Lowering the bar for traditional Chinese medicine for ideology and profit

Last week, I saw a story in Nature that caught my eye. Regular readers know that I’ve written a lot about “traditional Chinese medicine” (TCM) a system of medicine that is based on the “five elements” and encompassing herbal medicine, acupuncture, and various reflexology-like systems of diagnosis. So naturally a story by David Cyranoski entitled China to roll back regulations for traditional medicine despite safety concerns:

Support for traditional medicine in China goes right to the top. President Xi Jinping has called this type of medicine a “gem” of the country’s scientific heritage and promised to give alternative therapies and Western drugs equal government support. Now the country is taking dramatic steps to promote these cures even as researchers raise concerns about such treatments.

From early next year, traditional Chinese medicines may no longer be required to pass safety and efficacy trials in humans in China. Draft regulations announced in October by the China Food and Drug Administration (CFDA) mean traditional medicines can skip such costly and time-consuming trials as long as manufacturers prepare ingredients using essentially the same method as in classic Chinese formulations. The State Administration of Traditional Chinese Medicine and the CFDA will compose a list of the approved methods.

I noted last year that the Chinese government had gone “all in” promoting TCM when it passed The Law on Traditional Chinese Medicine. This law basically mandated the “integration” of TCM with science-based medicine, at least in China, while providing considerable resources to China’s already its $114 billion traditional medicines pharmaceutical industry, which represents 29% of China’s pharmaceutical industry, to promote the export of TCM products and elevate the status of TCM thusly:

To this end, the new law said China puts TCM and Western medicine on equal footing in China, with better training for TCM professionals, with TCM and Western medicine learn from each other and complementing each other.

The state will support TCM research and development and protect TCM intellectual property.

Special protection will be given to TCM formulas that are considered state secrets, it said.

Use of technology and expansion of TCM in dealing with emergency public health incidents and diseases prevention and control should increase.

The state will protect medical resources including protection and breeding of rare or endangered wildlife, the law said.

The law went on to pledge enhanced supervision of raw TCM materials, banning the use of toxic pesticides.

Support for TCM in China going right up to the top is not a new phenomenon. In actuality, it was pioneered by Chairman Mao Zedong, beginning in the late 1940s, actively promoted the use and export of TCM. In essence, current Chinese government policy is merely an extension of a policy begun by Mao nearly seven decades ago. For those not familiar with the story, it is definitely worth recapping.

The conventional view of TCM is that it is an ancient, unified system of medicine that has stood the test of time. This concept was solidified in the West in the 1960s and 1970s by a string of seemingly spectacular anecdotes that “proved” the efficacy of TCM. These tales involved Westerners who traveled to China, became ill, and were treated with acupuncture and other TCM modalities brought back reports of amazing healing, such as the use of acupuncture for anesthesia. The most famous of these is that of James Reston, a New York Times editor who underwent an emergency appendectomy while traveling in China in 1971. As I described at the time, Reston’s story was actually not that remarkable. The Chinese surgeons appeared to have used a fairly standard anesthesia technique, most likely an epidural. Acupuncture was used to treat Reston’s cramping on the second evening after the surgery. The story is familiar to any surgeon; about a day and a half after surgery Reston had some cramping, likely due to postoperative ileus that kept the gas from moving through his bowels the way it normally does. It passed after an hour or so Around that time, the staff at the hospital used acupuncture to treat his discomfort, and the logical fallacy known as post hoc ergo propter hoc fallacy (and a bunch of credulous Westerners, eager to believe that some magical mystical “Eastern” wisdom” could do what “Western medicine” could not, did the rest. Most likely what happened is that Reston finally farted, letting the built up gas move through and relieving the cramps and bloating. About a day or two after an uncomplicated appendectomy is about right for that.

Over time, other similar stories of “acupuncture anesthesia” trickled out of China, as described by Kimball Atwood in “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I, Part II, Part III, Part IV, and Part V). In reality, these anecdotes don’t hold up to scrutiny as evidence that acupuncture can be used for anesthesia effectively.

What is also little known about TCM is that in reality its story was, in essence, retconned by Chairman Mao Zedong, the myth being promulgated being simple: That TCM is a coherent philosophical and scientific whole when in fact it was never more than a hodgepodge of competing and often contradictory folk medicine traditions; that acupuncture was thousands of years old (at least 2,000), when in fact acupuncture as practiced now probably doesn’t date back more than 100-200 years, with previous versions of acupuncture being far more akin to bloodletting than anything else; and that TCM was highly effective, so much so that it should be “integrated” with “Western” medicine. Indeed, Chairman Mao, facing a shortage of physicians and other science-based health care providers, decided to enlist his “barefoot doctors” (i.e., TCM practitioners) to provide healthcare to his people and promote the “unification” of TCM and “Western” medicine to achieve this.

Indeed, arguably Chairman Mao provided the template used by “integrative medicine” advocates today to integrate prescientific, pseudoscientific, and mystical concepts and treatments into medicine as though there were a scientific basis. A whole propaganda apparatus was developed in the Chinese medical system to promote this idea, using, among other things, stories of Westerners treated in China as grist for its propaganda mill, all of this despite Mao saying that he did not believe in Chinese medicine and didn’t use it. There were conferences. There were themes promoted that began as the “cooperation of Chinese and Western medicines” in the late 1940s and concluded in the late 1950s as the “integration of Chinese and Western Medicines.” One might say tht the integration of pseudoscience and mysticism in medicine in the form of TCM goes back at least to the late 1940s, although it really didn’t take off in the way that we see today until the last 20 years or so.

Clearly, the Chinese government recognizes the popularity of quackery in the US and Europe, and, channeling Mao, is doing its best to promote the sales of TCM herbal products to the West. There are a couple of aspects of this promotion that should trouble you. First, while it is good that the Chinese government will now be screening products for pesticides and heavy metal products, it is most definitely worrisome, however, that China has decided, in essence, to give TCM a privileged position, such that it is no longer subject to anything resembling science to demonstrate its efficacy and safety. It’s not as though certain Chinese herbal medicines haven’t been implicated in adverse health outcomes. For instance, recently researchers in Singapore published an article in Science Translational Medicine that linked liver cancer to a common aristolochic acid, an ingredient widely used in traditional remedies. In addition, aristolochic acid has also been linked to cancers of the urinary tract and can cause fatal kidney damage.

As is typical of an authoritarian government, China doesn’t like criticism of its policies:

With strong government support for the alternative medicines industry, Chinese censors have been quick to remove posts from the Internet that question its efficacy. On 23 October, an article on a medical news site that called for closer attention to the risks of aristolochic acid was removed from social media site WeChat. The story had been viewed more than 700,000 times in three days.

Debate over TCMs has been silenced before in China. Last year, a Beijing think tank — the Development Research Center of the State Council — proposed banning the practice of extracting Asiatic black bear bile, another common ingredient in TCMs. The think tank’s report questioned the remedy’s efficacy and suggested using synthetic alternatives. It was removed from the think tank’s website after the Chinese Association of Traditional Chinese Medicine, which supports the development of TCM, called it biased and demanded an apology.

The Chinese Association of Traditional Chinese Medicine is indeed very powerful, and, as you can see, its influence is such that it can result in the Chinese government clamping down on criticism, even criticism as justified as proposing the end of the cruel and barbaric practice of harvesting black bear bile for TCM remedies. Anything that interferes with growing the TCM industry is to be opposed, and the Chinese government’s plans are ambitious:

The government’s ultimate goal is to have all Chinese health-care institutions provide a basic level of TCMs by 2020. A roadmap released in February 2016 by the State Council, China’s highest administrative body, plans to increase the number of TCM-licensed doctors to 4 per 10,000 people, an increase from less than 3 practitioners per 10,000 people. The government also wants to push TCMs’ share of pharmaceutical sales from 26% to 30% by the end of the decade.

If that’s not enough, the Chinese government has also made it easier to become a TCM practitioner:

As well as reducing regulations for TCMs, the Chinese government has made it easier to become a doctor of traditional medicine and to open hospitals that use the approach. Since July 2017, students studying traditional medicine no longer need to pass the national medical exams based on Western medicine. Instead, traditional medicine students can attend apprenticeship training and pass a skills test. And practitioners who want to open a clinic no longer need approval from the CFDA. They need only register with the authority.

Lowering the standard to become a TCM practitioner and not even requiring any real science any more? I suppose one could argue that the Chinese government is abandoning even the pretense of “integrating” TCM with science-based medicine on a scientific basis even as it more deeply integrates TCM with its medical system and provides more resources to its TCM industry to export its products abroad. Now that TCM is being “integrated” into so many academic medical centers and medical schools with ideology and muscle (and money) from billionaires, that the narrative of TCM providing effective medicines for various diseases, there is a willing market for what China’s selling. Who cares if what China is selling can be shown scientifically to be safe and effective treatments for anything. China doesn’t even care any more.

Somewhere, Chairman Mao must be laughing.