The Nobel Prize versus traditional Chinese medicine

Last week, in response to the awarding of the Nobel Prize in Physiology or Medicine to Chinese scientist Youyou Tu, who isolated Artemisinin and validated it as a useful treatment for malaria back in the 1970s, I pointed out that the discovery was a triumph of natural products pharmacology, not of traditional Chinese medicine (TCM). So did Scott Gavura, a pharmacist who blogs at my favorite other blog, Science-Based Medicine, who also emphasized that the path from TCM remedy for fever to pill used to treat malaria was the very model of how pharmacologists isolate medicines from plants. Basically, we both noted that Artemisinin is extracted from wormwood, but that the process of turning it into a drug involved a lot of trial and error, the elucidation of which wormwood plants contained enough Artemisinin to be useful for manufacturing larges amounts of it, and chemical modification fo the compound to make it more potent. None of this had anything to do with the basic ideas at the heart of TCM, such as the five elements or the imbalances in heat, damp, and the like to which TCM ascribes the cause of all diseases.

I hadn’t planned on writing about this again unless some quack wrote a particularly juicy and stupid bit of nonsense about how Artemisinin proves that TCM works and the awarding of the Nobel Prize to Tu was finally an acknowledgement of that. It turns out that I didn’t have to wait for that because there was an article in the New York Times over the weekend about just what I was talking about, the tension in China between TCM advocates who want to claim the Nobel Prize for Artemisinin as validation of TCM and Chinese scientists who will have nothing of these claims. It’s a story about the Academy of Chinese Medical Sciences, where Youyou Tu did her work back in the 1960s through the 1980s and changed the course of Chinese science. The article lays out the essential conflict quite starkly:

Traditionalists say the award, in the “physiology or medicine” category, shows the value of Chinese medicine, even if it is based on a very narrow part of this tradition.

“I feel happiness and sorrow,” said Liu Changhua, a professor of history at the academy. “I’m happy that the drug has saved lives, but if this is the path that Chinese medicine has to take in the future, I am sad.”

The reason, he said, is that Dr. Tu’s methods were little different from those used by Western drug companies that examine traditional pharmacopoeia around the world looking for new drugs.

Why, I wonder, would Changhua be sad that Youyou Tu helped bring TCM into modern times? The answer is obvious. He believes in the whole system. That includes the whole set of prescientific concepts upon which TCM is based, including the five elements, which are believed to be the five aspects of qi, the life force or energy. Much like the case with the four humors in what I like to call traditional European medicine (i.e., humoral theory), it is “harmonious” balance between the elements that TCM teaches to be the basis of health. There are also six pernicious influences, the six excesses, or the six evils (e.g., wind, cold, heat, dampness, dryness) that are blamed for disease. There is also the concept that one can unblock blockages in the flow of qi using acupuncture needles.

And that’s the problem. TCM is loaded with mystical pseudoscience. There are the vitalism behind the concept of qi, four humors-like nonsense of the five elements, and diagnostic silliness like tongue diagnosis, which is a lot like reflexology for the tongue, where specific areas of the tongue are claimed to map to specific organs, the way reflexology maps areas on the soles of the feet and palms of the hands to specific organs. Don’t even get me started on pulse diagnosis. Yes, assessing the pulse can be a great aid in determining if a patient is dehydrated, possibly septic, or suffers from a heart condition that leads to irregularities in the heartbeat, but that’s not what pulse diagnosis is about in TCM. There are 29 types of pulse in TCM pulse diagnosis, none of which really correlates convincingly to any physiological condition. There are notations such as how a “hesitant” pulse shows that “Blood and essence failing to nourish the meridians. Blood is not flowing smoothly.” Physiologically, this is meaningless. As Steve Novella put it, pulse diagnosis and other aspects of TCM are excellent examples of knowledge disconnected from reality.

Now, of all the aspects of TCM, the one aspect most likely to produce useful treatments is the herbal medicines, for the simple reason that plants can contain chemicals that can be drugs. That’s it. That was the case with Artemisinin, but I note that it took Tu’s screening over 2,000 TCM herbal remedies for activity against the parasite that causes malaria. She tested various ways of extracting it from the plant. She chemically modified it. She had to figure out how to make it into pills. All of that is very different from this:

But the most sophisticated part of Chinese medicine, Dr. Liu said, involves formulas of 10 to 20 herbs or minerals that a practitioner adjusts weekly after a consultation with a patient. And yet almost no research has been done on how these formulas actually interact with the body, he said. Instead, the government has poured money into finding another Artemisinin — with no luck.

“Are we truly respecting this cultural heritage?” Dr. Liu said. “When we think Chinese medicine needs to be modernized and the path it shall go down must be like Tu Youyou’s path, I think it is a disrespect.”

Here’s the problem. From a medical standpoint, the vast majority of TCM desn’t deserve respect. We might respect it from a cultural and historical standpoint, but medically it’s a prescientific system of medicine not based on science. If everything not rooted in science were to be stripped from TCM, all that would be left is the herbal medicine—and then only a small proportion of it, the herbal remedies that have thus far been shown by science to have uses, so far a vanishingly small number. It is that small part of TCM that might have value—if “modernized” and taken down Youyou Tu’s path—that TCM advocates point to as proof that TCM as a system of medicine works.

Indeed, this is what some Chinese scientists themselves say:

But many Chinese think it should not be respected at all. Scientists like He Zuoxiu, a member of the prestigious Chinese Academy of Sciences, say that the ancient pharmacopoeia should be mined, but the underlying theories that identified these herbs should have been discarded long ago.

“I think for the future development of Chinese medicine, people should abandon its medical theory and focus more on researching the value of herbs with a modern scientific approach,” Dr. He said in an interview.

These radically different views on Chinese medicine go back at least a century, and get to the heart of how modern China sees itself.

It’s been discussed in detail how Chairman Mao Zedong retconned the history of TCM in order to make it more palatable to his people after his Communists took the country over in 1949. What was a mish-mash of many different folk medicine traditions that included bloodletting as a precursor to acupuncture was transformed into a single system of medicine, which Mao sought to “integrate” with “Western medicine.” One thing that the NYT article points out is that Mao also demanded that TCM “modernize,” which it tried to do by setting up traditional Chinese hospitals, schools and research facilities like the academy in Beijing. After Mao’s death, however, China invested far more heavily in “Western” medicine:

But money has flowed overwhelmingly toward Western medicine. In the Mao era, rural health care workers — “barefoot doctors” — were often traditional practitioners, which raised the profile of Chinese medicine. After Mao’s death and with growing prosperity, the government doubled down on Western medicine.

Today, China has 1.1 million certified doctors of Western medicine, versus 186,947 traditional practitioners. It has 23,095 hospitals, 2,889 of which specialize in Chinese medicine.

“It’s part of the nation, but the nation of China defines itself as a modern nation, which is tied very much to science,” said Volker Scheid, an anthropologist at the University of Westminster in London. “So this causes a conflict.”

In China, it would appear that TCM is dying. Fewer and fewer aspiring practitioners are becoming TCM practitioners; they want to become doctors instead. The government supports scientific medicine more than TCM. TCM advocates know it, which is why they latch on to this Nobel Prize to reassure themselves that it isn’t so, that TCM is scientific, that it is now respected and embraced.

The sad thing is that China is moving in the right direction. In the “West,” with the rise of “integrative medicine,” which often wholeheartedly embraces TCM, we are going in the wrong direction.