Earlier this year, the World Health Organization (WHO) included a chapter on traditional medicine in its International Classification of Diseases (ICD) for the first time – in what many perceived to be a boon to traditional Chinese medicine (TCM).
The ICD is an influential document. In the WHO’s own words, “ICD is increasingly used in clinical care and research to define diseases and study disease patterns, as well as manage health care, monitor outcomes and allocate resources.” Its impact spans more than 100 countries. While the WHO maintains that traditional Chinese medicine is not endorsed by its inclusion in the ICD, and that its inclusion merely represents an opportunity for “optional dual coding” (i.e. integrating traditional Chinese medicine and allopathic medicine into a treatment regimen), it was not perceived that way by many – including traditional Chinese medicine practitioners themselves.
Traditional Chinese medicine: A centrepiece of Chinese healthcare
As a Nature editorial put it, “TCM practitioners around the world have celebrated its incorporation into the document as crucial for the international spread of the system. So has China. On 26 May, a government newspaper called it a “major step for TCM’s internationalisation” and a tremendous help in establishing TCM centres around the world.”
For many years, traditional Chinese medicine has been promoted by the Chinese government at home and abroad. A 2000 Lancet editorial wrote of traditional Chinese medicine as “a fully institutionalised and government-supported part of the Chinese health-care system, with the same legal status there as western biomedicine. It delivers almost forty percent of total healthcare [services] in contemporary China. Like biomedicine, TCM in China is predominantly hospital based. Besides almost 3,000 dedicated hospitals, over 95 percent of western medical hospitals also have fully-fledged Chinese medicine ward.”
In the almost two decades since, traditional Chinese medicine remains big business in China and beyond. It is worth US$130 billion in China, home to 3,966 TCM hospitals and 45,528 TCM clinics as of 2015, as well as being a US$60 billion+ global industry spanning 180 nations. Many have expected the WHO decision to fuel the industry’s growth.
TCM’s inclusion in the ICD: Criticism and concerns
For the medical and scientific communities, the inclusion of traditional Chinese medicine in the ICD was an error. “The World Health Organization Gives the Nod to Traditional Chinese Medicine. Bad Idea” read the headline of a Scientific American editorial, calling the decision “an egregious lapse in evidence-based thinking and practice. Data supporting the effectiveness of most traditional remedies are scant, at best…while it’s a good idea to catalogue TCM and make health workers aware of treatments used by millions, their inclusion in the ICD recklessly equates them with medicines that have undergone clinical trials.”
A further bone of contention surrounding the WHO’s decision was the prospect of a risk to endangered species – including in India – as some traditional Chinese medicine practitioners use animal body parts such as tiger bones and rhino horns in their remedies (even as many bodies devoted to TCM practices have outlawed their use). Some feared that the perceived legitimation of traditional Chinese medicine by the WHO could even offer encouragement to poachers.
“Today, the tiger, pangolin, bear, rhino and other species are poached for their organs that are used in TCM to treat ailments from arthritis to epilepsy to erectile dysfunction,” said the Environmental Investigation Agency. “Wild cats, in particular, are under threat, and the threat is increasing dramatically due to TCM and the demand it has created for ever-higher volumes of wild animal parts. With fewer than 4,000 tigers left in the wild, there is growing evidence that poachers have now set their scopes on lions, jaguars and other big cats.”
India is home to almost 3,000 tigers – representing seventy percent of the world’s tiger population. As such, the risk of poaching in the country is real and regular. “We already know that TCM uses animal products, such as rhino horns, pangolin scales and so on,” Indian conservationist and Forest Service official Parveen Kaswan told Asia Times when the WHO issued its recognition of traditional Chinese medicine. “Recognising that as a legitimate thing will certainly increase their demand. After all that is the very purpose behind recognition of such ancient medicines. We cannot quantify the increase in pressure on these products,” he said, but “obviously the whole process will increase illegal wildlife trade.”
Between 1994 and 2016, the Asia Times report adds, as many as 1,110 tigers were poached in India as well as 4,831 leopards. This could well be an underestimate, however, as “the Customs authorities multiply known offenses by ten to estimate the size of an illegal trade.”
Promotion of alternative medicine: Not just in China
Traditional Chinese medicine refers to a broad set of techniques and remedies aimed at promoting the health of the individual, dating back millennia. Whilst undeniably popular, and a crucial segment of China’s medical tourism industry, an evidence-based approach to all medical treatments for the sake of the health of the individual is imperative.
India is no stranger to the promotion of traditional medicine. Its Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) stands as testament to this. The same is true of plans for a considerable expansion of AYUSH health infrastructure throughout the country.
Such systems of medicine have much in common with traditional Chinese medicine and TCM practices such as cupping therapy are promoted by some AYUSH practitioners in India – with the AYUSH Ministry even proposing that practices such as cupping therapy be covered under the Centre’s health insurance scheme Ayushman Bharat.
Why traditional Chinese medicine needs to be regulated
With the promotion of traditional Chinese medicine at the global level, and its inclusion in the ICD, doctors are calling for its regulation. On Thursday, a joint statement of the European Academies’ Scientific Advisory Council (EASAC) and the Federation of European Academies of Medicine (FEAM) was issued calling for such a measure and criticising more broadly the inclusion of the system of medicine in the ICD.
“We don’t give drugs and surgical treatments unless there is real evidence that they work and do no damage and basically the feeling is that most of the traditional Chinese medicine drugs are unregulated,” said FEAM president Professor George Griffin. “They are not tested properly for toxicity. They probably vary greatly between batches produced, for example seaweed, which is the latest, and they may be harmful. The other side of the equation is that they may be deluding patients into thinking they are taking appropriate therapies for serious disease.”
Concurring, Royal Swedish Academy of Sciences president Professor Dan Larhammar said “just because the World Health Organization includes a chapter on Traditional Chinese Medicine in its new International Classification of Diseases, it is not automatically safe to use without robust evidence.”
Larhammar did acknowledge “examples where some Traditional Chinese Medicine has undergone thorough preclinical investigation and proven in rigorous clinical trials to contribute significant health benefit – e.g. artemisinin therapy for malaria.” As such, “there may be more leads to diagnosis and therapeutic benefit yet to be discovered, but this can in no way mean that other claims can be accepted uncritically.”
Of the potential legitimisation of traditional Chinese medicine, former Professor Jos van der Meer acknowledged that “it may not be the intention of the WHO to legitimise and encourage the use of Traditional Chinese Medicine without substantial evidence being available.” However, van der Meer said, “but the inclusion in the new diagnostic coding will encourage proponents to push for market uptake.” This could be at the expense of wellbeing: “some traditional Chinese medicine can have serious side effects and interactions with other treatments. Moreover, patients may be at risk that severe diseases are treated ineffectively and conventional medical procedures delayed.”
Similar investigative rigmarole to ensure patient safety and investigate the efficacy of alternative and traditional medicine treatment ought to be encouraged in India. With the growing popularity of alternative medicine in the country – and it becoming a centrepiece of the country’s expanding medical tourism sector – heightened vigilance is essential.
Will the sector itself be resistant to such scrutiny? Earlier this year, an advisory note from the AYUSH Ministry disavowed allopathic researchers from investigating such therapies unless an AYUSH practitioner contributes. This prompted the condemnation of scientists. As Health Issues India contributor and neuroscience graduate Nicholas Parry wrote in an op-ed, “such a prospect undermines the scientific process. Any guise of impartiality is lifted and only those with a vested interest will, under the recommendation of the AYUSH Ministry, be even allowed to publish information on the matter unless working in tandem with AYUSH researchers.”
The same is true of traditional Chinese medicine. Rigour must applied to investigating its efficacy, making the EASAC and FEAM call necessary and one the scientific community in India should echo. At a time when traditional and alternative systems of medicine are growing in their influence, standards must be enforced and practitioners and therapies must be held to account for the sake of public welfare and the population’s health.