The holidays must truly be over. I say this because, starting around Sunday, the drumbeat of blogging topics that I haven’t covered but that apparently you, my readers, want me to cover has accelerated. However, before I can move on to what might or might not be greener blogging pastures, material-wise, I feel obligated to finish what I started yesterday, namely the deconstruction of an advertising supplement promoting the “integration” of “traditional medicine” (in particular, traditional Chinese medicine, a.k.a. TCM) for which Science and the American Association for the Advancement of Science (AAAS) have sold their collective souls, part one of which is here. One reason is that I don’t like to risk not finishing a series that I have planned. The other reason is that, unfortunately, Science has promised that this is just the first part of a three supplement series, and I didn’t want to risk not getting back to part one before part two of this paean to pseudoscience, quackery, tooth fairy science, and quackademic medicine is published.
The supplement was, as you recall, entitled The Art and Science of Traditional Medicine Part 1: TCM Today — A Case for Integration, and when it comes to tooth fairy science and quackademic medicine, plus, as Kimball Atwood would put it, the weasel words of woo, it’s breathtaking, as I described. Unfortunately, the fun, such as it is, continues in the articles in the supplement that I didn’t get to yesterday. For example, there is an article by Josephine Briggs, director of the National Center for Complementary and Integrative Health (NCCIH, formerly the National Center for Complementary and Alternative Medicine, or NCCAM) and a bunch of other advocates of “integrative” medicine entitled Integrating traditional medicine into modern health care. As you might expect, my first thought upon reading this title was: Shouldn’t we figure out whether anything in TCM has any scientific basis first?
Apparently not, although Brigs and company do at least explain their purpose:
This first issue introduces the WHO Traditional Medicine Strategy (2014– 2023), highlighting the global scientific challenges and showing how a systems biology approach can be applied to diagnosis, leading to integrated network-based medicine. Recent advances in mechanistic studies of acupuncture are also discussed. Some of the exciting areas in TCM research include the therapeutic potential of herbal remedies against influenza, cancer, diabetes, and cardiovascular diseases; the exploration of gut microbiota-targeted dietary interventions against chronic inflammation; and the study of the biological activities of complex polysaccharides present in medicinal plants. Chemogenomics and network pharmacology have been applied to predict molecular targets and decipher the mechanisms of action of pure compounds or phytocomplexes found in combinatorial herbal formulas. A better understanding of the philosophy of synergetic interactions of Jun, Chen, Zuo, and Shi classes of Chinese materia medica used in traditional formulations has led to a simplified Jun-Shi compatibility drug discovery strategy model.
Evaluating the safety of herbal medicines is critical to their wider acceptance as valid therapeutic agents. Integrated toxicological approaches have been successfully applied in this area, for instance to identify antifibrotic and profibrotic substances in certain medicinal plants. As research into the broader application of traditional medicine continues, newer ‘omics technologies and poly-pharmacokinetics will also play an increasing role in bridging the gap between the personalized approach of Chinese medicine theory and modern clinical research methodology.
No one disputes that powerful medicines can be isolated from plants and other natural sources. If that weren’t the case, then natural products pharmacology (or, as it’s also called, pharmacognosy) wouldn’t be such an important part of pharmacology. Of course, using herbal remedies means substituting impure extracts with high lot-to-lot variation in active ingredient(s) for purified, well-characterized pharmaceutical grade active ingredient(s). Perhaps you are wondering what Jun, Chen, Zuo, and Shi classes of Chinese materia medica are. Perhaps this little excerpt from an article on TCM will help you:
The Herbal was put under the name of Shennong or Godly Farmer but it was likely compiled during the Qin/Han dynasties (221 BC – 220 AD). It is the summary of pharmaceutical knowledge during that time. It discusses in detail 365 kinds of drugs, and it also mentioned the basic pharmacological theories which are still being taught in today’s Chinese medical schools. It includes the following: Jun Chen Zuo Shi (monarch, minister, assistant, and guide) indicating the different functions of drugs in a prescription; the Four Qi’s, four properties of drugs; Five Tastes, five kinds of flavours: sour, bitter, sweet, acrid, salty. Long term clinical practice and modern scientific researches have proved that most of the effects of the drugs recorded in this book are true, as with Chinese ephedrine (Herba Ephedrae) used in the treatment of asthma, goldthread root ( Rhizoma Coptidis) prescribed in dysentery, kelp (Sargassum) prescribed in goiter and so on.
If you look closer, you’ll find that Jun (ruler or emperor) corresponds to the principal ingredient directed at the main cause and/or symptoms of the disease, Chen (minister) describes herbs directed at the underlying cause of the disease as well as accompanying symptoms. (You know, Jun and Chen sound very similar to me.) Zuo (assistant) drugs are supposed to help the Jun and Chen drugs do their work by alleviating secondary symptoms of the disease and counteracting adverse effects of other drugs. Finally, shi (enabler or guide) drugs supposedly direct the action of all the others into the right “channels,” thus somehow making sure that the other drugs “do not exceed the patient’s capacity to cope with their actions.” It’s all very complicated and seemingly rationale sounding. Of course, in TCM, the “underlying cause” of diseases invariably involves imbalances in proteries like “dampness” and “heat” or the like, rather than anything with any basis in science. Remember that. These TCM herbs are all designed not based on any scientific understanding of a disease and its symptoms, but rather on a prescientific belief system rooted in religions beliefs (Taoism) very much like humoral theory that ruled in Europe for two millennia.
As I like to ask, where’s the love for traditional “Western” medicine, which postulates imbalances in characteristics not unlike those central to TCM beliefs?
Perhaps the most depressing part of this whole supplement is that the World Health Organization (WHO) is actively promoting the “integration” of traditional medicine, chief among them TCM, into science-based medicine, as indicated in a rather long article entitled The WHO Traditional Medicine Strategy 2014–2023: A perspective, by Zhang Qi and Edward Kelley.
Like other articles in this supplement, the article starts out with the logical fallacy of argumentum ad populum; i.e., an appeal to popularity. Yes, tiresome and predictably, the authors tout how much TCM is used in China. Strike that, they tout how much T&CM (traditional and complementary medicine) is used, bragging about countries in which traditional medicine is completely integrated into health care systems, including China, the Democratic People’s Republic of Korea (North Korea), the Republic of Korea (South Korea), India, and Vietnam. what I can’t figure out from this is why we in the “West” would want to imitate medical systems in North Korea or any of these countries. Yet, according to this article, the WHO’s objectives include more tooth fairy science on traditional medicine, assuring the safety of traditional medicine. Then, the third objective is:
Objective 3: To promote universal health coverage by integrating T&CM services into health care service delivery and self-health care. One of the most significant questions raised about T&CM in recent years is how it might contribute to universal health coverage by improving service delivery in the health system, particularly primary health care. A first step is to capitalize on the potential contribution of T&CM to improve health services and health outcomes. Mindful of the traditions and customs of peoples and communities, member states should consider how T&CM might support disease prevention or treatment as well as health maintenance and health promotion. This process should be consistent with safety, quality, and effectiveness standards and in line with patient choice and expectations. Based on each country’s realities, it is recommended that models for integrating T&CM into national health systems should be explored.
Talk about weasel words of woo. How would “integrating” traditional medicine ito health care delivery services promote universal health coverage? It wouldn’t, at least not unless you define “universal health coverage” as encompassing pseudoscience and quackery or, at the very least, treatments based on prescientific notions of disease whose efficacy and safety are either not established or established, but not in the way the WHO wants. Seriously. you know how much I rail against the infiltration of quackery into medical academia, calling it quackademic medicine? I had no idea that the WHO is actually actively promoting the infiltration of quackery not just into medical academia but into health care systems around the world. It boggles the mind.
Next up is an article by Josephine Briggs. I had hoped to avoid it, because it’s really full of the weasel words of woo, but I can’t. Perhaps the most brain-melting non sequitur I’ve ever seen comes in the second paragraph of her article, entitled A global scientific challenge: Learning the right lessons from ancient healing practices. Make sure you aren’t drinking anything while you read this. Otherwise, I’m not responsible for ruined keyboards:
For many living in developing economies, traditional healers and herbal remedies are the only source of available health care. In contrast, developed economies typically use these approaches as an optional complement to modern medicine, driven by patient preference. However, in both China and India, the ancient medical traditions—traditional Chinese medicine and Ayurvedic medicine—have flourished either in parallel or integrated with advanced modern care. Currently, in North America and Europe certain ancient healing practices—such as acupuncture, traditional Chinese medicine, massage, and meditation—have generated increasing interest and are seen as gentler, “low-tech” complements to conventional care.
The persistence of such traditional practices in these settings suggests we have much to learn from them. Modern scientific methods can offer means to examine traditional practices. In this brief perspective, a few examples of traditional remedies are discussed to illustrate the issues we face in thinking about the intersection between modern medicine and traditional healing practices.
Um, no. It doesn’t. At least, it doesn’t except in the most trivial meaning of the term “learning something.” Think of it this way. Belief in ghosts persists, despite science that shows that ghosts don’t exist. Does this mean that we have “much to learn” from studying ghosts? No. Perhaps we have something to learn from studying believers in ghosts as a means of studying human belief and credulity. No doubt we can do the same with alternative medicine, but that doesn’t mean that we should adopt belief in alternative medicine by “integrating” it wholesale into national health systems any more than we should adopt belief in ghosts as a national policy.
OK, that was a bit of a strained analogy, but you get the point.
Briggs pulls out the standard tropes about how the identification of natural products somehow validates TCM, pointing out that half of the pharmaceuticals approved by the FDA were “either natural products, synthetic derivatives, or had at their core a prototype molecule derived from a natural product.” Certainly, there’s no doubt that natural products and their derivatives are an important source of drugs. That doesn’t mean one has to “integrate” TCM with scientific medicine in order to have the benefit of these compounds. Again, that’s what we have natural products pharmacologists for. Indeed, adopting TCM instead of cherry picking herbs that can be demonstrated to have medicinal benefit would be counterproductive because of all the pseudoscience and mysticism associated with TCM.
Next up, Briggs admits that acupuncture is primarily a placebo intervention but says that we should use it anyway. She cites a paper by Vickers et al that was widely touted as “proving” that acupuncture works for pain but doesn’t prove anything of the sort. Then she writes:
Specifically, when acupuncture was compared to no acupuncture (in effectiveness studies), the benefit appears to be quite sizable, approximately 50% reduction in pain severity. In contrast, when acupuncture is compared to a sham treatment (in efficacy studies), more modest effects are observed (Figure 2). Although statistical significance is achieved, the reduction in pain severity is not as substantial, typically only 20%. Based on this analysis, it seems reasonable to conclude that needling itself may be contributing to acupuncture’s pain-reducing effects, and that the overall benefit is heavily dependent on context—on the reassurance and expectation produced by the acupuncture ritual.
What does this mean for clinical practice? Here, the arguments erupt. Is a contextual effect (some would call it a placebo) that relieves pain and reduces the need for medication an acceptable form of treatment? This is still, for many Western practitioners, a quandary to which there is no simple answer. Building a better biological understanding based on the neuroscience of pain may provide some common ground. As we learn more about the central effects—specific and nonspecific—can also be teased out. pain circuits, the mechanisms underlying acupuncture’s effects—specific and nonspecific—can also be teased out.
Shorter version: The evidence is most consistent with the conclusion that acupuncture is a theatrical placebo (although we really, really hope that the needling actually has pain relief properties), but we should use it anyway, damn the ethical objections to lying to patients. After admitting that “traditional medicine diagnoses” are often not related to science or reality, she then concludes that “clearly, Western medicine does not have all the answers, and systems of care that allow thoughtful integration of healing traditions with modern medicine may offer help to troubled patients.” In other words, let’s fill in the gaps with magic, the same way creationists fill in the gaps in evolution with God.
Last up (for me at least) is a jaw-dropping article by Jan van der Greef and others entitled East is East and West is West, and never the twain shall meet? It begins with a blatant appeal to cultural relativism, saying that “modern Western scientific model” arose in its own cultural context. In comparison, “A different approach to understanding reality and the laws of nature arose in Eastern cultures, such as China. Both models can be considered valid, each with its own model-dependent realism.”
Postmodernism reigns supreme!
Based on postmodernism, van der Greef continues:
One way to bridge the two worldviews is through unification of diagnosis, based on an integration of the collections and arrangements of symptoms and signs. Western biomedical advances offer a plethora of biomarkers that can be detected and measured with advanced equipment, while Chinese medicine contributes knowledge about the dynamic relationships among signs and symptoms. The right side of Figure 2 provides an example of this inter-relationship for rheumatoid arthritis (RA). In Chinese culture, RA is classified as a “Bi Zheng,” a so-called painful obstruction syndrome. In TCM diagnosis every condition is primarily distinguished according to eight basic principles: External-Internal, Heat-Cold, Excess-Deficiency, and Yin-Yang. Figure 2 focuses on the Cold- Heat differentiation.
The signs and symptoms of RA are universally represented across peoples independent of culture, although variations in concepts and emphasis can be seen. In TCM, RA patients can be subdivided based on the predominance of “hot” versus “cold” symptoms. Examples of “hot” symptoms, as illustrated in Figure 2, are thirst, fever, irritability, restlessness, warm feeling, dry mouth, and pain that is relieved by cold, while “cold” symptoms include clear urine, sharp pain, stiff joints, and pain that is relieved by warmth. This systemic approach may help biomedical researchers to distinguish biological subtypes of RA in a manner that could lead to personalization of medical care; firstly, through more personalized lifestyle advice, and in the long term, through the application of modern biomedical technology in studies of RA subtypes. Ultimately, recognizing the particular individualized presentation of RA across different patients based on a systemic approach may improve treatment choices and outcomes.
Arrghh! Not this nonsense about rheumatoid arthritis again! I’ve dealt with it before in detail a mere two months ago, when I discussed a truly credulous Wall Street Journal article about TCM that described exactly this attempt to use systems biology to “prove” that TCM diagnostic criteria and concepts accurately describe the pathologic processes resulting in RA. van der Greef even discusses the same research as justification for his “unification,” complete with this diagram:
There’s more in the next article, this time by Leung et al and entitled Integrated network-based medicine: The role of traditional Chinese medicine in developing a new generation of medicine:
According to the philosophy of traditional Chinese medicine (TCM), health is the state of harmony between individual internal physiological networks (IPNs) and external environmental networks (EENs). Aberrant interactions between and within these networks cause complex diseases. TCM is grounded in these holistic principles, integrating philosophies from art and science; it stresses the maintenance of balance, or homeostasis, between the systems of the body and nature.
We believe that this kind of network-based holistic approach to medicine offers a useful counterpoint to today’s biological reductionism-based thinking. We champion integrated network-based medicine (INBM) which takes a systems approach to understanding the individual’s body as a whole, as opposed to relying on discrete components such as gene mutations, in order to explain illness (1). Built on the principles of IPNs and EENs, INBM offers a comprehensive medical system that integrates fundamental theories, diagnostic methods, and therapeutics based on a holistic and dynamic network-based approach.
What does this even mean? Sadly, I know. It means “integrating” TCM with “Western” medicine and then pointlessly applying all sorts of advanced systems biology techniques to give it the sheen of real state-of-the-art science. There’s even another chart:
Do you get the message? See how TCM is in the same circle as personalized medicine and digital medicine surrounded by all sorts of science-y terms and illustrations, with the circle being on the right end of an arrow, the end labeled “future perspective”? That’s right. The message is that the “integration” of TCM with science-based medicine is the future. You pesky reductionist “Western” scientists who dismiss the Five Elements and imbalances of dampness, dryness, heat, and cold (for instance) are the past.
The scary thing is, the authors might actually be right. “Integrating” quackery with medicine does seem to be the future these days, and universities, the NCCIH, the WHO, Science, and the AAAS appear to be doing their very best to make that future a reality.