The conspicuous lack of scientific evidence underpinning the efficacy of traditional Chinese medicine remains a significant concern 

Natural is best. That’s what most of us believe – that’s what we’ve been led to believe. And yet, inundated with information, it’s often hard to decipher the facts from all the noise. Multibillion-dollar industries, propping themselves up with falsehoods, certainly do not help in this scenario. Authoritarian rulers, prestigious supranational organisations and pure financial might don’t either.

With China’s government behind it, there appears to be little that can get in the way of traditional chinese medicine’s expansion

But let’s back up for a moment. Traditional Chinese medicine (TCM) has been expanding at a notable rate as of late: in 2016, the sector grossed CNY 860bn ($130bn), then expanded a further 20 percent throughout 2017, according to China Daily. A similar pattern can be seen overseas, too: according to Nature, a weekly science journal, the selling of TCM and other related products to One Belt One Road countries has surged. Between the years 2016 and 2017, exports experienced a whopping 54 percent growth to $295m. Indeed, according to the National Centre for Biotechnology Information, China exported TCM to 185 countries and regions around the world in 2016, with $526m worth exported the US alone – making up 15 percent of China’s annual TCM exports at the time.

There are a number of reasons behind this swelling demand. First, there is the inevitable convergence of TCM and other global-facing trends, such as wellness and organic foods. Increasingly prevalent and powerful, common rhetoric these days advocates the ingestion of pure, natural ingredients, as opposed to artificial, chemical compounds. The conversation almost equates to a stark debate of good versus evil: the honest farmer versus the big bad corporation; gentle herbs versus toxic substances, and so on.

As this conversation continues to gather momentum, industry players have happily jumped on the bandwagon. One such market is TCM, but its story is far more complex than one simply related to a growing awareness about wellbeing.

Making a case
There are some powerful arguments in favour of TCM. Of particular note is artemisinin, an antimalarial drug that has played an instrumental role in reducing malaria-related mortality worldwide. It was first discovered in 1972 by Chinese professor Tu Youyou, who, as part of a secret government operation, was on the search for Chinese herb recipes with antimalarial properties. Winning the Nobel Prize in Physiology or Medicine in 2015, artemisinin arguably marks China’s most significant contribution to global health.

Then there’s aspirin, one of the cheapest, most widely used painkillers on the planet. This drug, with its analgesic, anti-inflammatory and anti-pyretic properties, is derived from willow bark – or, more specifically, its key ingredient, salicylic acid. First used by the ancient Egyptians and further espoused by the father of modern medicine, Hippocrates, willow bark has also been used in TCM for thousands of years.

More recently, traditional Chinese remedies have inspired some fascinating work. For example, Dr Paul Iaizzo, Professor of Surgery, Integrative Biology and Physiology at the University of Minnesota, is using artificial bear bile (bear bile being a common ingredient in TCM) to improve the success of organ transplants. “If we use a preconditioning of delta opioids, fatty acids or even some of the bile acids, we show improved function immediately after reanimation and for extended periods,” he told World Finance. This work could be a game-changer for organ transplants.

These examples – among others – make for persuasive vindication. Surely if these gems have been found among the troves of TCM, there must be others too.

Pressure from above
The Chinese Government – specifically, President Xi Jinping – is consciously driving the expansion of the TCM market at present. This became all too clear in a speech he gave in spring 2018, during which he also outlined plans to stay on as premier indefinitely. According to sources familiar with the matter, he devoted at least half an hour of his speech strictly to TCM, and explained there was no need to test the efficacy and toxicity of such treatments. The president also revealed a key stratagem in the market’s global expansion: the opening of some 300 TCM centres in various countries around the world. Domestic TCM centres, meanwhile, continue to attract more visitors to China, effectively becoming medical tourism hotspots. Since 2002, for example, some 50,000 foreigners (the majority being from Russian-speaking nations) have visited Sanya, a city in China’s Hainan province, for TCM treatments.

Clearly, there is a strong financial incentive for promoting TCM around the globe. And this is all the more pronounced given China’s recent economic slowdown, which has seen GDP growth drop to levels not seen since the 1990s (see Fig 1).

Moreover, Xi’s TCM ambitions have a strong political component. Dr Donald Marcus, Professor of Medicine and Immunology Emeritus at the Baylor College of Medicine, told World Finance: “He’s pushing it very hard for two reasons. One, he’s on a campaign to promote China as a great power and a source of all kinds of wonderful cultural and scientific things. He’s also facing the same problem that Chairman Mao faced, which is that they don’t have enough western-trained doctors to take care of a huge Chinese population, so they’re promoting the idea that TCM is just as good.” He added: “So it’s part of this nationalism push, but also, they’re making a lot of money with it.”

Africa, a continent that has a growing dependency on China, is one of the main targets for China’s plans. Africa is the perfect market for TCM. Like China, it suffers from a shortage of western-trained doctors and medical centres, leaving many – particularly those in remote, rural areas – with little access to healthcare. TCM offers a solution to this problem, as it’s far cheaper than western medicine. Furthermore, it does not require anything like the same level of training for practitioners.

In less developed nations that are unable to provide western medicine to sprawling populations, TCM can make for very profitable business. It also acts as a means for giving individuals the impression that they are being treated, when in reality, this is not quite the case.

“Insofar as it is being adopted, the impetus to try comes from clever marketing and does not come from any evidence whatsoever that TCM is scientifically sound or medically effective,” said Dr Steven L Salzberg, Professor of Biomedical Engineering, Computer Science and Biostatistics at Johns Hopkins University. Sadly, by using TCM, unknowing patients are less likely to seek proven treatments, which could in turn worsen their respective ailments. But this tragic tale does not end there.

Natural-born killer
Aristolochic acid, which is derived from aristolochia, a large plant genus, is a common ingredient that has been used in Chinese herbal remedies for thousands of years. Following an outbreak in the Balkans in the late 1950s, it was discovered that not only does aristolochic acid trigger nephropathy, or kidney failure – it can also cause cancer. “The International Agency for Research on Cancer has said it’s one of the most potent carcinogens in humans, but what we didn’t know until this century was just how big a problem it is in places like China and Taiwan, where aristolochic acid is used,” Marcus told World Finance.

Aristolochic acid is the embodiment of the dangers that alternative medicines pose

“Several studies that were done in Taiwan and China in this century found that close to 50 percent of kidney tissues from patients with kidney failure or cancer had the molecular signature of aristolochic acid nephropathy,” Marcus explained. “Those data indicate that tens of millions of people in Asia are at risk for aristolochic acid nephropathy.”

While many websites in China once brandished warnings about the dangers of aristolochia, it has been noted that within just weeks of Xi’s aforementioned speech, they had all disappeared. But how is it that more is not being said overseas? With this question comes another, perhaps more worrying, player in this increasingly conspiratorial story.

Affirming the illusion
Last year, the World Health Organisation (WHO) revealed that, by 2022, TCM would be included in its 11th International Statistical Classification of Diseases and Related Health Problems. According to the organisation’s website, the document is “the diagnostic classification standard for all clinical and research purposes”. The work also sets the healthcare agenda for more than 100 nations worldwide.

For China’s burgeoning TCM market, this is massive news. It marks the first time that TCM will be recognised by an international body with the prestige of the WHO. It also sets a scene wherein TCM is more commonly used as ‘acceptable’ treatment for various diseases.
And yet, there is little to no evidence of the effectiveness, or even simply the safety, of many of the treatments offered by TCM. This is all the more surprising given the high standard of testing that the WHO usually requires.

When asked what the WHO could possibly be thinking with such an extraordinary divergence from its standard procedures, Salzberg answered: “The WHO’s endorsement of TCM seems to be the culmination of a campaign by one person – its former director – who mistakenly believes (or seems to believe) that TCM is real medicine.” He is referring to Margaret Chan, who was director of the WHO between 2006 and 2017. “I don’t understand her motives, but scientifically speaking, she’s mistaken.” The WHO did not respond when contacted by World Finance.

The WHO’s Traditional Medicine Strategy 2014-2023 confirms the organisation’s backing of TCM and its integration into health systems around the world. To this end, the WHO recommends that member states ensure reimbursement mechanisms are in place and insurance companies are fully aware.

Among the scientific community, it is widely acknowledged that aristolochia is a powerful carcinogen, which can also cause irreversible kidney damage. But despite the fact that around 400 papers attesting this had been published by 2014, there is not a single mention of aristolochia in the WHO’s strategic report from the same year.

Aside from Xi’s assertion that TCMs need not be tested, as well as the WHO’s glaring omission, matters are made even worse by the fact that labels on TCM products are often incomplete, failing to list all ingredients included. This is particularly worrying given the ubiquity of aristolochia and its horrendous side effects. Back in 2012, a study by Murdoch University was carried out on 15 TCM samples seized by Australian customs. Testing found that the samples contained 68 plant families, including aristolochia and another poisonous herb, ephedra. On all samples, there was a clear lack of labelling with regards to these ingredients and their concentrations. “We also found traces from trade-restricted animals that are classified as vulnerable, endangered or critically endangered, including the Asiatic black bear and saiga antelope,” lead scientist Dr Mike Bunce stated at the time. A more recent study could not be found, which only further emphasises the lack of testing in the field.

Smoke and mirrors
Despite the dearth of scientific evidence verifying the effectiveness of many TCMs, such treatments have numerous advocates around the globe. Of course, among them are those with a clear financial reason for supporting the market, but there are also countless individuals that anecdotally attest to the wonders of TCM. Now, in the case of ingredients such as willow bark, there is plenty of scientific evidence to confirm its effectiveness, but for hundreds upon hundreds of others, there simply is not. So, how can we explain the success stories of those without financial incentives?

Without testing and standardisation of natural ingredients, the room for error is simply too great

The placebo effect plays a central role. Up until the 19th century, few medicines and herbal remedies actually worked. Nevertheless, when people met with medical practitioners, their symptoms soon subsided. While prescribed treatments were thanked, the nature of symptomatic illness means that they often improve even without medication.

Placebos are extremely powerful. Just the expectation of improvement upon having seen a doctor can lead to an easing of symptoms, or even a reduction in pain. In fact, a study by Dr Jon Levine from the University of California in the 1980s found that the typical placebo effect is comparable to an 8mg dose of morphine. This phenomenon goes a long way in explaining why, for centuries, so many people experienced improvements after taking TCMs, despite the lack of actual scientific evidence to corroborate their effectiveness.

As for the ingredients that have been proven to be effective, here comes another revealing factor in the case against TCM: referring to artemisinin and Taxol, an anti-cancer medication derived from the yew tree, Marcus told World Finance that “the crude extracts of both do not work very well”. He continued: “So in order to get them to work and be useful, they had to be purified, characterised and standardised.”

He also points to digitalis, a plant genus used to treat congestive heart failure and atrial arrhythmias. “When I was starting my medical career as a young physician a long time ago, we were using crude extracts of digitalis… [It] was a nightmare because it wasn’t standardised, so the content varied all over the place and had a very narrow range of safety. And beyond that, it caused hair-raising toxicity and even fatalities.”

Without testing and standardisation of natural ingredients, the room for error is simply too great. Any single component in a plant can vary enormously in concentration from year to year – even when grown in the same place. This painfully came to light with digitalis and its active ingredient, digoxin: only when digoxin is extracted and manufactured as a pure chemical can it be used safely and effectively.

Marcus added: “There’s nothing mysterious about what the active ingredients of herbal remedies are. They are chemicals, just like the chemicals that we use for prescription drugs. They have the same potential for causing a variety of good effects and bad effects, so if the belief that natural medicines are in some mysterious way different from purified prescription medications and that they’re safer, it’s totally wishful thinking.”

Follow the science
Today, many of us believe that natural must be best, but this is simply not the case when it comes to medicine. As Salzberg explained: “We now have treatments and even cures for a host of ailments that no one could treat centuries ago. Thus if you’re sick, you want to get the latest,
science-based treatment. Selling people on the idea that ancient practices are somehow superior – in the absence of any real evidence – may cause people to suffer unnecessary pain and even permanent disability.” But there are powerful engines in play to make us believe otherwise, for there are billions of dollars to be made from alternative therapies. Accordingly, the market is now expanding at a rapid rate, not just in western countries among educated, high-income individuals, but also in developing nations as a far cheaper option for proper medical care.

Aristolochic acid is the embodiment of the dangers that alternative medicines pose. Unfortunately, however, in the battle for global health, the opposing side has a great deal at stake. In addition to the formidable financial incentives for growing the TCM market, there are strong political motivations also. Indeed, it would seem that TCM is currently being used as a political tool – a marker of China’s growing prestige and authority around the globe. The WHO’s worrying actions seem to attest to this.

But the science speaks for itself. “If a treatment works, it’s medicine. If it doesn’t work, it’s something else. Labelling it as ‘traditional’ or ‘alternative’ or ‘holistic’ (to name a few) doesn’t make a practice legitimate,” said Salzberg. In the case of TCM, the wheels are already in motion: with the weight of China’s government behind it, there appears to be little that can get in the way of the market’s expansion. Our only hope, as always, rests with education. With greater awareness about the dangers of aristolochic acid – and, indeed, the threat of using alternative medicines in place of proven treatments – perhaps we might just be able to stop this market from growing to epidemic proportions.