The World Health Organization: Embracing traditional Chinese medicine pseudoscience in ICD-11

I debated about whether or not to write about this, given that I’ve covered the topic in a fair amount of detail before around six months ago. However, after seeing this topic pop up on Twitter and be mentioned by Steve Novella, Steve Salzberg, and Edzard Ernst, I figured it was worth a mention again in order to provide you, my readers, with the latest update, albeit a few days later than I normally would have. So, if you remember how I discussed the impending “integration” of “traditional medicine—mostly traditional Chinese medicine (TCM)—into the latest (11th) version of the International Classification of Diseases codes, commonly abbreviated ICD-11, you’ll be unhappy to know that the World Health Organization definitely plans to turn what was a trial system into a permanent part of the ICD-11. In other words, the World Health Organization (WHO) is going to formalize quackery by including it alongside real medical diagnoses in the upcoming version of ICD-11, which is scheduled to replace the current ICD-10. In case you don’t know what ICD codes are, they’re alphanumeric codes used to classify diagnoses that is a system that’s been maintained and updated by the World Health Organization since its founding in 1948 The most current version is ICD-10, which was endorsed in May 1990 by the Forty-third World Health Assembly and formally adopted by the WHO in 1994.

ICD-11 fully embraces TCM

There’s a story in Nature about it that’s so full of false balance that it makes me wonder what’s become of Nature. (Oh, wait, given that Nature published a special section on TCM a few years back that was basically an advertisement for quackery, I suppose I shouldn’t have asked. Nature is shilling for TCM and of late has been publishing opinion pieces supporting the integration of quackery into medicine.)

So, behold! Here’s Why Chinese medicine is heading for clinics around the world by David Cyranowski, which has the helpful subtitle, For the first time, the World Health Organization will recognize traditional medicine in its influential global medical compendium. You can see why it annoyed both Steves, Edzard, and myself:

Choi Seung-hoon thought he had an impossible assignment. On a grey autumn day in Beijing in 2004, he embarked on a marathon effort to get a couple of dozen representatives from Asian nations to boil down thousands of years of knowledge about traditional Chinese medicine into one tidy classification system.

Because practices vary greatly by region, the doctors spent endless hours in meetings that dragged over years, debating the correct location of acupuncture points and less commonly known concepts such as ‘triple energizer meridian’ syndrome. There were numerous skirmishes between China, Japan, South Korea and other countries as they vied to get their favoured version of traditional Chinese medicine (TCM) included in the catalogue. “Each country was concerned how many terms or contents of its own would be selected,” says Choi, then the adviser on traditional medicine for the Manila-based western Pacific office of the World Health Organization (WHO).

But over the next few years, they came to agree on a list of 3,106 terms and then adopted English translations — a key tool for expanding the reach of the practices.

And next year sees the crowning moment for Choi’s committee, when the WHO’s governing body, the World Health Assembly, adopts the 11th version of the organization’s global compendium — known as the International Statistical Classification of Diseases and Related Health Problems (ICD). For the first time, the ICD will include details about traditional medicines.

As I said the last time I discussed this issue, this has been a long time coming. The result of Choi’s work became the basis for the International Classification of Traditional Medicine (ICTM), which ultimately became the ICD-11 TM chapter, or Chapter 26. Six months ago, the ICD-11 TM chapter was optional. It’s not clear to me from the Nature story whether it will still be optional after ICD-11 is adopted by the World Health Assembly as the official successor to ICD-10. From the story, I get the feeling that it will not be. In fairness, though, the draft version of ICD-11 currently residing on the World Health Organization website still states in the introduction to Chapter 26:

The use of the ICD-11 TM Chapter is optional for those who would like to record epidemiological data about traditional medicine practice. This chapter should not be used for mortality reporting. * ‘TM1’ refers to Traditional Medicine conditions – Module I. The (TM1) designation is used throughout this chapter for every traditional medicine diagnostic category in order to be clearly distinguishable from conventional medicine concepts.

I would argue that even being optional is bad enough, given that traditional Chinese medicine is a prescientific, vitalistic system of medicine rooted in ancient Chinese religious beliefs. It has no business in a modern medical diagnosis code system.

TCM versus “traditional Western medicine”

I like Steve Novella’s teaser introduction to his post on the topic:

The World Health Organization (WHO) has announced their 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD). In a controversial new chapter they include Traditional European Medicine diagnoses, such as excess bile or stagnant blood.

These diagnoses refer to Galenic medicine, which is almost 2,000 years old and dominated Western medicine for 13 centuries. Treatments frequently include blood letting and purgatives, and are based on traditional examinations, which may include a detailed analysis of the color of one’s urine.

By including Galenic medicine in the latest WHO classification, this will allow researchers to track the use of these methods more accurately. Patients may also find such traditional practices more affordable and accessible, and this will also encourage insurance companies to offer coverage.

Oh, except there is one tiny change – the WHO is endorsing Traditional Chinese Medicine (TCM), not traditional European medicine. But the move is just as unscientific and outrageous.

Steve’s correct. TCM is very much like the four humors, except that in TCM it is the five elements. Like the four humors, whose imbalance was thought to cause disease and whose rebalancing was thought to be the path to healing. Similarly, in TCM, imbalances in the five elements were (and, sadly, are still) thought to be the cause of disease and rebalancing necessary to restore health.

That’s not all, though. As Edzard Ernst points out, the basis of TCM is Taoist philosophy, from which these assumptions come:

• The human body is a miniature version of the universe.
• Harmony between the two opposing forces, yin and yang, means health.
• Disease is caused by an imbalance between these forces.
• Five elements—fire, earth, wood, metal, and water—symbolically represent all phenomena, including the stages of human life, and explain the functioning of the body and how it changes during disease.
• The vital energy, qi or chi, flows through the body in meridians, is essential for maintaining health.

That last part about qi is where the prescientific vitalism comes in, with qi being a mystical magical “vital force” (these days more commonly translated as “life energy”) that distinguishes living from nonliving tissue and disturbances of whose flow cause disease.

Fantasy codes

As a result of the mystical prescientific philosophy at the heart of TCM, we will soon be treated to ICD-11 TM codes like this one in the new system:

SF57 Liver qi stagnation pattern (TM)
A pattern characterized by distending and burning pain of the hypochondrium, along with restlessness, irritability, bitter taste, dry mouth, red tongue with yellow coating or a wiry rapid pulse. It may be explained by long-term stagnation of liver system qi induced internal fire factor that affects tissues and functions associated with the liver system.

And:

SA20 True heart pain disorder (TM1)
A disorder characterized by persistent, sharp pain in the chest accompanied by sweating, cold limbs, white complexion and blue lips, faint and barely perceptible pulse. It may be explained by stagnation or obstruction of qi, yang, or blood in the chest, deficiency of qi, blood, yin or yang, an accumulation of phlegm blocking the movement of qi, or cold.

Or:

SA55 Diarrhea disorder (TM1)
A disorder characterized by passing three or more loose or liquid stools per day, or as having abnormally frequent bowel movements. It may be explained by wind, cold, dampness, fire or heat factors, improper diet, emotional upset, or deficiency of yang qi in the spleen or kidney systems.

I love how many vague things this last one can be due to. For instance, in TCM, diseases and conditions are often described as being due to imbalances between heat (fire) and cold or between damp (water) and dryness. But if you want to get an idea of how TCM is just a fancier version of humoral theory that substitutes interactions between the Five Elements for interactions between the four humors, just read this bit about Five Element “theory”:

In TCM, the Five Elements are dynamic: they create, control, and constantly interact with each other. Each element is said to generate—give rise—to another element. This generating sequence is a type of “mother-son” relationship, where the parent gives life to and nurtures the child. In Five Element theory, Fire generates Earth. Earth generates Metal. Metal generates Water. Water generates Wood. Wood generates Fire. One jumping off point for remembering this sequence is to think of how rubbing twigs (ie: wood) together can create fire.

Additionally, each element controls and is controlled by another element, creating a system of checks and balances. Ideally, this system guarantees that one element will not over-dominate another element for any lengthy period of time. The controlling sequence is as follows: Fire controls Metal. Metal controls Wood. Wood controls Earth. Earth controls Water. Water controls Fire. An easy way to begin memorizing the controlling relationships is to think of how water can easily douse—control—fire.

Disturbances in these natural generating and controlling orders give rise to pathological symptoms. For instance, if the Wood element is too excessive in the body it may begin “over-controlling” the Earth element. This is a common pathology in clinical practice. One way it can be used is to understand why feeling excessively angry (Wood’s emotion) can give one a stomachache (the Stomach is one of Earth’s organs).

Yes, just as ancient Europeans thought that one has to keep the four humors (yellow bile, black bile, phlegm, and blood) in balance, ancient Chinese thought that you had to keep the elements of Wood, Earth, Metal, Water, and Fire in balance. If you really want to see what I mean, compare this chart of TCM’s Five Elements:

With this chart of the four humors:

See the resemblance? In both there is hot, dry, cold, and wet, and in both the components control. See Steve’s point? If the World Health Organization is enshrining the Asian version of humoral theory into its ICD-11 manual, why isn’t it enshrining the European Galenic version of humoral theory? Where’s the love for traditional European medicine, dammit? Or should I call it traditional Western medicine? Or should I care any more? Unfortunately for me, I can’t help it; so I soldier on.

Ideology and money: The real reason for ICD-11

To his credit, Cyranowski actually tells us why. It all comes down to China and the leadership of Margaret Chan, who ran WHO from 2006 to 2017. During that time, the ties between WHO and China became closer, and the WHO became more and more credulous towards the prescientific nonsense that is TCM:

Chan has supported traditional medicines, and specifically TCM, and has worked closely with China to promote this vision. In 2014, the WHO released a ten-year strategy that aims to integrate traditional medicines into modern medical care to achieve universal health coverage. The document calls on member states to develop health-care facilities for traditional medicine, to ensure that insurance companies and reimbursement systems consider supporting traditional medicines and to promote education in the practices.

In the same year, Chan wrote an introduction to a supplement that ran in Science and was sponsored by the Beijing University of Chinese Medicine and Hong Kong Baptist University2. (Nature ran a similar paid-for supplement in 2011.) Chan wrote that traditional medicines are “often seen as more accessible, more affordable, and more acceptable to people and can therefore also represent a tool to help achieve universal health coverage”. In a 2016 speech in Singapore, Chan said that TCM has excelled at preventing or delaying heart disease because it “pioneered interventions like healthy and balanced diets, exercise, herbal remedies and ways to reduce everyday stress”.

I wrote about the supplements that ran in both Science and Nature. They were both bad. Real bad. They were unabashed advertisements for TCM and other “traditional medicines,” chock full of credulous takes on both.

Also, take special note of that part about integrating “traditional medicines into modern medical care to achieve universal health coverage” and urging the development of healthcare facilities for traditional medicine? That’s exactly the vision of Chairman Mao Zedong, who first came up with the idea. Cyranowski does briefly mention that “China’s support of TCM started with former leader Mao Zedong, who reportedly didn’t believe in it but thought it a could reach under-served populations,” but fails to mention that in order to achieve this Mao had his entire medical establishment basically retcon the history of TCM to present dozens of folk medicine traditions falsely as a coherent whole and promoted “miracle cures” due to TCM that, when examined critically (which Westerners seldom did), showed nothing miraculous or even effective at all.

These tales usually 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 the right for that to happen, as any general surgeon knows.

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.

Cyranowski also notes that the Chinese government recently passed laws to support the promotion of TCM in China and around the world, and indeed it did, as I described in detail when it happened. Unfortunately, China has also taken other steps to promote TCM, the most egregious of which has been to weaken the regulations governing TCM, or, as I called it at the time, lowering the bar for TCM for ideology and profit. For example, draft regulations passed a year ago by the China Food and Drug Administration eliminated the requirement for traditional Chinese medicines to pass safety and efficacy trials as long as manufacturers prepare ingredients using essentially the same method as in classic Chinese formulations, with the state drafting a list of approved methods. Chinese censors have also been aggressively removing posts on social media sites and the web that question the efficacy of TCM. For example, from a Nature story a year ago:

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.

Also, if you’re Chinese and living in China, don’t criticize a TCM manufacturer like Hongmao Pharmaceutical, which makes Hongmao liquor, a best selling concoction of over 60 kinds of medicinal herbs and animal products advertised as a treatment for basically anything that ails you, including painful joints, frail kidneys, spleen ailments, stomach problems, anemia, and basically dozens of ailments. You could end up like Tan Quindong, who criticized the concoction for the lack of evidence and the false advertising by its company and found himself arrested, thanks to Hongmao’s pull with regional authorities. True, the publicity that resulted backfired on Hongmao spectacularly, but the message was clear: Criticize a state-sanctioned TCM manufacturer, and you risk prison. At the time I wrote my post about this persecution, China’s TCM business was worth $116 billion and represents nearly 29% of China’s pharmaceutical industry. Cyranowski notes now:

Current Chinese President Xi Jinping has strongly supported TCM and, in 2016, the powerful state council developed a national strategy that promised universal access to the practices by 2020 and a booming industry by 2030. That strategy includes supporting TCM tourism, which steers large numbers of people to clinics in China. Every year, tens of thousands of mostly Russian tourists flock to Hainan off the southern coast seeking relief through TCM. The government has plans to build 15 TCM ‘model zones’ similar to the one in Hainan by 2020.

The country also has global ambitions. China’s Belt and Road trade initiative calls for creating 30 centres by 2020 to provide TCM medical services and education, and to spread its influence. By the end of 2017, 17 centres had sprung up in countries such as the United Arab Emirates, Hungary, Kazakhstan and Malaysia.

The ties are paying off. Sales of TCM herbal medicines and other related products exported to Belt and Road countries surged by 54% between 2016 and 2017, to a total of US$295 million.

In the end, it’s all about ideology and money and “other ways of knowing” preferred by too many over science. The current Chinese government believes TCM is a “gem,” regardless of how little evidence there is for all but a handful of its practices and how its belief system has no relationship to science and what we understand about human pathophysiology, largely because it is viewed as a Chinese cultural, if not scientific, triumph. Then, there’s the profit to be made. The TCM industry in China is growing rapidly, supported by the government, both in terms of bringing in medical tourists and exporting TCM supplements and herbal medicines to the rest of the world. Now it’s exporting TCM clinics to the rest of the world, although I can’t help but note that it probably doesn’t even need to, at least not in the US, given how academic medical centers like the Cleveland Clinic are setting up TCM clinics without Chinese help.

Expansion of TCM will cause animals (and people) to die, as Steve Salzberg noted. Indeed, one of the most despicable aspects of TCM is the barbaric practices that is a feature, not a bug, of TCM, rife with animal cruelty. Bears are often kept in cages with catheters surgically inserted in their gallbladders to extract the bile for TCM remedies. (Chilling stories can be found here.) By facilitating the spread of TCM, whether intentionally or not the WHO is promoting animal cruelty and, likely, the extinctions of endangered species.

The mission of the WHO is to promote health and combat disease throughout the world. It states that two of the ways (among others) that it does this are by:

• setting norms and standards and promoting and monitoring their implementation;
• articulating ethical and evidence-based policy options;

Well, here the WHO is failing miserably on both counts. My only hope for the US is that we’ll take as long to adopt ICD-11 as we did to adopt ICD-10. We didn’t adopt ICD-10 until over 20 years after it was formally adopted by the WHO. In this case, foot dragging would be good. Unfortunately, I doubt that US sluggishness adopting the new ICD codes will be shared by the rest of the world.