Monday, 18 January 2016

World can gain from more TCM research: Lee Wei Ling

By Lee Wei Ling, Published The Sunday Times, 17 Jan 2016

Doctors might be asked to express their view of traditional medicine from time to time. It can be a sensitive subject as traditional medicine tends to be bound up with a philosophical system.

Consequently, cultural chauvinism might surface, as during discussions about national healthcare systems. This was evident in reactions to the award of the 2015 Nobel Prize in medicine, half of which went to China's Tu Youyou. She was recognised for extracting an effective anti-malarial drug, artemisinin, from sweet wormwood.

There is no question that she deserves her Nobel award as artemisinin is the most effective anti-malarial drug now available. But I am ambivalent about the impact of the award because it might lead laymen to believe traditional Chinese medicine (TCM) is more effective than it actually is.

Indeed, the Nobel committee had stressed that it was not giving a prize to traditional medicine but for specific scientific work inspired by it. This contradicts what Chinese Premier Li Keqiang said when he hailed her discovery as an example of the "great contribution of TCM to the cause of human health".

The extent to which chauvinism and vested interests can rise even here is illustrated by what was faced by Singapore's father of paediatrics, Professor Wong Hok Boon. In the late 1970s, Prof Wong, publicly stated that to ingest TCM is equivalent to eating grass. Soon after that, he received death threats. Prof Wong took the threats seriously enough to accept the presence of security officers who accompanied him publicly for a couple of weeks.

As a scientifically trained doctor, I have always tried to dissuade my patients from turning to TCM for many reasons. First, TCM, until recent years, generally does not adopt a scientific approach to illness and the medicines do not usually target specific illnesses. Second, faith in TCM often has cultural roots and is not based on clear evidence of its efficacy.

TCM champions argue that it is unlikely for no effective medicines to emerge after five thousand years of continuous Chinese civilisation. Even my father was inclined to believe this. My reply to Papa was: "Life is cheap in China."

A cultural bias can also lead to contradictions. Professor Volker Scheid of London's University of Westminster, who studied TCM for 30 years, said: "I would say 95 per cent of Chinese would think I cannot be a very good TCM practitioner because I am not Chinese, but, at the same time, China wants to make Chinese medicine global."

I personally think TCM is unreliable (regardless of who the TCM practitioner is) because it lacks a scientific basis. Most times, it could be just hocus-pocus.

The basis of TCM is not about human biology, as we know it. It postulates that the human body contains a life force called qi. And illness is the result of imbalances between the five elements - fire, water, earth, metal and wood. None of this has ever been proven but, to believers, that is irrelevant.

Nobel laureate Tu's achievement is that she chemically extracted the active ingredient of a single plant in isolation. Such extraction is absent when a TCM shop prepares doses from a variety of plant and, occasionally, animal sources. No one knows the active ingredient at work, the concentration of such substances, or the presence of active components that are detrimental to health. But instructions on how to prepare and take the herbal brew, combined with folklore and cultural belief, can give the patient a false sense of security.

Every now and then, our Health Sciences Authority issues a statement of caution warning the public that certain batches of TCM medicines have been tested and found to contain lead or arsenic. Both these substances are toxic and dangerous to humans.

In 1980, I accompanied my parents on Papa's second official visit to China. The wife of the Chinese official accompanying us on that trip was a doctor trained in TCM and Western medicine. She told me that spine X-rays of a patient with back pain often show excess bone on the spinal column (spondylosis), a problem common in older people which may or may not cause back pain.

According to her, after practising qigong for some time, the X-rays of patients revealed no excess bone. She had published her findings in a Chinese medical journal. This is totally unbelievable, since qigong cannot cause bone to disappear. What is possible is that the patient did have back pain (which may or may not have been due to spondylosis) and the qigong, as a form of exercise, helped to reduce the back pain.

Many TCM practitioners sell hope. I will never forget a 10-year-old old girl whom I saw with brainstem glioma (brain tumour). When I told her parents the prognosis was grim in her case, they asked around and found a TCM practitioner who assured them that if he treated the girl, there was a 30 per cent chance of a cure.

I tried to dissuade them from taking this route but her father said: "He offers me a chance for hope, how can I not try it?" A few weeks later, the parents brought the patient back to see me because her condition had deteriorated due to the natural progression of the disease. The father was $20,000 poorer by then (this was in the 1980s when $20,000 represented a large sum of money). TCM did not lead to adverse effects but my treatment would have somewhat relieved the patient of suffering, although Western medicine could not change the natural course of the disease.

TCM physicians claim that, unlike Western medicine, TCM works gently and gradually. Western drugs are said to be too powerful and abrupt in their action. This situation makes it difficult for patients to know whether the medicine is effective, and also difficult for science to establish if the medicine works. When patients delay seeking proper treatment by seeing TCM physicians instead, that delay could have detrimental consequences.

TCM often uses herbs, and practitioners claim what they prescribe is natural and works like a general tonic, unlike a drug that specifically targets certain organs or certain diseases. Examples are ginseng and cordyceps.

Laymen, as a rule, connect "natural" with "safe". But remember that nature did not evolve to serve mankind. For example, digoxin, which is used in treating heart disease, was first obtained from the leaves of a digitalis plant. But it certainly can be fatal in overdose.

Quite a few TCM practitioners might add effective Western medicine to their "natural" prescription. For an asthmatic, they might include a corticosteroid such as prednisolone. That will indeed improve the asthma and make the patient put on weight. Both are desirable outcomes for the mother of a patient. But there are other important negative effects to health when ingesting excessive amounts of certain substances.

Although I am cynical about TCM, I am not saying all TCM treatments are ineffective. What the world can benefit from is research into the active components of each particular TCM medicine and into how it works. By doing so, we can more precisely identify what agents are effective and test their wider application as well as their side effects. In studying the mechanism of action of the active agent, we will gain valuable knowledge of the pathogen as well as how the human body reacts towards the pathogen.

I do not reject TCM but I feel patients deserve better care than the way TCM is currently applied. I also hope researchers will be able to learn more about the benefits possible from TCM medicines. Whatever the form of medicine, ultimately what matters is that patients are helped to recover and risks to them are minimised.

TCM - cultural practice or valuable science?
By Justin Lee, Published The Straits Times, 8 Feb 2016

Once associated with musty medical halls frequented by the older generation of Chinese, traditional Chinese medicine (TCM) now has a larger base of believers.

It's been given a boost by the Nobel Prize in medicine being awarded last year to China's Tu Youyou for extracting the anti-malarial drug artemisinin from sweet wormwood. Also, last December, Singapore Athletics signed a one-year deal worth $280,000 with a TCM company so that its athletes can use TCM treatments for strains and aches.

Singa Charity Medical, a new TCM clinic near Little India, said it has started to serve patients beyond its usual Chinese base.

Biomedical interest in TCM has fuelled a slew of clinical trials attempting to establish the efficacy of various TCM procedures and herbs. But there are doctors schooled in orthodox medical practice who remain circumspect.

In a recent op-ed in The Straits Times, Dr Lee Wei Ling, senior adviser to the National Neuroscience Institute, argued that there should be more research to establish the efficacy of TCM interventions. Patients desperate for a cure may seek alternatives to Western medicine and end up paying a lot of money for treatments that do not work. Her concern as a doctor and a scientist is a dose of healthy scepticism about untested treatments. What can TCM advocates and practitioners do about this?

Patients and mainstream medical institutions are increasingly open to TCM.

Medical research centres such as the UCLA Centre for East-West Medicine, founded in 1993, have long espoused the virtue of "integrative medicine" that blends modern Western medicine with TCM. In Singapore, the Nanyang Technological University offers a double degree in TCM and biomedical science that was started back in 2005. A number of public hospitals already have TCM operators co-located on their premises, with some hospitals themselves providing TCM interventions. For example, the National University Hospital operates an acupuncture clinic under its Department of Rehabilitation Medicine.

Despite such signs, TCM is far from being fully integrated into the biomedical mainstream. According to medical researchers Kelvin Chan and Zou Jian-Xiang, in a book titled The Way Forward For Traditional Chinese Medicine, many orthodox medical health professionals who practise acupuncture and have seen patients benefit from it have dispensed with, or even ignored, TCM concepts. These health professionals are happy to mine TCM interventions if they prove to be effective, but have little interest in the alternative etiology, that is, causal explanations utilising traditional concepts such as "qi" which refers to the "life force" of one's body.

In fact, scientific research into TCM has aimed to identify the "actual" biochemical basis for the observable effects of its treatments, and replaced traditional concepts with biochemical processes. For example, some have argued that an oft-used TCM concept - the "imbalance of yin and yang" - which is used to describe an imbalance between the complementary energies that make up "qi", can be better understood using the more precise and developed biological concept of homeostasis that regulates a body's internal environment in response to external conditions to maintain stability.

So far, only academics are interested in this issue - with advocates saying that TCM is grounded in a keen observation of the body while those who are critical say Western medicine continues to evolve while Chinese medicine is "pre-scientific" and based on superstition. However, these unresolved questions about the scientific status of TCM have urgent policy implications for the organisation of healthcare in Singapore. Should we have a dual-track healthcare system whereby TCM operates parallel to Western medicine? Or should we seek to integrate TCM with biomedicine?

Besides throwing up herbs and interventions for testing and therefore cooptation by the biomedical establishment, does TCM also offer a useful approach to healing that should be preserved?

The solution to the uncertain status of TCM is not to wait for the outcomes of academic debates. The TCM community can muster collective will to decide its own fate. It can learn from alternative healing practices that have now become part of mainstream medical care, namely chiropractic treatments, and those that have not, such as ayurveda.

Chiropractic treatments are now seen as semi-legitimate. For this to happen, chiropractors had to restrict claims about the scope and efficacy of such techniques and allow results to slowly speak for themselves. More importantly, they discarded the spiritualist language from chiropractic therapy's "metaphysical heritage". Early chiropractors believed that disease was caused by interruptions in "innate intelligence", a life force that represented God's presence in man that occupied the spine. Today, some general practitioners even make referrals to chiropractors.

Contrast this to ayurveda, an Indian healing practice that has decided to position itself as a cultural and religious practice. In the United States, ayurveda's ideology has gradually shifted from a "medical" to a "metaphysical" emphasis. As a cultural practice, ayurvedic practitioners do not have to be scrutinised by the standards, tests and regulations required of scientific medicine.

TCM can either adapt to the institutionalised rules and requirements of scientific medicine, or it can theorise itself as a cultural practice. For some time now, TCM has occupied and benefited from this strategically ambiguous position. But with TCM increasingly being seen as a medical option, its practitioners should learn the language of science and incorporate knowledge of modern Western medicine into their professional education.

Nobel Prize winner Tu Youyou has been lauded for having the empirical knowledge of TCM and the scientific training of biomedicine. But we cannot rely on individuals or pockets of pro-TCM Western doctors and researchers to unify medical knowledge.

The TCM community as a whole should collectively learn the language and methods of science and gradually discard its cultural or metaphysical roots. This is because the diversity of culture adds richness to our experience, but in science, it is the unity of knowledge that matters.

Justin Lee is a research fellow at the Institute of Policy Studies. He studies issues relating to society and identity, including how groups on the peripheries adapt and professionalise themselves.

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