Gone are the days when taking traditional Chinese medicine (TCM) only meant slurping a steaming cup of broth, slathering on an herbal ointment, or necking a glass of medicinal wine. Today, many TCM remedies are, at first glance, indistinguishable from conventional medications: They come in tablets, capsules, and even IV drips.

Generally speaking, there are two main ways to create modern drugs. The first is through pharmaceutical engineering, in which raw materials undergo a chemical reaction to produce synthetic drugs. The second is through bioengineering, which may, for example, isolate antibiotics from microorganisms or extract active ingredients from plants and animals. Similarly, the antiviral medication Tamiflu is made from the shikimic acid found in star anise.

Among practitioners of Western medicine and their patients, TCM is often seen as a parallel tradition of largely bogus treatments. Yet some TCM products do contain medically active ingredients, and as the government sponsors a modernization campaign designed to better regulate TCM, TCM manufacturers are increasingly extracting active ingredients through the scientific processes described above. Regardless of your personal views on the efficacy of TCM, the discipline is hewing closer to its Western counterpart: While some patients still concoct soups of roots and leaves, more and more are popping pills that claim to contain the essence of the same thing.

Counterfeit drugs are a problem across the world, especially in developing countries. Such products are at best ineffective against disease, at worst harmful to the patient. In China, counterfeiters frequently target TCM drugs, either by substituting one ingredient for a similar-looking, cheaper one; by adulterating or diluting existing ingredients; or by creating completely falsified medicines from scratch. In most cases, fakers target the key medicinal ingredients, meaning that all modern forms of treatment — from skin salves to IV drips — are at risk of being compromised.

Most commonly, counterfeiters swap one active ingredient for another. A well-worn trick is to replace high-quality American ginseng with its blander Chinese counterpart. Others exchange peppermint, which contains large amounts of the menthol used to treat inflammation and high temperatures, for spearmint, which contains minimal amounts of menthol.

Using cheaper, but less effective plant variants in place of true medicinal ones can easily deceive those who lack specialized knowledge of botany. For example, the most reliable way to differentiate between the root of Rumex chalepensis — a subspecies of a genus of plants known as docks and sorrels — and Rheum palmatum, or Chinese rhubarb, involves looking at them under an ultraviolet lamp. (The former emits a fluorescent purple glow; the latter does not.)

Other drugs contain wildly different ingredients from what they list on the package. Instead of adding Chinese magnolia berries to cough medicines, TCM counterfeiters sometimes use unripe wild grapes; instead of Gastrodia elata, an herb used to relieve rheumatic pain, they might use processed potatoes; and instead of saffron powder, believed to boost circulation, they might use dyed corn silk. In each case, people think they are taking TCM remedies, when they are actually just consuming cheap vegetables.

Often, counterfeiters mix in completely unrelated substances in order to increase the weight of the final product. Red-brick powder can bulk out the spores of the Japanese climbing fern to create an ineffectual cure for kidney stones. Longan fruit, used mainly for its nutritional value, fetches a higher price when coated in sugar. And sellers often cake pangolin scales in salt to ensure that the final price is worth risking punishment for trafficking a protected species.

Animal-based drugs can also contain substitutions. The sharp-nosed pit viper, a venomous snake found across a broad swath of China, is used in several TCM treatments. But sometimes, counterfeiters will mix parts of other commonly found snakes into the remedy, and sell it for the price of a pit viper treatment.

Perhaps most shocking are the painstakingly constructed fake versions of expensive, animal-based medicines: plastic antelope horns, deer antlers made of nothing more than animal hair and glue, or dried caterpillar fungus made from flour and water.

Disturbingly, the side effects of consuming such medicines aren’t limited to their inferior effectiveness. Some counterfeit medicines are toxic: The Japanese star anise’s common and cheap fruit — known in Japanese as shikimi — is sometimes used in place of star anise, and is poisonous enough to kill.

In a historically lightly-regulated industry like TCM, counterfeit drugs have a long history — there have always been sellers blinded by greed. But the proliferation of fake TCM drugs in today’s China is largely due to serious failings on the part of the country’s regulatory bodies, most obviously the China Food and Drug Administration (CFDA).

There are several steps that the CFDA could take to address the issue of fake TCM treatments. First, they should strengthen existing standards and legal definitions for traditional medicines, for example by delimiting the source, processing standards, packaging, and labeling of key medicinal substances.

Second, they should impose harsher punishments on those who violate these standards. At present, China’s Drug Administration Law generally bases punishments on calculations of the production and sales value of counterfeit goods. But because individual batches of counterfeit medicine contain comparatively small amounts of fake ingredients, punishments are usually too lenient to dissuade fakers from doing it again.

Third, TCM practitioners should be given access to specialist technology when enforcing national standards. Many officials, wholesalers, and TCM pharmacists continue to use traditional, hidebound techniques to identify fakes by sight or touch. Meanwhile, wily counterfeiters routinely embrace the necessary technological developments to stay one step ahead of the game.

Today, when many Chinese people get sick, they tend to turn to Western medicine first. But TCM still plays a major role in markets for health supplements. As disposable incomes rise across the country, more and more Chinese people are willing to spend money on health care products. This has brought huge profits to certain players in the TCM industry, even though they are subject to laxer regulation than their peers in Western medicine.

Chinese society retains a deep-seated cultural attachment to the value of traditional medicine. We cannot expect consumers alone to police unscrupulous peddlers of fake treatments that potentially endanger public health. The onus is on officials to get smart about fake TCM and ensure a safer environment for all.

Translator: Kilian O’Donnell; editors: Zhang Bo and Matthew Walsh.

(Header image: A pharmacist inspects medicinal herbs at a Traditional Chinese Medicine pharmacy in Fuyang, Anhui province, Sept. 25, 2017. Wang Biao/VCG)