European Atherosclerosis Society: Publishing quackademic pseudoscience about traditional Chinese medicine in its official journal

One of the purposes of this blog from near the very beginning has been to shine a light on the infiltration of pseudoscience and quackery into what should be bastions of science-based medicine, academic medical centers. Indeed, just the other day I wrote about how it’s wending its way into my medical alma mater, much to my horror, as well as how a true believer in acupuncture has been appointed director of the foremost legitimizer of quackademic medicine, the National Center for Complementary and Integrative Health, thus assuring the likelihood of a steady stream of pseudoscience from the NIH for years to come. Unfortunately, academic medical centers aren’t the only part of the academic establishment that are becoming prone to what I like to refer to as quackademic medicine. The biomedical literature appears to be increasingly prone to publishing “studies” that, when examined critically, turn out to be pure pseudoscience. For example, just get a load of this article describing a new nomenclature for auricular acupuncture. Sadly, even Atherosclerosis, the official journal of the European Atherosclerosis Society, is not immune:

Thread alert! Atherosclerosis (official journal of @society_eas) publishes a #review on #TraditionalChineseMedicine (#TCM). It's simultaneously a bit frightening and hilarious (1/16)https://t.co/LjZEhZ35bJ pic.twitter.com/kv6EQCiywp

— Pauli Ohukainen (@POhukainen) September 6, 2018

The article is Treatment of atherosclerosis by traditional Chinese medicine: Questions and quandaries. The authors are several academics from China and Japan. The result is, unsurprisingly, pretty credulous. The result has also been published a respectable journal with a respectable impact factor. The purpose of this review article is also laid out right in the abstract:

In this review, we provide an overview of the pathophysiology of atherosclerosis viewed by Western and traditional Chinese medicine, summarize pros and cons on the efficacy of CHMs for atherosclerosis and discuss what is necessary for CHM use to spread to Western societies.

Seldom have I seen the purpose of an article advocating quackery laid out so honestly right there in the abstract. Did the European Atherosclerosis Society or the editors of Atherosclerosis not see that? Yes, the purpose of this article is to discuss what is needed to evangelize traditional Chinese medicine (TCM) so that it is adopted in “Western” societies. As a prelude to making the case, the authors posit this history of TCM:

Traditional Chinese medicine (TCM) has a more than two thousand-year history, and is still practiced in China and many other Asian countries. According to a national survey in China, practitioners of TCM received 907 million visits from patients in 2009, which accounts for 18% of all medical visits to surveyed institutions, and the number of TCM inpatients was 13.6 million or 16% of the total in all hospitals surveyed [1]. It has been estimated that even in the US, more than 15 million people consume herbal remedies or high-dose vitamins [2,3]. On the other hand, as the primary killer in the world, atherosclerotic disease is not a unique ailment to contemporary humans because atherosclerosis was present in ancient people 4000 years ago [4,5]. For example, an unearthed 50-year-old Chinese noblewoman, Lady Dai, who died 2300 years ago, was found to have coronary atherosclerosis [6]. Interestingly, in the tomb, there were herbal medicines, such as cinnamon, magnolia bark, and peppercorns, suggesting that the noblewoman had angina pectoris i.e., atherosclerotic complication. According to Han medical canons, these medicines were prescribed for patients with coronary heart disease, similar to prescriptions by TCM doctors today [6].

So. Many. Fallacies. Here. So much nonsense in the official journal of the European Atherosclerosis Society.

Seriously, look at the paragraph above. While it’s correct that TCM is practiced in China and other Asian countries and that it’s big business there. The rest needs to be unpacked. For instance, there are TCM inpatients? People are hospitalized in TCM hospitals? I’ve been aware of the Chinese government’s efforts to support and promote TCM (in particular, TCM herbal medicines and supplements, which make up a significant chunk of Chinese pharmaceutical company sales) and to require the offering of TCM in its state health care facilities, I have to wonder if these inpatients are inpatients in regular hospitals that also offer TCM. Be that as it may, note the deceptive conflation. In order to make it sound as though a lot more people in the US use TCM than actually do use TCM, the authors have cited a statistic that 15 million people consume herbal remedies or high dose vitamins. (Hint: High dose vitamins are not TCM. Vitamins weren’t even known when the principles of TCM were being developed based on prescientific vitalism and religion.) Also note the deceptive juxtaposition. Lady Dai died 2,300 years ago, and her corpse was found to have coronary atherosclerosis. She also had herbal remedies in her tombs that apparently were prescribed by TCM practitioners for angina. The implication is that 2,300 years ago TCM knew something about the nature of atherosclerotic coronary artery disease other than symptoms.

I haven’t even gotten into the revisionist history of TCM. TCM as we know it now is not the TCM of 2,000 years ago. Rather, it is a result of perhaps the most successful campaign of disinformation ever applied to medicine. That’s because in the 1940s and 1950s, Chinese state medical authorities, under the direction of Chairman Mao Zedong, basically invented TCM. Dozens of disparate folk medicine traditions were combined and fused through a narrative that implied that TCM was a unified system of medicine dating back at least 2,000 years whose precepts formed a coherent and scientifically supportable whole. The crude bloodletting based on astrology that had previously been acupuncture became a system using delicate, thin, filiform needles, with little or no blood seen. It’s an effort that continues today, even though Chinese people want effective, science-based medicine, not TCM.

Next up is a history of the “Western” understanding of atherosclerosis, which was first described by autopsy during the late 16th century when Gabriel Fallopius observed arterial calcifications. Atherosclerosis was first proposed to be the cause of nearly all obstructive disease of the arteries a mere 114 years ago by Russian physician Nikolai Anichkov, who also was the first to make the connection between hypercholesterolemia and atherosclerosis. After the description of the utility of statins for preventing atherosclerosis, we’re treated to a non sequitur:

This notion has been further strengthened by numerous epidemiological studies [10] and clinical trials in which the lipid-lowering drug statins reduced atherosclerotic disease [11]. Recently, new antibody drugs against proprotein convertase subtilisin/kexin type 9 (PCSK9), alirocumab and evolocumab, further enhanced the efficacy of statins to reduce cardiovascular events [12], leading to a new era in which plasma LDL-cholesterol levels in high-risk patients should be lowered to reduce cardiovascular events. However, many patients are resistant or intolerant to statins, and thus cannot be treated with statins alone [13]. Moreover, statin therapy alone leads to only a 30% reduction in the incidence of coronary events [14,15]. Therefore, other non-statin therapies are required for many patients who are not responsive to statins [16]. In China, Chinese herbal medicine (CHM) has long been used for the treatment of atherosclerotic complications, such as angina pectoris, myocardial infarction and stroke, but has been rejected by the Western society [17] because it is unclear how CHM is applied, and whether it is safe and effective. In this review, we attempt to overview atherosclerosis in terms of its pathology, complications, manifestations, diagnosis and treatment, with special reference to the different views between TCM and Western medicine on this disease.

See the non sequitur? I’ll spell it out. Just because statins only reduce coronary events by 30% and some patients are intolerant or resistant to statins leading to the need for non-statin therapies for cholesterol reduction does not mean that TCM is the answer. The authors concede that the reason “Western” doctors reject TCM as a treatment for atherosclerotic heart disease is because it is “unclear” whether it is safe and effective, which is, of course a perfectly reasonable rationale for rejecting it.

It gets worse, though. Sections 2 and 3 of the article are entitled Atherosclerosis viewed by Western medicine and Atherosclerosis according to TCM, respectively. This is basically false balance, in which a scientific understanding of atherosclerosis built up over nearly 120 years is compared to an understanding based on fairy dust. It’s basically the equivalent of juxtaposing a cardiology textbook with a religious text describing heart disease as a punishment from God and declaring them basically comparable. In any case, the section on the “Western medicine” understanding of atherosclerosis is a fairly standard recounting of the current understanding of the pathophysiology of atherosclerosis, its risk factors (e.g., hypercholesterolemia, diabetes, smoking, obesity, hypertension), its diagnosis, and its treatment and prevention (exercise, dietary modification, smoking cessation, dietary modification, statins, treating predisposing conditions like diabetes and hypertension). It’s the section on the TCM “understanding” that’s full of nonsense.

I’ll give the authors credit in that they admit that atherosclerosis is a “new TCM diagnosis” because “concept of atherosclerosis does not exist in the ancient TCM theory.” This is attributed to the influence of Confucianism in China, which precluded doing autopsies. Given that medicine in Europe didn’t really start its development into a scientific system until the religious proscriptions against “desecrating” the body by dissecting it were finally overcome, one wonders how TCM could be considered any better. The authors are clever, though. They make it sound as though the investigations of Chinese scientists (and a European scientist working in China) studying atherosclerosis were the equivalent of TCM studying atherosclerosis:

The first pathological study of Chinese atherosclerosis was reported by Dr. Oppenheim in 1925 when he was working at the Pathological Institute of Tung Chi College and Paulun Hospital. He performed 100 autopsies and only found one case of atherosclerosis [22]. However, the pioneer atherosclerosis study was first performed by Dr. Zhengang Lin, a pathologist at Peking University in 1934 [23]. Dr. Lin examined human coronary atherosclerosis and attempted to elucidate the pathogenesis of atherosclerosis [23], at the same time when Western researchers started to investigate this disease mechanism [7].

I can’t help but note that one of the articles cited (ref. 23) was about syphilis as a cause of atherosclerosis. The other (ref. 22) noted that “atherosclerosis was rare, which is in keeping with the fact that the blood pressure of the Chinese is lower than that of Europeans; atherosclerosis was pronounced in one case only.” One wonders how, if atherosclerosis was so uncommon in the Chinese as recently as the 1920s, TCM practitioners could have such extensive knowledge of the disease process.

The authors next note that, although atherosclerosis was unknown to ancient TCM practitioners, coronary heart disease (CHD) was not and was recorded mainly by its symptoms:

Symptoms of CHD were first described in ancient medical textbooks as far back as the Han Dynasty (206BC-220AD). The famous medical book Yellow Emperor’s Inner Canon (Chinese name: Huang Di Nei Jing) described CHD as a chest pain that may progress towards the back. The patients can also have shortness of breath, especially when lying flat. Another example of an early description of CHD was found in the Synopsis of the Golden Chamber (Chinese name: Jin Kui Yao Lüe Fang Lun) written by Zhongjing Zhang, a famous Han Dynasty doctor (219AD). He said that “chest pain syndrome usually presents as wheezing and cough, pain on the back of the shoulder and shortness of breath”. It is said that CHD can be diagnosed by the pulse on the wrist artery: the first position will be slow and sinking, whereas the pulse of the second position will be rapid with slight tightness. (http://www.shen-nong.com/eng/health/atherosclerosis_define.html).

Therefore, ancient TCM defines the modern concept of atherosclerosis established by Western medicine only as the manifestations of heart ischemia, such as CHD, caused by atherosclerosis rather than atherosclerosis itself.

Well, yes. I note that Hippocrates dates back to around the same period, give or take a couple hundred years, and he, too, described heart disease based on its symptoms. In fact, one can easily argue that the Greek understanding of the heart was probably more sophisticated than the Chinese understanding. Ancient Greek physicians knew the anatomy of the heart and great vessels, including detailed descriptions of the cardiac valves; knew that the atria contracted independently of the ventricles; and produced a description of angina like this:

This pain was distinguished from localized chest pain due to empyema which called for warm application at the site of the pain. The typical relation of cardiac pain to exertion was not mentioned by Hippocrates but the aggravation of angina pectoris by cold winds maybe the subject of the following aphorism: “Of daily constitutions, such as are northerly…aggravate any pre-existing pain in the chest….” Aphorisms I, 17 (Jones, 1923-1931). In a discussion of the causes of angina, Hippocrates may have been describing myocardial infarction when he wrote: “Angina is serious and rapidly fatal when no lesion is to be seen in either throat or neck, and moreover, it causes very great pain and orthopnea; it may suffocate the patient even on the first day, or on the second, third or fourth.” Prognostics XXIII (Jones, 1923-1931). Further evidence that angina pectoris was observed at the time of Hippocrates appears in Coan Prognostics, 280 where it is stated that: “Frequent attacks of pain in the chest of an old person often denote sudden death.” (Litre, 1839-1861; Chadwick and Mann, 1950).

Indeed, Hippocrates and his contemporaries and followers recorded clinical descriptions recognizable as heart failure, Adams-Stokes syndrome, Cheyne-Stokes respiration, rheumatic fever, and cardiac pain. So let’s just say that the ancient Greek understanding of heart disease was at least as advanced as the ancient Chinese understanding of heart disease, if not more so given that the Greeks knew way more anatomy than the Chinese did. Yet, oddly enough, no one is proposing that we treat atherosclerotic heart disease by bloodletting or balancing the four humors or that we update Hippocratic medicine with what we now know about heart disease. Similarly, the fact that ancient Chinese physicians somewhat accurately recorded the symptoms of heart disease should not mean that we should start “integrating” the five elements into cardiology. Yet, the authors appeal to ancient Chinese understanding of atherosclerotic heart disease as a rationale for studying TCM and a justification for adopting TCM in “Western societies.”

The rest of the article is basically a recounting of TCM treatments for CHD. Not surprisingly, it’s a discussion of a bunch of herbs and plants, basically herbal medicine. Of course, no one argues that herbs can’t contain real medicines. They certainly can and do. Many of our existing drugs are derived from plants or chemically modified natural products. Of course, herbal medicines are “dirty” in that they are mixtures of hundreds of compounds, which dilute the active compound or compounds and whose potency can vary greatly from lot to lot, depending on how the plants are grown and prepared and how the herbal medicine is produced. That’s why we have pharmacognosy, which is a discipline that identifies active drugs in plants and natural products. Given the huge number of TCM herbal remedies in existence, by random chance alone, a few of them are likely to have some useful pharmacological activity. However, just because TCM produced Artemisinin, for example, does not mean that TCM as a system is scientifically valid, no matter how much advocates try to argue otherwise. Yet that’s basically the argument being made here. My take is that there might be useful medicines in some of those TCM herbs and plants; however, the answer to figuring that out is pharmacognosy, not “integrating” TCM into cardiology.

Articles like this one published in Atherosclerosis drive me up a wall. I have to wonder who the peer reviewers were and what the editors were thinking. The European Atherosclerosis Society should be ashamed for publishing this combination of pseudoscience, revisionist history, and a defense of prescientific vitalism in its official journal.