JOHN DWYER. The extraordinary determination of China to have the world embrace its traditional medicine. (Part 3 of 3.)Oct 19, 2018
The artemisia annua plant has been used for centuries in China to fight malaria. In 2011 a Chinese scientist, Tu Youyou, discovered how to extract the ingredient responsible for the anti-malarial effect (now called Artemisinin) and her reward was a Nobel Prize. Where there is good anecdotal evidence that something in a herb or plant can help with certain diseases, it’s more than appropriate for modern scientific techniques to be used to try and identify, purify and standardise the responsible chemical. This has nothing to do with the concepts associated with Traditional Chinese Medicine (TCM). Many of the drugs we use today are derived from plants thought to have medicinal properties in numerous cultures.
TCM relies on the “cocktail” approach. Individual patients are given mixtures of as many as 20 different herbal extracts that the practitioner thinks is right for that individual patient. As all illness is caused by interruption to the flow of Qi, TCM focuses on symptom relief. The expectation is that one or more ingredients in the cocktail might help! The approach is different when it comes to using animal parts. Specific bits of a specific animal help with a number of problems. Tigers, bears, snakes and the rhinoceros are particularly valuable. Recently I was in Vietnam and while discussing health care in that country with local doctors I was told that the Vietnamese are the world’s biggest users of rhinoceros horn. There is no public health system in Vietnam and many poor people who cannot access private health care spend money they can ill afford on rhinoceros horn which they are told can cure cancer.
The application of TCM in western countries, however, requires some adjustment to traditional thinking as patients will be disease-orientated. So the websites of TCM practitioners make claims for the successful treatment of many diseases including serious conditions such as rheumatoid arthritis, cancer, AIDS and depression. What follows is a litany of failures to protect consumers from false advertising and expensive, largely useless treatments.
The embracing of TCM in our trade agreement with China and the realisation that treatments had a high incidence of serious side effects led to a government decision to add TCM to the list of health professions supervised by AHPRA. That organisation established a Chinese Medical Board and practitioners would need to be registered, as are doctors, nurses, pharmacists etc, having met the educational requirements specified by the Board. All the AHPRA Boards demand that their registrants advertise services in accord with the “National Law” which specifies that claims made must be based on credible scientific studies. In the case of TCM, so poor is the available data to meet that requirement that the Board specified that the data relied upon must have been generated in the last five years. One could argue that strict adherence to that policy would all but disenfranchise the profession. As with all of the health boards, however, the current legislation governing their work has one fatal (sometimes literally) flaw. Boards can tell registrants what they cannot advertise but have no control over what they actually do (“scope of practice”). Currently AHPRA is reviewing more than 400 Australian websites where claims for TCM seem to breach the standard required.
Another layer of consumer protection is meant to flow from the Australian Therapeutic Goods Administration (TGA), supposed to safeguard the health of Australians through “effective and timely regulation of therapeutic goods”. This organisation also demands that there is credible evidence to support the claims made for therapeutic products. In reality the authority has never been good at fulfilling its mandate and recent government-endorsed changes will make matters worse. The TGA is funded by the pharmaceutical industry, creating an enormous conflict of interests. Under enormous pressure from the pharmaceutical industry, particularly the manufacturers of “supplements” and “Alternative and Complementary” medicines, the TGA will allow products to be sold that are not supported by scientific studies but are used according to “Tradition”. So on more than 1000 TCM products you may find nonsense claims such as “harmonises middle burner”, “unblock/open/relax meridians”, “balance Ying and Yang” and “helps healthy liver regeneration”. Despite pleas from scientific, medical and health consumer organisations the TGA will not follow the lead of the FDA in the United States and warn consumers on a product label that “there is no scientific data to support the claims made”.
TCM has a poor safety record so that the risk to benefit ratio should be unacceptable . China itself reported that in 2014 there were 230,000 reports of adverse reactions made to its Adverse Drug Reaction monitoring authority. TCM features three physical interventions to improve the harmony between Ying and Yang: Moxibustion, “Cupping” and Acupuncture. Moxibustion is the burning of mugwort over acupoints. (Mugwort is a member of the daisy family, related to ragweed and, like ragweed, a common cause of hay fever. It is also used in food and was used in beer before hops was discovered.)
Practitioners use either “direct” or “indirect” moxibustion. In direct moxibustion, a small, cone-shaped amount of mugwort is put on an acupuncture point and burned. This direct moxibustion is further divided into scarring and non-scarring. With scarring moxibustion, the mugwort or “moxa” is placed on an acupuncture point and burnt until it causes blisters and scarring, what we in medicine would call a deep-partial-thickness second degree burn! With non-scarring moxibustion, the burning moxa is removed before it burns the skin. With indirect moxibustion, a moxa cigar is held over the skin until the area turns red. A recent reviewer commented: “How a second degree burn could be helpful for any process, much less mythical qi, mystifies me”.
Many Australian TCM websites claim that moxibustion can turn a breech baby. Mugwort is burned beside the outer corner of one fifth toenail then the other. A review of all the available well conducted studies by the Cochrane Collaborative, a world wide association of experts in evidence based medicine, concluded, not surprisingly, that it did not work. Australian obstetricians warn that attempts to turn a breech baby should only be attempted in a hospital setting. In any case about 90% of babies in the breech position manage to turn themselves around without any intervention. Which brings us to Acupuncture.
TCM holds that along the meridians (channels) through which flow Qi, blockages can occur and if that blockage occurs at specific points (acupoints) specific symptoms will develop. By needling these acupoints (acupuncture) flow can be restored and symptoms relieved. A number of such points may need simultaneous stimulation. Here I can only summarise careful scientific evaluation of the technique and report that there is no convincing evidence that acupuncture can influence any disease process or alter body functions such as the release of hormones. It is however a superb theatrical placebo with many recipients saying that they have experienced benefit albeit short lived. Turns out that the same effect is noted if one uses toothpicks instead of needles with no difference noted with the anatomical spot chosen for stimulation. Indeed if the practitioner tells you the same effect can be obtained by just pressing on acupoints (acupressure) then the placebo effect is activated. Scientific medicine has studied placebo effects (which are generated by a range of techniques wherein the subject believes benefit is likely; everything from the laying on of hands to taking sugar pills) and we know that physiological changes occur. Effects are not sustained of course and cause of a disease is not affected. The deliberate use of the placebo effect, which necessarily involves deceiving a patient, is regarded as unethical by the medical profession.
Many millions of tax-payer dollars are spent each year subsidising acupuncture therapy. Despite credible scientific studies showing that acupuncture does not increase a woman’s chance of conceiving, claims to the contrary are made on hundreds of websites and acupuncture is offered at many fertility clinics. Scam merchants even offer it for cosmetic improvements.
In 2002, accepting the advice of Chinese doctors, the WHO endorsed the claims that acupuncture was “clinically proven to be effective in the management of more than 90 diseases and disorders”. The endorsement was and is used by hundreds of practitioners of TCM in Australia to support their practice. This despite the fact that when scientific studies of the claims found them to be false, the WHO withdrew its recommendations and the Chinese Medical Board of Australia ordered TCM registrants to stop saying that acupuncture was supported by the WHO. They did not say that acupuncture provided nothing but a placebo effect.
Tragically (I don’t use the word lightly) the politicisation of the WHO becomes ever more obvious. Margaret Chan, who led the organisation for the last decade, was a strong promoter of Chinese medicine and recently with much pressure from China, the WHO has accepted that Traditional Medicine should have equal footing with Western Medicine in the struggle to have universal access to health care. Operationally the WHO is a treasured resource; think of the struggle to contain the Ebola virus and its success in minimising the spread of AIDS. But how disturbing to see this great agency succumb to political pressure and endorse a policy that signals its retreat from the gold standard that is evidence-based medicine.
John Dwyer, Emeritus Professor of Medicine at UNSW, is the President of “Friends of Science in Medicine”, an organisation championing the need for credible scientific evidence of effectiveness to underpin health care in Australia.