Unexpected healers : Chinese medicine in the age of global migration ( Lima and California , 1850-1930 )

The massive waves of Chinese migrants arriving in California and Lima in the second half of the nineteenth century played a crucial role in expanding Chinese medicine in both settings. From the late 1860s on, herbalists expanded their healing system beyond their ethnic community, transforming Chinese medicine into one of the healing practices most widely adopted by the local population. This article uses a comparative approach to examine the diverging trajectories of Chinese healers in Peru and the USA, as well as the social and political factors that determined how this foreign medical knowledge adapted to its new environments.

História, Ciências, Saúde -Manguinhos, Rio de Janeiro D uring the nineteenth century, various coastal cities on the Pacific Ocean received a large influx of Chinese immigrants as part of a movement known as the "age of global migration."Approximately 2.5 million Chinese nationals emigrated to different parts of the globe (Tong, 2003, p.20).Although a large proportion of these "children of the Celestial Empire" worked in commercial enterprises, others practiced medicine and sold herbal remedies, and it was these activities that spread the furthest outside the immigrants' own communities.While in recent years new research has uncovered different socio-cultural features such as the lifestyles and survival strategies of Chinese migrants to the Americas, these communities have typically been analyzed by isolating them from other groups in society.A similar situation occurs in research on the history of medicine.Various studies have examined the principal medical advances and European scientific influences at the time, while ignoring non-western healing practices, which have been included in narratives about "alternative" medicine or simply studied in opposition to the process of professionalization and advance of scientific medicine.
This article uses a comparative approach to examine the development of herbalism and Chinese medicine in the three cities with the greatest number of Chinese immigrants on the Pacific coast in the latter half of the nineteenth century: San Francisco, Los Angeles and Lima (along with its neighboring port of El Callao).The analysis covers a period of six decades, from the arrival of rural Chinese immigrants in these three cities in 1870, up to 1930, when a systematic crackdown on Chinese doctors and the sale of Asian herbs began.This study focuses on issues relating to the circulation and adaptation of foreign medical knowledge in Peru and the US, showing how in these countries -unlike China, where traditional medicine was declining in the face of western medicine -local patients increasingly adopted treatments provided by Chinese herbalists and doctors.
For the purposes of this analysis, Chinese medicine is seen as a set of diverse systems for diagnosis and healing used by Chinese practitioners to cure ailments, and it is examined on the basis of the following three related questions: (a) why did large numbers of the local population use Chinese medicine?(b) what mechanisms helped popularize Chinese medicine in non-Asian contexts?and (c) what were the main differences between Chinese medicine in California and Lima?
While there has been a great deal of research on the Chinese diaspora in both locations, only very recently has a comparative approach been used to study the two contexts.Pioneering studies such as those by McKeown (1996McKeown ( , 2001) ) and Hu-Dehart (2005) have shed light on the trajectory of these communities and their complex relationship with the local authorities and other ethnic groups in the US, Cuba and Peru.A comparative perspective allows us not only to highlight the transnational nature of these groups but also to analyze the dissimilar trajectories of Chinese medicine in the two different spaces and the factors affecting those trajectories.One of the greatest challenges of my research for this article was comparing documentary sources that were so disparate in terms of production and location.As Paul Buell points out (1998, p.102), American historians are fortunate to have a wide variety of sources at their disposal, many of which are available in digital form.In Peru, there are few studies and sources that directly describe this type of medical knowledge in the nineteenth century.This article incorporates medical discourse by analyzing official sources from the City of Lima Health Board (Dirección de Salud de la Municipalidad de Lima) and the School of Medicine in Lima (or San Fernando), but also by patient testimonies in the press, thus offering an alternative focus to official discourses on public health.
The article is divided into three parts.The first explores how Chinese medicine became established in Lima and California, and how it expanded beyond Chinese circles in the late nineteenth century.The analysis focuses mainly on local patients and the benefits they obtained from Chinese medicine in comparison to western medicine.The second part focuses on the main strategies used by Chinese doctors and herbalists to expand their business to the local population, and how these strategies came into conflict with the interests of local physicians.Lastly, I examine the main differences between medicine and herbal medicine in Lima and California, focusing on how the local context shaped this foreign medical knowledge.

The arrival of Chinese medicine in the Americas
Chinese medicine came to the Americas with the mass immigration of Chinese workers in the mid-nineteenth century.Economic and political conditions in China and in various countries in North and South America became determining factors in Chinese migration.By 1850, China was undergoing a period of economic, political and social instability: provinces such as Kwangtung and Fukien -where most of the migrants were from -were impoverished and overpopulated.The Taiping Rebellion of 1851-1864 caused thousands of deaths and devastated the economy (Bowen, 1993, p.21).China also suffered from European imperialism, which precipitated the first and second Opium Wars, hindered growth and caused great economic and social harm in some regions such as Guangdong.All of this led to massive migration from 1840-1900 to various parts of the world, especially the Americas (Tong, 2003, p.20).
Meanwhile, various countries in the Americas were undergoing great economic growth.From the mid-nineteenth century on, European markets demanded more natural fertilizers and agricultural products like cotton and sugar.This led to a surge in production requiring a larger workforce, which was a serious problem in countries like Peru, especially after the abolition of African slavery in 1854 (Aguirre, 2005).Given the need to increase the labor force, the Peruvian government passed an immigration law in 1849 allowing foreign workers to enter the country.Thus from 1849-1874, an estimated ninety to one hundred thousand "Chinese settlers" arrived in Peru, most of whom were semi-forced laborers deceived by contracts they were obliged to sign before embarking (Rodríguez, 2000(Rodríguez, , 1989;;Lausent-Herrera, 2011;Stewart, 1976).
Despite the massive influx of settlers to Peru, the Chinese immigrants' main destination was California, also known as the "mountain of gold."Before 1848, the territory that is now part of California belonged to the government of Mexico, and the land was mainly used for agricultural purposes.When the Treaty of Guadalupe was signed at the end of the Mexican-American war (1846-1848), California became part of the US.That same year, the História, Ciências, Saúde -Manguinhos, Rio de Janeiro history of California took a new turn when James W. Marshall discovered traces of gold on General John Sutter's ranch in Coloma (near Sacramento) in January 1848.In a few months' time, the rumors spread rapidly, triggering an unprecedented wave of immigration from all over the country and the world (Rolle, 1998).
The number of Chinese immigrants who came to California was particularly large.Between 1848 and 1882, when a law was passed banning migration from China, an estimated three hundred thousand Chinese came to the US.After working for some years in the mines and on the railways, many of them migrated to the great cities on the Pacific coast, mainly San Francisco and Los Angeles (Brownstone, 1988, p.26).By 1870, the city of San Francisco had the greatest concentration of Chinese in California, 24.4% of the population of the entire state.They rapidly opened various commercial establishments, mainly laundries, and came to have a monopoly over these (Trauner, 1978, p.72).Chinese immigrants brought their culture with them, and medicine was an important part of the traditions they kept up in Peru and the US.It expanded beyond Chinese circles, providing competition with local physicians by the late nineteenth and early twentieth century.

Early expansion of Chinese medicine
The expansion of Chinese medicine in California began around 1871, when large numbers of Chinese immigrants settled in the biggest cities in the state, Chinatowns began to grow up and herbal dispensaries and clinics were opened, mostly in residential and commercial districts.Initially, their opening was in response to the health problems of the community living in big cities.The explosive growth of cities like Los Angeles and San Francisco led to serious public health problems.In San Francisco, successive epidemics of cholera, smallpox and bubonic plague devastated the city, and as racism spiked, the Chinese were stigmatized and held largely responsible for the dreadful hygiene and sanitary conditions in the city (Shah, 2001).Racism also restricted the Chinese community's access to western medicine.Although San Francisco was the city with the most Chinese in the US, healthcare centers in the city refused to treat them -or they were confined to isolation hospitals.Their admission rate to public hospitals was less than 0.1% in the period 1870-1882 (Liu, 1998, p.176).Under these circumstances, Chinese migrants responded to epidemics and diseases by turning to their own healing lore.
By the late 1860s, various clinics and herbal dispensaries began to be set up, so the Chinese community could receive treatment without being exposed to the anti-Asian climate.In 1869, Reverent A.W. Loomis (1869, p.496), a Presbyterian minister, gave one of the earliest descriptions of the "medical art" of the Chinese in San Francisco, stressing the importance of herbal dispensaries and pointing out that, "[j]udging from the number of apothecary stores, one would suppose that the Chinese were large consumers of medicines."His impression was based on the dozen such establishments in San Francisco that prepared and sold medicinal herbs, a business that was considered very lucrative.In his account, Loomis assumed that if the number of remedies being sold in the country was so great, there must be a correspondingly large number of doctors who could apply them.However, these two phenomena were not directly related, since in the early decades of immigration, the number of professional doctors was low, and as various observers suggested, many of those who practiced medicine were not professionals (Loomis, 1869, p.497).Thus, the problem of so-called "medical charlatanism" was not limited to western doctors.William Tisdale (1899, p.412), a journalist who traveled throughout California in the late nineteenth century, documented the presence of genuine Chinese healers who used herbal medicines and were respected in the community.Alongside them were others who claimed to be doctors and sought to deceive patients, mainly "white patients" who were timidly venturing to use and understand this new type of cure.
However, it was during the period of epidemics that devastated the Pacific coast that Chinese medicine expanded most rapidly.During the epidemic of bubonic plague that hit San Francisco in 1900 and Lima in 1903, anti-Chinese prejudice grew exponentially, with huge consequences for public health (Risse, 2012;Cueto, 1997).In 1900, the Californian authorities imposed quarantine on Chinatown in San Francisco, launching discriminatory health policies including intrusive housing searches, disinfection and mandatory vaccination.The residents of Chinatown responded by distrusting white doctors and turning to Chinese doctors and their traditional herbal medicines.Given the mistrust of vaccination, for example, the health authorities sought to ally themselves with Chinese doctors, allowing them to vaccinate whomever they wanted, thus legitimizing their position in the community and getting them to act as cultural brokers (Shah, 2001, p.120-142).
In the case of Peru, the expansion of Chinese medicine was determined by the internal migration of ex-coolies within Peru and the yellow fever epidemic of 1868.As in California, once the Chinese served out their contracts in coastal areas, large numbers of them migrated to the largest cities in the country, especially the capital, Lima, where they moved into other kinds of work, particularly in industry and commerce.However, a small group of them were involved in healthcare work, practicing as doctors and herbalists in their own herbal shops (boticas chinas) (Rodríguez, 2000, p.221).While it is possible that there were Chinese doctors and herbalists from the 1850s on, this healing system only became visible in 1868 with the widespread chaos generated by the outbreak of yellow fever in Lima and the neighboring port of El Callao.
Within a few months the epidemic had affected some ten thousand Lima residents, almost 10% of the population, and at least four thousand people had died.In the nineteenth century, the etiology of yellow fever remained unknown, so the success of the medical treatments given by doctors at the School of Medicine in Lima was limited.Given the ineffectiveness of professional medicine, patients had no problem turning to healers with no professional diploma, or "miracle drugs" advertised in the local press (Lossio, 2002).Thanks to the accurate diagnoses of Chinese doctors, word of which spread mostly through the press, municipal authorities authorized some of them to open their own herbal shops.The first mention of Chinese doctors appeared in the newspaper El Nacional, which stated in an editorial on May 12, 1868 that "people say that a Chinese doctor has appeared in this capital who is working wonders by curing victims of the epidemic." 1 The residents of Lima were evidently not used to seeing Chinese people practicing medicine, since the newspaper adds: "it sounds like a joke, but the fact is the Chinese doctor cures and saves those hit by the epidemic" (Médico chino, 12 mayo 1868).
In subsequent months, reports and news of the presence of Chinese doctors curing people in the capital kept rising (Coello, 2009).In July that year, doctor José María Macedo sent a report to the mayor of Lima on efforts to fight the epidemic in one of Lima's five districts.In his report, he noted the existence of a Chinese doctor said to be capable of resuscitating the dead; the news had spread through the whole capital and as a result patients from all over the city were going to see him (Macedo, 20 jul. 1868).By September of that year, some herbal shops could already be found in various parts of the capital, and according to the newspaper El Comercio, they were "attracting a considerable number of clients, both Asian and of other nationalities."These clients -the paper says -were going not only to stock up on medications, but also for consults with the doctors there (Boticas…, 10 sep.1868).The epidemic marked the beginning of a rise in the popularity of Chinese doctors and a long competition with western medicine that only ended in the 1930s, when sale of Chinese herbs was declared illegal in the country.
Medicine was one of the most socially prestigious professions in the nineteenth and early twentieth centuries in both the US and Latin America: doctors were linked to state bureaucracy, took part in political life and enjoyed the gratitude of many of their patients.As Chinese medicine expanded outside Asian circuits, Chinese herbalists and doctors became more prestigious than other members of their community, who did work commonly seen as inferior.Their privileged situation meant that the various racist policies and attitudes identifying the Chinese as an "inferior race," a population subject to strict hygiene rules, did not affect them to the same extent (Marcus, Chen, 2011).Even during the most racist period under the "Chinese exclusion era" in the US , herbalists were still in demand among Caucasian patients and some were able to obtain voting rights and permanent residency in the US (Marcus, Chen, 2011, p.374;Tisdale, 1899, p.416).
Chinese herbalists and doctors in Peru also enjoyed higher status in comparison to other members of their community, especially those in commercial work.It is interesting to note that despite dozens of complaints by the health authorities about Chinese herbalists from 1868 through the 1930s, most of the arguments made by professional physicians for banning the sale of Chinese herbal medicines focused on Chinese doctors and herbalists' lack of professional university degrees, which meant they did not meet the legal requirements for running herbal shops.The type of medicine they practiced was rarely questioned.There are no records showing that the criticisms were racially motivated, although this could well have been a major implicit factor in the attempt by elite medical professionals based in Lima to prevent the Chinese from practicing medicine.
What were the local population's main motivations for turning to Chinese herbs and medicine?There are many reasons that might explain their rise in popularity.To start with, there was a popular belief that Chinese doctors had more knowledge, or at least more success, than local doctors in curing certain diseases.As Buell argues (1998, p.101;Schwartz, 1984, p.43-45), many western patients preferred going to a Chinese doctor for blood and venereal diseases, since they apparently had a lot more experience and success than American doctors, who lacked the training to cure such ailments.It is not surprising, therefore, that prostitutes were the main clients turning to "celestial Hippocrates" to prevent and cure venereal diseases, a situation that continued until at least 1930, when a pharmaceutical industry emerged to treat these illnesses (Leong, 1936, p.230).
A similar argument was used in Peru to explain the effectiveness of treatments used by Chinese herbalists to cure the yellow fever epidemic.It was believed -and the press echoed the rumors -that Chinese doctors had more experience treating yellow fever because it was endemic in their native country.This belief was so widespread that the campaign waged by the School of Medicine authorities to discourage the use of Chinese medicine sought to dispel it as a myth.In one of his publications on yellow fever, doctor Casimiro Ulloa (1868, p.231)described the claims that Chinese doctors had saved many lives as nothing but rumors, and he adds that it was not true it was an endemic disease in China, so therefore Chinese herbalists and doctors had no more knowledge about this tropical disease than local physicians.
Another reason why local patients chose Chinese medicine was that western patients considered it less invasive, both in terms of treatment and diagnosis.Chinese doctors became an alternative for hundreds of patients wary of the leeches, emetics and other aggressive remedies that were part of western medical treatments.In the opinion of Dora Mayer de Zulen (Mayer, 1924, p.107), a Peruvian intellectual who defended the Chinese community and advocated for the presence and use of Chinese herbs in Peru, European medicine "was an imperfect science," and patients in both contexts preferred treatment methods that were less painful and aggressive.The use of medicinal herbs was not unknown by patients either in California or Lima, since they had been using them for some time (Liu, 1998).Like native peoples in the Americas, the Chinese did not operate on their patients, which reduced their chance of dying since anesthesia was not yet very advanced and antibiotics had yet to be discovered (Schwartz, 1984, p.68).In 1873, the Peruvian newspaper El Comercio included a news item titled "It may not be science, but it is providential," which recounted a Chinese doctor's successful cure of a certain mister Velarde, who had serious vision problems.A panel of doctors from the School of Medicine had told him the only solution was to "remove one eye" so as to save the other.Mister Velarde refused to have his eye removed and went to a Chinese doctor who, according to the newspaper, cured him with the use of herbs, and as a result "he has no pain now and enjoys the use of two good, healthy eyes" (No será…, 11 jun.1873).Clearly, this type of testimonial only boosted the fame of Chinese doctors, often to the detriment of professional western medicine, so that they came into competition with the medical and pharmaceutical professions, whose members were quick to criticize their work and actively sought to close Chinese medical establishments down.
Faced with a possible legal ban on Chinese medicine and reprisals against those who practiced it, local patients did not stay neutral; in many cases, they publicly defended Chinese doctors.Some of the first to support Chinese medicine in Peru were Carlos Yansen and Adolfo Birmen, residents of the city of Lima, who sent a letter to El Comercio criticizing the work of Peruvian doctors and their medical treatments as highly invasive, and the School of Medicine for its attitude to Chinese doctors.Yansen and Birmen asserted that the Chinese only sought to use herbs to cure the bodies of the inhabitants of Lima, weakened by "high doses of quinine, mercury, calomel, poisonous acids and a thousand other compounds" administered in recent years by medical professionals.They also criticized police officials for persecuting the herbalists, "closing their dispensaries without even examining what they sell, on the pretext of public health, although deep down their goal is to line their own pockets at patients' expense" (El protomédico…, 11 dic.1868).
Chinese doctors were defended not only by patients but also by some police officials, who sought to protect them from persecution by the School of Medicine in Lima.Licenses for opening and running Chinese herbal dispensaries were an important source of income for the city, so on more than one occasion some civil servants deliberately turned a blind eye to legislation stating that a pharmacy could only be opened with prior authorization from the School of Medicine.In other cases, their protection was explicit, which led to criticism from San Fernando.As doctor Casimiro Ulloa complained, efforts to repress the Chinese doctor who supposedly resuscitated the dead came to naught thanks to the political authorities.Although that particular doctor decided to leave the capital because of the constant complaints by the School of Medicine physicians, his self-exile to the port of El Callao was short-lived.This was because the prefect of Lima personally contacted his counterpart in El Callao to offer the Chinese doctor protection so he could return to the capital.Needless to say, this action caused anger and criticisms from San Fernando, which protested yet again about the authorities' lack of support in combatting medical charlatans (Ulloa, 1868, p.231).
In California, both patients and authorities came out in defense of Chinese doctors, especially the most influential ones.From 1910 on, Chinese doctors and herbalists suffered persecution from local physicians, and many of them were taken to court.Cases like that of doctor Hong Chung, arrested for possession of medicines, or of G.T. Lai, accused of practicing medicine without a license, recurred continually in the newspapers of various cities in the state of California (Chinese…, 20 sep. 1912;Chinese…, 19 dic. 1917).This persecution became more intense after 1925, when a bill prohibiting herbalists was debated in Congress.Nevertheless, some important herbalists like doctor Li Po Tai, one of the richest men in San Francisco, had the support of leading citizens such as Senator Leland Stanford and Governor Mark Hopkins, both share-holders in the first transcontinental railway (Stanford was also the founder of Stanford University).These powerful members of the Republican Party in California protected Po Tai and prevented him from legal action (Tisdale, 1899, p.416).
Other Chinese doctors were less fortunate and several were sued for practicing medicine, at a time when professions physicians were struggling to maintain their monopoly.However, several Chinese doctors managed to emerge victorious thanks to the support of their patients.One of the best documented cases is that of Fong Wan, a herbalist based in Oakland, California.In 1929, Wan published the book Herb lore, one of the most complete works on Chinese medicine, in which he not only explained the uses and preparation of medicinal herbs but also demonstrated the efficacy of his treatments with patient testimonials.Wan writes that in 1915 he was summoned to appear in court on over twenty occasions, on all of which he was ruled not guilty.The testimonials of his patients, mostly residents of the city who did not belong to the Chinese community, played a crucial role in his acquittals (Wan, 1933).
Although medical professionals labeled patients who consulted Chinese doctors as ignorant, the testimonials that appeared in the press and in publications by Chinese doctors and herbalists show that the patients came from different social groups.Many of them were well educated and saw the success of the procedures they had undergone as providing an alternative to western medicine.This support among the public allowed Chinese doctors to evade legal prohibitions and criticisms by professional physicians in both locations.

Chinese herbal shops: the visibility and commercialization of Chinese medicine
Chinese herbal shops played a key role in expanding Chinese herbal medicine in California and Lima.They sold various natural products, generally directly imported from China, even though there was a wide and rich variety of local flora in both California and Peru.According to American ethnographer Stewart Culin (1887, p.2), in the US, all remedies were imported either from Hong Kong or Canton, and many of them were exotic products with medicinal uses such as "dragon bones," scorpions, snakeskin and seeds.While some herbalists used local herbs, the ones grown in China were believed to be of higher quality.Thus, once yellow fever started dying down in Lima in 1868, Chinese doctors set off "in search of medicines from their country that they could not find here" (Médico chino…, 30 mayo 1868).
In California, herbal medicine became big business, and major companies were created to import and sell Chinese herbs in California, such as Fong Wan Herb Co., based in Oakland.It is no surprise that one of the richest men in San Francisco at the end of the nineteenth century was doctor Li Po Tai, who owned one of the largest herbal dispensaries in the city, with annual income of over $75,000 at the time.According to Tisdale (1899, p.412), he saw 150-300 patients a day.In Los Angeles, there were 22 herbal dispensaries and drugstores in the international directory of Chinese businesses published in 1933, which gives us an idea of how important these stores were not only for the Chinese but because of the substantial income they brought in through customs tariffs in both countries (Bowen, 1993, p.33).In San Francisco, the first few such stores grew up in Chinatown.J.W. Armes (oct.1875, p.501) says in his description of Chinatown in San Francisco in 1875 that it contained various herbal dispensaries and teashops, one of which was run the great and well-known doctor Po.As doctor Lui (1948, p.202) remarks, many herbalists sought to set up their stores in affluent neighborhoods, outside Chinatown, but only a minority succeeded in doing so.
Chinese doctors used a variety of strategies to attract local clients to their herbal shops.The main one was to imitate western physicians' style.In 1906, an editorial in the important Peruvian medical journal La Crónica Médica noted that Chinese herbalists had not only opened their own medical and pharmaceutical establishments, but that one of them had História, Ciências, Saúde -Manguinhos, Rio de Janeiro gone so far as to purchase a "medical coach," a sort of ambulance in which he paid home visits to patients "just like Peruvian or foreign doctors who are legally registered in the Peruvian medical profession" (Coolies…, 30 sep. 1906).Physicians from the School of Medicine also described the use of calling cards or prescription pads that emulated those used by local doctors.
Another widely-used strategy was to replace the Chinese language with English or Spanish, chiefly in publicity.While the herbalists continued to use Chinese to write their prescriptions, many of them increasingly used the local language in their medical consults.In 1858, the herbalist Wo Tsun Yuen in Chinatown in San Francisco was the first to post an advertisement in English in his store to attract the Caucasian population (Liu, 2006, p.143).In Peru, Kam-Jim advertised his services in the newspaper El Comercio and announced to his "innumerable clientele" that he used various types of medicinal herbs.At the end of his advertisement is a note stating that "in light of the obstacle presented by not being able to issue a complete diagnosis of illnesses, I am accompanied by an interpreter who is equally familiar with Chinese and Spanish" (Aviso…, 2 oct.1877).Some Chinese herbalists in California attempted to broaden their clientele by using Spanish-speaking translators to attract the Hispanic population.
Even among the Chinese doctors who maintained their traditions, many opted for an American marketing style so as to reach a wider audience (Marcus, Chen, 2011, p.379).The use of advertisements in newspapers in California has been extensively studied.Various historians have stressed the use of texts written in English or Spanish to deal with local and Mexican patients, along with a photo of the herbalist(s) in typical Chinese costume so as to appear skilled and competent in the medical field.These advertisements also establish the type of medicinal herbs available and the types of treatment offered, especially pulse diagnosis and the use of herbs (Bowen, 1993, p.72-75;Liu, 2006, p.143-144).Often, the advertisements were accompanied by testimonials of successful cures, above all by Caucasians who had undergone treatment and been cured by the herbalist in question.Thus, advertisements in the newspapers are a valuable source for finding out who the patients were and what main diseases were being treated by the Chinese doctors.They published their advertisements in the same sections of the paper as their American counterparts, declaring that " [d]iagnosis and examination [are] free," which clearly rendered them not only competitors but treacherous competitors, in the eyes of the local physicians (Marcus, Chen, 2011, p.379).
In the case of Peru, we know that the first advertisements for herbalists started to appear in the press from 1870 on, and they bear many similarities to the ones in California.In the nineteenth century, advertisements contained lengthy texts specifying the diseases cured by medicinal herbs.In the decade after 1910, they started becoming more attractive and including images of herbalists dressed in western clothing, emulating the style of professional physicians (see Figure 2).
While these strategies were successful in terms of attracting patients, they also drew the attention of professional physicians, who were seeking to put an end to herbal medicine in Peru.Dora Mayer stated in 1924 that the local authorities should not deprive herbalists their traditional embrace of the healing arts.However, she acknowledged it was "clearly imprudent" on the part of Chinese doctors to publish advertisements in the papers, since these had drawn the wrath of Peruvian physicians and exposed the (il)legal position of Chinese medicine in the country.Mayer (1924, p.107) remarked that the advertisements were "much more striking than those of almost any other professionals, and they always draw disagreeable comparisons with western allopaths." The owners of the herbal dispensaries also resorted to hiring local receptionists or cashiers who could act as interpreters and assistants.As Liu argues, in southern California,  História, Ciências, Saúde -Manguinhos, Rio de Janeiro herbalists commonly hired young Mexican women as secretaries or nurses to help with local clients.Apparently, herbalists used the same strategy in Peru.In the labor complaint filed by Rosa María Cañamero against the famous Peruvian herbalist Carlos Pun for unfair dismissal in 1926, the woman states that she was hired by mister Pun as cashier of his Chinese herbal store and fired for no reason when she was owed a great deal of money.
Although the herbalist accepted that she had worked in his store, he declared that she had left the job of her own accord.An interesting piece of background information revealed by this case is that the rise in racism against the Chinese community in the late 1920s was affecting leading members of the community.Pun stated that according to his employees and relatives, "this girl had said she didn't want to work in Chinese businesses because they were looked down on" (Perú, 4 ene. 1926).Thus, the strategies used by Chinese doctors were very similar to those of western physicians: eye-catching publicity in the press, testimonials of successful cures, and opening businesses in important areas of the city.This expansion caused a backlash, seen especially in the wholesale crackdown on Chinese medicine in the late 1920s, which led to a new era focused on the persecution, transformation and -in Peru -banning of herbal medicine and "disappearing" Chinese pharmacies and doctors, at least in the public sphere.

Chinese medicine in local context
While in the 1920s various members of the new nationalist government in China proposed abolishing traditional medicine, considering it the antithesis of modernity (Lei, 2014, p.3), in California and Lima the number of stores offering herbal medicines, needle treatments and pulse diagnosis kept growing and they became increasingly important.In 1904, an inspection carried out by the Apothecary Store Inspection Committee (Comisión Inspectora de Boticas) of the School of Medicine in Lima reported 62 such establishments in Lima selling medicinal products.30% of these were Chinese herbalists and 40% were in the neighboring port of El Callao (FML, 1904).There were various commonalities in the practice of traditional Chinese medicine in both contexts, mainly in the strategies used to expand outside Chinese circles and the use of similar medicinal products.Isabel Lausent-Herrera (2011, p.71) has established that the big importing firms based in San Francisco, like Wing Fat Co., sold plant-based and manufactured products not only in California but also in Lima, so it is possible that herbalists in both places used similar products.Nevertheless, there were important differences, mainly in the way the Chinese healing system adapted to local conditions.
In the nineteenth century, there was a difference between the US and Peru in terms of the legality of practicing medicine without certification by a healthcare organization.From the time it was established in 1856, the School of Medicine in Lima was in charge of monitoring the profession and reporting anyone who practiced medicine without legal credentials to the authorities.After the yellow fever epidemic of 1868, the School repeatedly denounced "Chinese doctors," calling for their stores to be closed down and for their advertisements to be withdrawn from the newspapers.Certified physicians argued that Chinese herbalists were practicing medicine and pharmacy at the same time under the umbrella of their commercial establishments, without having the qualifications to practice either of those healthcare professions (Villar, 1878).In 1876 San Fernando started a campaign against the herbalists that ended in 1879 with the latter winning a decisive victory.That year, the Supreme Government declared that herbalists' shops were not pharmacies, and that they were therefore entirely at liberty to sell Asian herbs in these establishments (FML, 16 sep. 1879).
Undeterred, the School of Medicine launched a campaign to clamp down on the Chinese herbalists, reporting any who publicly advertised their medical practice and calling on the City of Lima to fine establishments that offered healing practices.Yet, Chinese herbalists and doctors managed to practice for many years in Peru by exploiting the ambiguous status of their profession.While they presented themselves in the press as Chinese doctors, they told the police and health authorities that they were simply selling herbal remedies, and that their activities were protected by the right to free enterprise (Municipalidad de Lima, 1876).The ambiguity is obvious in one of the best definitions of the status of Chinese herbalists in Peru in the early twentieth century, by Dora Mayer (1924, p.106): the legitimate Chinese herbalist is in no way a simple store-owner, because he is more than a purveyor of articles.Nor is he exactly a pharmacist, because he not only dispenses remedies, but diagnoses his clients' diseases.Nor is he a doctor in the sense of European-style academies -far from it.Nor does he belong in the category of faithhealers, who mix quackery and fraud in their treatments … rather, he is skilled in a healing art that differs from the European therapeutic approach.
In the US, there was a wide variety of medical treatments in the nineteenth century and Chinese medicine was just one of many natural healing alternatives available to patients.It was practiced alongside homeopathy, hydrotherapy, and hypnotism, among other systems.Unlike in Latin America, where the medical community urged the state to enforce its professional status and its monopoly over medical practice, until the early twentieth century, university-trained physicians in the US were not endorsed by the state, which adopted a non-intervention, free-market policy (Haller Jr., 1981).Chinese herbalists, who were a product of this freedom to practice, were able to operate in the nineteenth century without any problems, as long as their establishments paid the necessary taxes.
In the early 1900s, the American Medical Association (AMA) managed to join forces with representatives of state and local governments to crack down on non-licensed doctors, legitimize scientific medicine and present it as superior to other medical practices.In this process, the crackdown on Chinese herbalists was extremely useful to professional physicians in explaining the differences between regulated, licensed medicine and nonregulated medicine or "other practices" (Venit, 2013, p.270).However, the decline of Chinese medicine did not come in response to a state policy -as in Peru -but because of obstacles in importing Chinese products in the mid-twentieth century.As a result of the Second World War (1939War ( -1945)), and the embargo on Chinese goods after the Korean War (1950)(1951)(1952)(1953), it became increasingly difficult to obtain medicinal herbs, which led many dispensaries in San Francisco and Los Angeles to close down and forced herbalists to practice as chiropractors (Liu, 1998, p.204).
História, Ciências, Saúde -Manguinhos, Rio de Janeiro In Peru, the decline of Chinese medicine was caused by the ban on Chinese herbal shops in December 1930, enacted after the fall of President Augusto B. Leguía, who was associated with the Chinese community in the country.McKeown (1996, p.87) has shown that the Chinese were excluded from the idea of nationhood by Leguía's successor, Commander Luis Sánchez Cerro, for whom "foreign capital and yellow skin were undesirables."Chinese doctors were marginalized in healthcare spaces by the racism rampant in society, but also because the Peruvian state and the medical elites were becoming stronger.Chinese medicine disappeared from the public sphere in the 1930s, but the sale of Chinese herbal medicines continued on a smaller scale thanks to the pharmacies in Lima, which kept this lucrative business running.
Another of the differences between the two areas lay in the type of therapies offered by Chinese doctors.Unlike California, in Peru many fewer products were imported directly from China, so Chinese herbalists in Peru resorted to other methods of healing -besides the use of herbs -such as needles, known nowadays as acupuncture.As Bowen has shown (1993, p.74), acupuncture was not among the therapies offered by Chinese doctors in California.Nevertheless, acupuncture was not an unknown technique.In December 1910, the Los Angeles Herald published a report on the use of acupuncture in China during surgery.The article stated that this technique had been used traditionally to relieve fractures, constipation, and even cholera, but the doctors at the Peking College of Medicine had discovered its benefits for the human body when used during surgery (Acupuncture…, 11 dec. 1910).Despite the benefits, this technique was not systematically used outside Chinese circles until the 1970s, with the re-establishment of diplomatic relations between the US and China, which led to the return of Chinese medicine in California (Bowen, 2002, p.186).
In Peru, Chinese doctors had been using acupuncture since the nineteenth century, and the first reports of it are from the yellow fever epidemic of 1868.Local press coverage of the epidemic noted the presence of a Chinese doctor using a technique not seen before.The daily paper El Nacional write that "treatment of the disease by this celestial Hippocrates is truly Chinese, since it largely involves the use of pins" (Médico chino, 12 mayo 1868).The use of "pins" was referred to again in the press that year in a letter sent by Carlos Yansen and Adolfo Birmen publicly endorsing the Chinese doctors practicing in Lima.According to these witnesses, "the Chinese doctor with his medicines and the needle instruments he applied has perhaps healed a greater proportion of patients than the learned professors of the School of Medicine with all their degrees" (El Protomédico…, 11 dic.1868).We do not know how widespread the practice was, since most of the references to Chinese medicine in subsequent years deal with herbal dispensaries.However, it is interesting to note the early adoption of this healing method in the Americas.
Lastly, there was a major difference between Peru and the US in the type of patients who went to see Chinese herbalists and doctors.Although in both cases Chinese medicine spread beyond Chinese circles from 1870 on, the cost of consults and medicines determined what kind of patients had access to these healers.In the nineteenth century, the press in Lima shows how expensive it was to go to an herbalist.Because of the high price of herbs imported from China, the herbalists' clients were leading residents of the city of Lima.However, in the twentieth century, Chinese medicine became a healing system used mainly by low-income patients.As the intellectual Dora Mayer states (1924, p.107), "wealthy people are the ones who use the herbalists the least."According to Mayer, such people consulted Chinese doctors only when they were dissatisfied with their local doctors and European science was powerless to help them.For the poor, however, Chinese herbalists were probably the only viable form of healthcare, since doctors' fees were extremely high.Although some people did go to see professional physicians, very few could complete the treatments they recommended, because of the high fees and the costliness of the medicines they prescribed.
Thus, a major part of the public debate about herbalists in Lima in the early twentieth century had to do with a wider debate about the role of the state and its inability to provide healthcare for a growing population.Some therefore defended Chinese medicine as a necessary evil given the high cost of professional medicine, which mainly affected the most vulnerable sectors of society.Unlike the situation in Peru described by Dora Mayer, in California William Tisdale (1899, p.413) argued that the poorest and least-educated sectors could not afford the high fees charged by Chinese doctors, so many of their clients were professional men like attorneys, journalists and even physicians, who could pay for their treatment.Chinese doctors charged for each consult and the price of the prescription depended on the ingredients, a system that became costly because treatments never lasted less than three months (p.415).

Final considerations
Mass migration by Chinese people to the Americas from 1848 on meant not only the arrival of a human contingent willing to do the hardest jobs, but also the introduction and subsequent spread of Chinese medicine.The study of Chinese doctors, their practices and herbal shops allows us a more nuanced analysis of the lifestyles and interactions of one of the largest immigrant communities on the Pacific coast.While the herbalists were a minority in their own community, their presence forces us to be more cautious about generalizing that all members of the Chinese community in the Americas lived in precarious circumstances or were subject to physical or property attacks as a result of the racism rampant in the late nineteenth and early twentieth century.
This study suggests that while Chinese medicine was an ancient healing system that was brought to the Americas by the Chinese diaspora, its trajectory in the two contexts analyzed here was very different.In Peru, where there was more state intervention in social matters, herbalists had to practice medicine cautiously because they lacked professional credentials.In California, on the other hand, there was an affluent middle and upper class able to use Chinese medicine as a luxury commodity.This did not happen in Peru, where the precarious state of the healthcare system meant that herbalists found an important niche among the lower and working classes.
The study of Chinese medicine in Peru and California sheds light on various social and political processes that were occurring in both contexts, including the difficulties encountered by professional physicians in their fight to oust other competitors from the public health sphere and to legitimize their own profession.Patients and the political authorities were not unaware of the medical discourse seeking to eradicate certain healers; several of them publicly defended and thanked Chinese herbalists for their work.Thus, the study of this healthcare practice helps us understand the process of medicalization "from below," as patients defended healthcare therapies when they felt them to be "successful."Finally, the large-scale expansion of Chinese medicine beyond Chinese circles shows that medical pluralism was more common than classic medical historiography has assumed it to be.