I must admit that, these days, a lot of the topics for this blog show up on Twitter, such as when I see a link to a news story, health claim, editorial, or scientific study Tweeted. So it was when I saw this story on CNN, Chinese medicine gains WHO acceptance but it has many critics. The first thought I had when reading the article was that Chairman Mao Zedong must be smiling from beyond, wherever he is, because the World Health Organization’s acceptance of TCM into the eleventh version of its International Classification of Diseases (ICD-11). I’ll explain why in a moment. First, here’s the story:

Herbal remedies have been used by healers around the world for centuries to prevent and treat disease. But it’s in China that the practice has been most extensively used and documented. Advocates have campaigned to integrate Traditional Chinese Medicine into mainstream global health care and those long-standing TCM efforts have paid off: The World Health Assembly, the governing body of the World Health Organization, on Saturday formally approved the latest version of its influential global compendium, which includes a chapter on traditional medicine for the first time. However, not everybody is happy with the controversial move. Some in the biomedical community say WHO overlooked the toxicity of some herbal medicine and the lack of evidence it works, while animal rights advocates say it will further endanger animals such as the tiger, pangolin, bear and rhino, whose organs are used in some TCM cures. In a strongly worded editorial, Scientific American magazine called the move “an egregious lapse in evidence-based thinking and practice.”

I’ve discussed WHO’s plan to integrate a section on TCM in the ICD-11 twice now, going back over a year before now, which is when I first heard of the scheme. I should have been aware of it long before that, to be honest, given that the development of ICD-11 has been in the works since the 1990s and had undergone field testing in 2017. So now the World Health Assembly has made the International Classification of Traditional Medicine (ICTM) officially part of the ICD-11.

World Health Organization and ICD-11

You can tell that even WHO is a bit sheepish regarding this new addition to the ICD-11 just by seeing the outright dissembling WHO representatives engage in when asked about it:

While traditional medicine originated in ancient China, today it’s widely used throughout Asia, including in Japan and Korea, and it took the WHO more than a decade to get representatives from Asian countries to condense thousands of years of knowledge into one neat classification system. Tarik Jasarevic, a spokesman for WHO, said traditional medicine diagnosis is poorly documented or not documented, and its inclusion in the ICD will “link traditional medicine practices with global norms and standard development.” However, he added the inclusion of traditional medicine was “not an endorsement of the scientific validity of any Traditional Medicine practice or the efficacy of any Traditional Medicine intervention.”

I rarely use language that rises to even PG-13 level, but I’m sorry. This is pure, unadulterated bullshit. Of course WHO’s inclusion of TCM diagnoses as formal codes in the ICD-11 confers the impression of scientific validity to the diagnoses! That’s exactly why China has been lobbying for this development for so long! Once ICD-11 is adopted, TCM quackery and science-based medical diagnoses will be featured side by side. Sure, the ICTM is not (yet) co-equal with the regular diagnoses in the ICD-11. For now, it is “optional.” Indeed, Chapter 26, the chapter of ICD-11 covering TCM, states, “This supplementary chapter is a subclassification for optional use. This chapter is not intended for mortality reporting. Coding should always include also a category from the chapters 1-24 of ICD.” Anyone want to bet how long that disclaimer will hold, particularly with China pushing so hard for normalization of TCM?

This brings us to why I entitled this post “Mao Triumphant.” It goes all the way back to the beginnings of Communist China under Chairman Mao Zedong. For, you see, Mao was the true originator of TCM. Indeed, the very history of TCM was retconned, beginning with Chairman Mao and continuing to this day, to produce a revisionist history in which there is one unified system of “traditional Chinese medicine,” complete with a clear philosophical basis and scientific support, rather than the real situation. In reality, there was no such thing as “traditional Chinese medicine.” Rather, there were traditional Chinese medicines. For many centuries, healing practices in China had been highly variable. Attempts at institutionalizing medical education were mostly unsuccessful and “most practitioners drew at will on a mixture of demonology, astrology, yin-yang five phases theory, classic texts, folk wisdom, and personal experience.” Mao realized that TCM would be unappealing to foreigners, as even many Chinese, particularly those with an education, understood that TCM was mostly quackery. For instance, in 1923, Lu Xun realized that “Chinese doctors are no more than a type of swindler, either intentional or unintentional, and I sympathize with deceived sick people and their families.” Such sentiments were common among the upper classes and the educated. Indeed, as we have seen, Mao himself didn’t use TCM practitioners. He wanted scientific “Western” medicine. The same was true of educated Chinese. It still is.

Mao’s strategy to deal with these criticisms and thus popularize TCM was quite deliberate—and clever. It consisted of two strategies, both designed to mythologize TCM as being a scientifically sound and harmonious “whole medical system” and to provide “evidence” in the form of testimonials that it worked. The second part of his strategy was to disseminate the most spectacular anecdotes he could find to “prove” that TCM works. The most famous of these was the case of James Reston, a New York Times editor who underwent an emergency appendectomy while visiting China in 1971. As I’ve related about Reston before, the surgeons there used a fairly standard anesthetic technique, as related by anesthesiologist Kimball Atwood. As I’ve described before (albeit not recently), acupuncture was used to treat Reston’s cramping on second evening after the surgery, which I interpreted as being the evening of postoperative day one. This clinical scenario is familiar to any general surgeon. About a day and a half after surgery Reston had some cramping, likely due to postoperative ileus that kept the gas from moving through his bowels the way it normally does. It passed after an hour or so. Around that time, the staff at the hospital used acupuncture to treat his discomfort, and the logical fallacy known as post hoc ergo propter hoc fallacy (and a bunch of credulous Westerners, eager to believe that some magical mystical “Eastern” wisdom” could do what “Western medicine” could not) did the rest. Most likely what happened is that Reston finally passed gas spontaneously (which is how postoperative ileus nearly always resolves), letting the built-up gas move through and relieving the cramps and bloating. About a day or two after an uncomplicated appendectomy is about right for that.

In any event, basically, Mao didn’t have enough trained physicians to take care of his people. So he decided to promote TCM to fill in the gaps. In addition, he instructed his medical and scientific authorities to begin a campaign to “integrate” TCM into medicine, thus originating “integrative medicine” 40 years before it became a thing in the US in the late 1990s. Again, Kimball Atwood has the story in his epic “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I, Part II, Part III, Part IV, and Part V) for the detailed version. Of particular interest to students of “integrative medicine” is Part III, in which Dr. Atwood has an entire section entitled “From ‘Co-operation’ to ‘Integration,'” in which he lists the five main party slogans about TCM from the late 1940s through the 1950s:

1945-50 ‘The Co-operation of Chinese and Western Medicines’

1950-8 ‘The Unification of Chinese and Western Medicines’

1950-53 ‘Chinese Medicine studies Western Medicine’

1954-8 ‘Western Medicine studies Chinese Medicine’

1958- ‘The Integration of Chinese and Western Medicines’

Unification, integration, it’s all the same thing, and it’s something that Mao had been working for since the late 1940s, although, pointedly, Mao did not use TCM himself:

Mao was under no illusion that Chinese medicine—a key component of naturopathic education—actually worked. In The Private Life of Chairman Mao, Li Zhisui, one of Mao’s personal physicians, recounts a conversation they had on the subject. Trained as an M.D. in Western medicine, Li admitted to being baffled by ancient Chinese medical books, especially their theories relating to the five elements. It turns out his employer also found them implausible. “Even though I believe we should promote Chinese medicine,” Mao told him, “I personally do not believe in it. I don’t take Chinese medicine.”

That didn’t stop Mao from promoting TCM as part of his plan to extend his healthcare resource sand also, it should be noted, out of a nationalistic pride in TCM. Indeed, nationalistic pride in TCM is a big reason why the Chinese government still promotes TCM, as the CNN article correctly notes:

Chinese leaders have been lobbying for the move. For them, it’s a huge win and the push has come right from the top: When President Xi Jinping visited WHO headquarters for the first time in Geneva in 2017, he brought along a bronze statue showing acupuncture marks on the body. The country has been promoting TCM on the world stage, both as away to burnish its global image and influence, and for a slice of a growing market internationally. In China, TCM is worth $130 billion, according to the country’s State Administration of Traditional Chinese Medicine.

It’s also about the money, of course.

I wrote about a law passed by China over two years ago that was custom-designed to promote TCM, both in China and throughout the world. According to the law, county-level governments and above must set up TCM institutions in public-funded general hospitals and mother and child care centers. As I put it at the time, what the Chinese government did then was the equivalent of a situation in which the German government mandated homeopathy clinics because homeopathy was invented by a German and is therefore a “national treasure” for its “unique theories and practices” (I was quoting the Chinese government) or if Greece mandated the opening of clinics utilizing the four humors theory to treat disease because Hippocrates taught humoral theory, making it a “national treasure” for its “unique theories and practices.” Of course, humoral theory is not so unique; it resembles TCM quite a bit in the basic concepts underlying it. While it’s true that the new law also mandated tighter regulation of TCM practitioners, regulating magic never works.

The end goal:

To this end, the new law said China puts TCM and Western medicine on equal footing in China, with better training for TCM professionals, with TCM and Western medicine learn from each other and complementing each other. The state will support TCM research and development and protect TCM intellectual property. Special protection will be given to TCM formulas that are considered state secrets, it said. Use of technology and expansion of TCM in dealing with emergency public health incidents and diseases prevention and control should increase. The state will protect medical resources including protection and breeding of rare or endangered wildlife, the law said. The law went on to pledge enhanced supervision of raw TCM materials, banning the use of toxic pesticides.

If you think that the acceptance of TCM diagnoses as part of the ICD-11 by WHO is not a major victory for China in legitimizing TCM on the world stage, I have a couple of bridges I’d be willing to sell you. It’s the sort of thing Mao could only have dreamed about, which is why China lobbied so hard for this change in the ICD-11 over so many years. Remember, in China, TCM is big pharma. It’s a favored industry, with state protection and promotion. Indeed, a year and a half ago, China took even more steps to promote TCM, including exempting traditional Chinese medicines from the requirement to pass safety and efficacy trials in humans in China, as long as manufacturers prepare ingredients using essentially the same method as in classic Chinese formulations. Never mind that the Chinese themselves are not nearly as enamored of TCM as China’s leaders. The educated among them recognize it for the quackery that it is.

Meanwhile, “Western” medical journals are falling all over themselves to prostitute themselves to TCM interests. For instance, Nature published an advertising supplement on traditional Asian medicine paid for by a Japanese supplement manufacturer, in essence shilling for TCM. Science hasn’t been immune either. It published a three-part series of supplements arguing for the “integration” of TCM with science-based medicine. In another example, the European Atherosclerosis Society published a cringe-inducing article arguing for the validity of TCM as a treatment for atherosclerosis. Meanwhile, TCM propagandists have done everything they could to misrepresent a recent Nobel Prize as a triumph for TCM rather than a triumph of standard old boring pharmacognosy, or natural products pharmacology.

Now, Mao’s efforts have been rewarded, nearly 70 years after he started promoting TCM as co-equal with science-based medicine. The WHO has provided us with diagnostic codes like:

SD70 Qi goiter disorder (TM1) : “A disorder characterized by diffuse swelling at both sides of the thyroid commonly soft with normal skin colour, sometimes accompanied by nodules. It may be explained by depression of liver system qi, qi stagnation, or yang deficiency, yin deficiency, or heat in the liver or heart systems, disharmony of the thoroughfare and conception meridians, or drinking contaminated water with associated accumulation of phlegm and qi in the throat.”

: “A disorder characterized by diffuse swelling at both sides of the thyroid commonly soft with normal skin colour, sometimes accompanied by nodules. It may be explained by depression of liver system qi, qi stagnation, or yang deficiency, yin deficiency, or heat in the liver or heart systems, disharmony of the thoroughfare and conception meridians, or drinking contaminated water with associated accumulation of phlegm and qi in the throat.” SD71 Wasting thirst disorder (TM1) : “A disorder characterized by increased thirst, excessive eating and increased urination with glycosuria, as well as by potential emaciation. It may be explained by factors which deplete yin fluids in the lung, spleen or kidney systems and generate fire and heat in the body, such as improper food intake, febrile disease, exhaustion, emotional factors.”

: “A disorder characterized by increased thirst, excessive eating and increased urination with glycosuria, as well as by potential emaciation. It may be explained by factors which deplete yin fluids in the lung, spleen or kidney systems and generate fire and heat in the body, such as improper food intake, febrile disease, exhaustion, emotional factors.” SD86 Dementia disorder (TM1) : “A disorder characterized by impairment or loss of intellectual capacity or personality. It may be explained by age related deficiency of qi and blood, blood stasis and a build up of turbid phlegm obstructing brain function, mental disturbance, or brain damage.”

: “A disorder characterized by impairment or loss of intellectual capacity or personality. It may be explained by age related deficiency of qi and blood, blood stasis and a build up of turbid phlegm obstructing brain function, mental disturbance, or brain damage.” SD87 Repressed fire disorder (TM1): “A disorder characterized by sensation of heat, stuffiness, dry mouth, anxiety, depression, irritability, headache, dizziness, loss of appetite, or epigastric distension. It may be explained by chronically repressed anger inducing mental and physical symptoms.”

Yes, thanks to WHO, we’re “integrating” diagnoses based on magic and prescientific concepts of how the body works into the system that’s been used for decades to categorize illnesses. Yes, if there’s an afterlife, Mao is smiling. If there isn’t, his descendants and the Chinese government are, not to mention the Chinese traditional medicine industry.