I’ve written a lot about traditional Chinese medicine (TCM) for the simple reason that it’s the form of pre-scientific medicine that seems to have garnered the most “respectability” in the world of academic medicine. Examples abound, including the traditional Chinese herbal medicine clinic at the Cleveland Clinic and the widespread adoption of acupuncture by a disturbing percentage of academic medical centers, including UCSF (which spent $37 million to build an “integrative medicine” center featuring TCM), Georgetown (which featured TCM and all manner of quackery in its glossy magazine), Harvard (which has offered a course for providers in acupuncture every year since at least 2008 and regularly defends acupuncture) and UC-Irvine (which received a massive $200 million gift from the Samuelis to promote “integrative medicine,” including homeopathy and TCM) as a treatment for, well, almost everything, including hot flashes to infertility to low back pain to whatever. Indeed, acupuncture and TCM figure prominently in the National Center for Complementary and Integrative Health’s (NCCIH) plan to study “integrative” nonpharmacologic treatments for pain, while the World Health Organization has “integrated” TCM into the ICD-10 disease codes used all over the world to classify diseases and symptoms. Meanwhile, the National Geographic is shamelessly promoting TCM quackery.
I’ve also written about how Chairman Mao retconned the history of TCM to make it seem as though, instead being of a rag-tag collection of folk medicines from all over what is now China, TCM is a thousands year-old philosophically consistent whole medicine system, camouflaging its origins. Today, such propaganda takes the form of misrepresenting a Nobel Prize for what is in essence natural product pharmacology as a triumph of TCM, while the Chinese government promotes TCM (which is big business in China, both domestically and as an export business) by passing laws to promote TCM by requiring it in state hospitals and lowering the bar for its approval, all while also passing laws to protect it against criticism, or what it calls “slandering” or “libeling” TCM.
Forcing people to use TCM to treat COVID-19
So I suppose it shouldn’t be a surprise that, earlier this week, I saw this AP story:
When police arrested the middle-aged Uighur woman at the height of China’s coronavirus outbreak, she was crammed into a cell with dozens of other women in a detention center.
There, she said, she was forced to drink a medicine that made her feel weak and nauseous, guards watching as she gulped. She and the others also had to strip naked once a week and cover their faces as guards hosed them and their cells down with disinfectant “like firemen,” she said.
“It was scalding,” recounted the woman by phone from Xinjiang, declining to be named out of fear of retribution. “My hands were ruined, my skin was peeling.”
The government in China’s far northwest Xinjiang region is resorting to draconian measures to combat the coronavirus, including physically locking residents in homes, imposing quarantines of more than 40 days and arresting those who do not comply. Furthermore, in what experts call a breach of medical ethics, some residents are being coerced into swallowing traditional Chinese medicine, according to government notices, social media posts and interviews with three people in quarantine in Xinjiang. There is a lack of rigorous clinical data showing traditional Chinese medicine works against the virus, and one of the herbal remedies used in Xinjiang, Qingfei Paidu, includes ingredients banned in Germany, Switzerland, the U.S. and other countries for high levels of toxins and carcinogens.
I would have written about this before, but this week has again been a bit crazy and, contrary to what I thought when I wrote Monday’s post, I haven’t gotten back to my regular posting frequency yet. (Hopefully next week.) In any event, this is downright horrific, and not just because the Chinese government is forcing patients with COVID-19 to use quackery to treat the disease, but more because the Chinese have turned the Xinjiang region into even more of a police state than the rest of China is and used the pandemic as a pretext to crack down on an already persecuted minority.
TCM vs. COVID-19: An appalling lack of evidence
None of this should come as any surprise to anyone, given the Chinese government’s authoritarian nature and its enthusiastic promotion of TCM as a “crown jewel” of Chinese culture and medicine dating back 70 years and continuing today. Indeed, fairly early in the pandemic (in May), a fair number of stories hit the media about how China was promoting TCM to treat COVID-19, such as this one in Nature:
The Chinese government is heavily promoting traditional medicines as treatments for COVID-19. The remedies, a major part of China’s health-care system, are even being sent to countries including Iran and Italy as international aid. But scientists outside China say it is dangerous to support therapies that have yet to be proved safe and effective.
In China, senior government officials and the state media are pushing a range of traditional Chinese medicine (TCM) as being effective at alleviating COVID-19 symptoms and reducing deaths from the disease. However, there are no rigorous trial data to demonstrate that the remedies work.
This description could apply not just to using TCM to treat COVID-19 but using TCM to treat just about anything. That’s because TCM is a system of medicine based on a religious and mystical prescientific understanding of how the body works and what causes disease. I’ve written about this many times before, but TCM is, at its core, not unlike what I like to call “traditional Western medicine” or “traditional European medicine.” Recall that, for many hundreds of years in Europe dating back to Hippocrates, in Europe disease was thought to be due to an “imbalance” in the four humors: blood, yellow bile, black bile, and phlegm. Indeed, the belief that some diseases were caused by an excess of blood was the basis of bloodletting as a treatment for so many diseases. Humoral theory was widely influential, having spread to Islamic and Persian medicine by around 1000 CE and persisted in “Western” medicine until well into the 1800s.
TCM is very much like the four humors, except that in TCM it is the five elements, instead of the four humors. 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. As Edzard Ernst has pointed 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. In my discussion of the “integration” of TCM diagnoses into ICD-11 codes, I list several examples of diagnoses based on “imbalances” between heat (fire) and cold or between damp (water) and dryness, which are related to the five elements. and, at the risk of being repetitive (which I do in some of my posts so that you don’t have to click on all the included links to know what I’m talking about if you’ve never read the relevant content or don’t remember it), I’ll repost a comparison between the five elements and the four humors:
Here is a chart of TCM’s Five Elements:
And here is an illustration of the four humors:
See the resemblance? In both there is hot, dry, cold, and wet, and in both the components control. As an aside before going on to discuss further just how badly China is abusing science and minority populations within its borders, I can’t help but ask: Why is TCM’s “imbalance” model considered respectable in so many academic institutions, NCCIH, and the WHO, while “traditional Western medicine’s” (TWM) is considered rank quackery based on ancient prescientific ideas about the human body and disease? Where’s the love for TWM, dammit?
Ancient nonsense, retconned
Worse, people fall for the BS justifications promoted by believers in TCM, such as:
“The theoretical basis for modern Western medicine has only been around for about two hundred years. Meanwhile, Chinese medicine has been passed down for thousands of years, based on cumulative experience,” said Zhu Tong, who works at a multinational pharmaceutical corporation.
Actually, TCM as practiced now has only been around for 70-80 years. I like to point out that acupuncture started out as a treatment very similar to the much (and rightly disparaged) “traditional Western medicine” treatment of bloodletting, formerly using much larger lancets, rather than needles. Harriet Hall cited a memoir by a Scottish surgeon named Dugald Christie, who lived and worked in China as a missionary from 1883-1913, which described how brutal acupuncture was a mere 107 years ago. As for acupuncture? The fine filiform needles now used in acupuncture are a new “innovation” and date back to, at the earliest, the late 1920s, when a Chinese pediatrician named Cheng Dan’an (承淡安, 1899-1957) proposed that needling therapy be resurrected because (he thought then) its actions could be explained through neurology, which is why he also proposed moving the needling points away from blood vessels. He also replaced the previously used coarse needles with the fine filiform needles in use today, in part because he wanted to do acupuncture on children and babies. It’s amazing how even scientists who are skeptical that acupuncture has any value don’t know its true history and how that history has been extensively retconned.
But what does TCM say about COVID-19? Amazingly, there are TCM advocates who basically seem to be claiming that TCM embraced germ theory thousands of years before Pasteur was ever born, first claiming that TCM has been very successful throughout history in stopping epidemics:
The understanding of pestilence has been documented throughout the history of traditional Chinese medicine (TCM). These theories have evolved over time and played a significant role in epidemic control. Some examples of great creativity became the inspiration of modern medical breakthroughs, such as variolation for the eradication of smallpox, and the discovery of artemisinin for malaria. From 243 before common era (BCE) to 1949, China suffered at least 500 devastating epidemic diseases. Unlike the Antonine Plaque (165–180 BCE) and Spanish flu pandemic in 1918 that killed millions of lives, epidemic disease in the history of China had been contained soon after the outbreaks. Over time, these successful experiences contributed to an established system to infectious diseases intervention using herbal medicine, non-drug therapies, and numerous single or compound formulas or techniques, such as the well-known Artemisiae Annuae for malaria and the use of variolation for smallpox 14. In 2003, TCM and traditional medical physicians made a major contribution to combating SARS in China.
While it is true that variolation for smallpox is believed to have originated in China (albeit in a different form, the nasal insufflation of powdered smallpox scabs up the nostrils), the use of artemisinin for malaria was a triumph of modern techniques of pharmacognosy (natural product pharmacology), not TCM! Nor is there good evidence that TCM was of any value against SARS in 2002-2003, although the anecdotal claims of TCM efficacy for SARS then do remind me very much of the anecdotal claims of TCM efficacy for COVID-19 now, and Chinese data regarding TCM for COVID-19 are less than reliable.
These advocates further claim:
Traditional Chinese medicine shares similar understandings of infectious diseases with modern medicine. It believes that the emergence, outbreak and threat of infectious diseases are closely associated with three interactive factors—epidemic pathogens (pathogenic microorganism), living environment and host (human being, Fig. 1)
Most fundamental theories of traditional Chinese medicine are founded on the Huang Di Nei Jing (Yellow Emperor’s Inner Classic), an ancient Chinese medical text written in the 2nd century BCE. This text mentioned the idea of “prevention before disease occurrence”, and the strategies of “prevention of transmission after occurrence” and “prevention of recurrence after recovery”. The measures to “prevent before disease occurrence” include staying away from the source of infection, cutting off the route of transmission, minimizing the environmental impact on susceptible population, and building the body’s self-defending ability against pathogens. After disease occurrence, active measures need to be taken to prevent mild conditions from developing into severe or critical ones. It is also important to take precautions to prevent recurrence upon recovery.
Do I even have to point out that there’s no way that any society could have had such a sophisticated understanding of infectious disease in the 2nd century BCE, particularly given that the tools necessary to discover microorganisms weren’t developed until the 1600s CE. The claim that any ancient system of medicine had such an understanding of infectious disease over two thousand years ago is simply ridiculous.
But they have figures! Here’s a figure about about TCM versus COVID:
There’s even a timeline included allegedly showing the advances due to TCM in the fight against epidemic infectious disease:
Talk about revisionist history!
Do I need to point out that there is no good evidence that TCM is effective against SARS, MERS, or COVID-19? Or that the following explanation of how TCM supposedly works against COVID-19 is pure mystical pseudoscience:
In traditional Chinese medicine, the essential principles for disease prevention and treatment are to “reinforce healthy (anti-pathogenic) qi and remove pathogenic qi” and “treat diseases according to three categories of etiological factors”. To reinforce healthy qi requires regulating the body functions, achieving homeostasis, and maximizing the body’s self-defending ability. In addition to Chinese medicine decoction or patent medicine, nondrug intervention methods include acupuncture, tuina (Chinese therapeutic massage), qigong, mental adjustment and nutrition. To treat disease by three categories of three etiological factors requires the physician to conduct individualized precision intervention according to different timing, geographic region and population groups.
In practice, “individualized precision intervention” in TCM means making it up as you go along using ancient texts with a prescientific understanding of medicine and pathophysiology as a rough guide.
Meanwhile, Australian researchers warned about the use of TCM against COVID-19:
We wish to highlight significant concerns regarding the association between traditional herbal medicines and severe, non-infective interstitial pneumonitis and other aggressive pulmonary syndromes, such as diffuse alveolar haemorrhage and ARDS which have emerged from Chinese and Japanese studies particularly during the period 2017−2019. Initially the association between traditional herbal therapies and pneumonitis was based on isolated case reports. These included hypersensitivity pneumonitis associated with the use of traditional Chinese or Japanese medicines such as Sai-rei-to, Oren-gedoku-to, Seisin-renshi-in and Otsu-ji-to (9 references in supplemental file). Larger cohorts and greater numbers now support this crucial relationship. In a Japanese cohort of 73 patients, pneumonitis development occurred within 3 months of commencing traditional medicine in the majority of patients , while a large report from the Japanese Ministry of Health, Labor and Welfare, described more than 1000 cases of lung injury secondary to traditional medications, the overwhelming majority of which (852 reports) were described as ‘interstitial lung disease .
Currently the constituent of traditional herbal medicines which is considered most likely to underlie causation of lung disease is Scutellariae Radix also known as Skullcap or ou-gon, which has been implicated through immunological evidence of hypersensitivity as well as circumstantial evidence, being present in all of those medicines outlined above . Notably, skullcap is a constituent of QPD as used and described in the paper by Ren et al. relating to COVID-19 . Scutellariae Radix-induced ARDS and COVID-19 disease share the same characteristic chest CT changes such as ground-glass opacities and airspace consolidation, therefore distinguishing between lung injury due to SARS-CoV-2 and that secondary to TCM may be very challenging. The potential for iatrogenic lung injury with TCM needs to be acknowledged .
Morbidity and mortality from COVID-19 are almost entirely related to lung pathology . Factors which impose a burden on lung function such as chronic lung disease and smoking are associated with increased risk for a poor outcome. Severe COVID-19 may be associated with a hypersensitivity pneumonitis component responsive to corticosteroid therapy . Against this background the use of agents with little or no evidence of clinical efficacy and which have been significantly implicated in causing interstitial pneumonitis that could complicate SARS-CoV-2 infection, should be considered with extreme caution.
In conclusion, the benefits of TCM in the treatment of COVID-19 remain unproven and may be potentially deleterious. We recognise that there is currently insufficient evidence to prove the role of TCM in the causation of interstitial pneumonitis, however the circumstantial data is powerful and it would seem prudent to avoid these therapies in patients with known or suspected SARS-CoV-2 infection, until the evidence supports their use.
I’ve seen nothing to change my opinion about this issue, an opinion that agrees with the statement above.
TCM vs. COVID-19: Human rights violations, including forced use of quackery
So what we’re talking about in China now are human rights violations on a vast scale in response to COVID-19, including the forced use of government-sanctioned quackery to treat it:
Not all the recent outbreak measures in Xinjiang are targeted at the Uighurs and other largely Muslim minorities. Some are being enforced on China’s majority Han residents in Xinjiang as well, though they are generally spared the extrajudicial detention used against minorities. This month, thousands of Xinjiang residents took to social media to complain about what they called excessive measures against the virus in posts that are often censored, some with images of residents handcuffed to railings and front doors sealed with metal bars.
One Han Chinese woman with the last name of Wang posted photos of herself drinking traditional Chinese medicine in front of a medical worker in full protective gear.
“Why are you forcing us to drink medicine when we’re not sick!” she asked in a Aug. 18 post that was swiftly deleted. “Who will take responsibility if there’s problems after drinking so much medicine? Why don’t we even have the right to protect our own health?”
A few days later she simply wrote: “I’ve lost all hope. I cry when I think about it.”
One Han businessman working between Urumqi and Beijing told the AP he was put in quarantine in mid-July. Despite having taken coronavirus tests five times and testing negative each time, he said, the authorities still haven’t let him out – not for so much as a walk. When he’s complained about his condition online, he said, he’s had his posts deleted and been told to stay silent.
“The most terrible thing is silence,” he wrote on Chinese social media site Weibo in mid-August. “After a long silence, you will fall into the abyss of hopelessness.”
“I’ve been in this room for so long, I don’t remember how long. I just want to forget,” he wrote again, days later. “I’m writing out my feelings to reassure myself I still exist. I fear I’ll be forgotten by the world.”
“I’m falling apart,” he told the AP more recently, declining to be named out of fear of retribution.
He, too, is being forced to take Chinese traditional medicine, he said, including liquid from the same unmarked white bottles as the Uighur woman. He is also forced to take Lianhua Qingwen, a herbal remedy seized regularly by U.S. Customs and Border patrol for violating FDA laws by falsely claiming to be effective against COVID-19.
Meanwhile, there’s profit, of course:
The Chinese government’s push for traditional medicine, given free to Xinjiang residents, is bolstering the fortunes of billionaires and padding state coffers. The family of Wu Yiling, the founder of the company that makes Lianhua Qingwen, has seen the value of their stake more than double in the past six months, netting them over a billion dollars. Also profiting: the Guangdong government, which owns a stake in Wu’s company.
“It’s a huge waste of money, these companies are making millions,” said a public health expert who works closely with the Chinese government, declining to be identified out of fear of retribution. “But then again – why not take it? There’s a placebo effect, it’s not that harmful. Why bother? There’s no point in fighting on this.”
I beg to differ. First, placebo effects are not going to make it more likely that a person will survive a coronavirus infection. Second, note how he says it’s “not that harmful.” That means in some cases it is harmful. When there is no known benefit, but there is documented harm due to a medicine, then that medicine should not be taken or promoted. Sadly, though, he’s likely correct that it’s impossible to fight an authoritarian state like China forcing people to use quackery to treat a potentially deadly disease.
Finaly, although there are Chinese scientists who claim Lianhua Qingwen is effective against COVID-19 based on studies in cell culture (where have we heard that before…cough, cough, hydroxychloroquine), in fact there is no good clinical trial evidence to suggest that it is in humans, and I was amused to find a meta-analysis that’s just a framework, without much in the way of actual studies included, although it does have this risible explanation of how the remedy supposedly works:
Lianhua Qingwen formula is based on the theory of collateral disease, to reveal the law of transmission of respiratory infectious diseases caused by virus. The treatment strategy of “active intervention” is put forward, which includes the treatment of both exterior and interior, the treatment of syndrome first, the treatment of disease cutting off, the overall adjustment, and multitarget treatment. It was created on the basis of establishing the treatment method of “clearing away plague and detoxification, releasing lung and heat.” Based on treatise on Maxingshigan Decoction of “Febrile Diseases” and yinqiao powder of “Differentiation of febrile diseases,”, the prescriptions are composed to protect Qi and treat together, promote lung, and relieve heat. In addition, we learned from the experience of Rhubarb in the treatise on “Febrile Diseases” in the treatment of epidemic diseases. We first used Rhubarb to cure the disease, dredge the internal organs and relieve the heat, and then made Huoxiang fragrant and moistening. It is compatible with Rhodiola to clear lung and remove blood stasis. All the prescriptions are used to clear the toxic heat in the lung, clear the lung qi, and cut off the disease. The composition of Lianhua Qingwen granules is consistent with the pathogenesis of the disease. It embodies the active therapeutic principles of clearing away plague and detoxification, releasing lung heat, and aromatizing dampness.
Again, this justification is nonsense, based on a prescientific understanding of human physiology. Of course, it must be conceded that Lianhua Qingwen is an herbal concoction. So it is possible that there are actual drugs in the mixture that might have activity against COVID-19. However, aside from some in vitro evidence, there’s no good evidence from randomized controlled clinical trials that this compound is effective. In this, I’m very much reminded of the antimalaria drug hydroxychloroquine, which in the “West” has been promoted as a miracle cure for COVID-19.
However, as irresponsible as the promotion of hydroxychloroquine, azithromycin, and other unproven treatments for COVID-19 has been, apparently the Chinese are taking the promotion of unproven treatments one step further and force their use.