen and other TCM-based products purported to be Covid cures, telling vendors that the products were unapproved and misbranded drugs.

National treasure

Such warnings ignore the results of a clinical trial published in May 2020, according to Lianhua Qingwen's producer, Shijiazhuang Yiling Pharmaceutical Co.

"It's found in the study in terms of clinical use that Lianhua Qingwen proved to be both safe and effective in treating Covid-19 in conjunction with conventional therapy as it could significantly relieve clinical symptoms of Covid-19 such as fever, debilitation, and cough, greatly improve pulmonary lesions, shorten the duration of symptoms, and increase the clinical recovery rate," the company said in a statement last June.

Lianhua Qingwen products generated revenue of about 4.3 billion yuan ($917 million) in 2020, with year-on-year growth of 150 per cent, according to Yiling's annual report from last April.

Yiling declined to comment on regulatory warnings against claims of TCM's efficacy against Covid-19 but said the company has never exported Lianhua Qingwen to countries where the drug has yet to get regulatory approval.

Meanwhile, researchers in China have published studies purporting to show the efficacy of herbal treatments and state media frequently quote Mr Xi calling TCM "a treasure of the Chinese nation." In May 2021, he said the Covid outbreak had helped people gain a deeper understanding of TCM.

TCM promotion is about geopolitics, not science, according to Professor Steve Tsang, director of the China Institute at SOAS University of London. "If TCM is proved to be an effective cure, I am sure the whole world will rejoice," he said. "The problem is that there is no solid evidence that it is."

A TCM component may not have any effect when used singularly but could work when combined with others, said Mr Danny Wong, chairman of Hong Kong-based Medisun Holdings Ltd, one of the partners promoting the TCM therapy Jinhuaqinggan as a Covid drug outside the mainland.

The drug was approved in 2020 for treating Covid after domestic studies claimed it relieved symptoms such as fever, muscle pain and headaches.

"The challenge to explain and unpack the working mechanism of TCM is like trying to figure out what exactly propels an automobile," said Mr Wong. "Is it the tires or the engine? They all contributed to moving the car forward."

Friendly nations

Given such challenges in establishing TCM's efficacy, there are limits to what even friendly countries will do to help.

One of China's closest friends in Europe is Serbia, which in March 2021 reached a deal to manufacture state-owned Sinopharm's Covid vaccines as well as TCM treatments and services. A year later, though, pharmacies in Belgrade have done little to boost sales of TCM cures and hospitals haven't added TCM to protocols for Covid patients.

Even China isn't betting entirely on TCM, approving in February Paxlovid, the first foreign pharmaceutical product for Covid to win acceptance from regulators.

With generic drugmakers worldwide now making inexpensive versions of Pfizer and Merck's antivirals, interest in China's herbal cures that pre-date Covid will likely fade, argues University of Liverpool professor of pharmacology and therapeutics Saye Khoo.

Early in the pandemic, "we went for the drugs we already had, and we didn't get a huge amount of antiviral benefit," he said. Now, "we are not in that era."

Back in Hong Kong, officials are planning to send herbal remedies to every household. The city recently started receiving significant supplies of antivirals, creating a chance to compare them with TCM, said Mr Dennis Lam, convener of the Hong Kong Alliance of Integrated Medicine Against Covid.

"This provides an opportunity for us to make a good randomised controlled trial," he said, "so maybe we will be able to share more about how good they are."