Of all the forms of unproven and disproven alternative medicine being enthusiastically "integrated" into science-based medicine by proponents of "integrative medicine" (formerly—and sometimes still—known as "complementary and alternative medicine," or CAM), so-called "traditional Chinese medicine" (TCM) is clearly among the most popular and seemingly the most accepted. After all, acupuncture, the most famous modality in the TCM armamentarium, is offered in dozens of academic medical centers and hundreds of medical centers in the US, but it goes beyond that. It doesn't matter that the totality of science and evidence, when critically examined, strongly supports the conclusion that acupuncture is nothing more than, as Steve Novella and David Colquhoun put it, a "theatrical placebo," with no detectable difference in effect compared to sham or "placebo" acupuncture. As I like to point out periodically, just twirling toothpicks on the skin produces equivalent perceived relief of back pain to acupuncture, overhyped and publicly discussing the use of "cupping" quackery to enhance their performance, thereby glamorizing it. Oh, sure, occasionally a drug derived from an herb used in TCM will be found to be useful for something, leading to TCM proponents to argue that this finding vindicates TCM, when in fact it's far more a triumph of pharmacognosy (natural products pharmacology) than a vindication of TCM. None of this stops academic medical centers from embracing TCM, as, for example, the Cleveland Clinic did when it set up a TCM clinic and hired an herbalist, which appears to have served as a prelude to its hiring Dr. Mark Hyman and embracing functional medicine, an effort that, unfortunately, has been wildly successful. Thanks to the specialty dubbed "integrative medicine" by its proponents (and more appropriately called "integrating quackery with medicine" by skeptics), you can find articles in the scientific literature discussing qi (life energy) and its flow through acupuncture meridians or diseases as deficiencies or imbalances in hot/cold or dry/wet as though there were actual scientific validity to them.

What many people don't realize, even skeptics, is that the "integration" of TCM into scientific medicine is not new. It was the realization of Chairman Mao Zedong's dream. Apparently it still is. I was reminded of this earlier this month by an article in Bloomberg entitled "Traditional Medicine Won't Cure China's Ills." It's based on a story published by Chinese media, "China adopts law on traditional medicine." Basically, China adopted a law to provide TCM a larger role in the Chinese health care system, in essence legislating the "integration" of TCM with science-based medicine.

A brief history of the "integration" of traditional Chinese medicine into "Western" medicine

I've written in detail before about how Chairman Mao and his medical authorities in Communist China more or less invented what we know today as TCM and how this history has in essence been retconned into the narrative we hear today about how TCM represents "ancient knowledge" and how acupuncture is thousands of years old. (Never mind that the technology to make such thin needles didn't exist two thousand years ago, and that, as recently as a century ago, acupuncture was a brutal and primitive, using nothing like the thin, shiny needles acupuncturists use today.) If you want the detailed account, check this post out. For purposes of this post I'll provide the CliffsNotes version, beginning with this quote by Chairman Mao:

Our nation’s health work teams are large. They have to concern themselves with over 500 million people [including the] young, old, and ill. … At present, doctors of Western medicine are few, and thus the broad masses of the people, and in particular the peasants, rely on Chinese medicine to treat illness. Therefore, we must strive for the complete unification of Chinese medicine. (Translations from Kim Taylor’s Chinese Medicine in Early Communist China, 1945-1963: A Medicine of Revolution .)

And, more pertinently:

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.”

Yes, the exportation of TCM to the world was quite deliberate, as part of a strategy to popularize it among the Chinese. There was a problem, however. There was no such thing as “traditional Chinese medicine” per se. 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. TCM is far less popular among educated middle class and affluent Chinese than conventional medicine.

Mao's strategy to deal with the criticisms of TCM of being prescientific and chock full of vitalistic and superstitious nonsense was quite 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” that it worked. In other words, his health officials did their best to "scientize" it. Textbooks were written that portrayed TCM not as a wide variety of disparate folk medicine traditions, but rather as a harmonious theoretical and practical whole, with the contradictions and self-contradictions in the "classic" texts papered over and pounded into a self-consistent system. Terms such as “holism” (zhengtiguan) and “preventative care” (yufangxing) were used to provide the new system with appealing foundational principles, principles that are now standard fare in arguments about the benefits of alternative medicine. This version of TCM was taught in newly founded academies and exported to the West.

The second part of the strategy was to provide spectacular anecdotes that appeared to demonstrate that TCM worked. 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. This story, it turned out, was very much overblown. In fact, the surgeons there used a fairly standard anesthesia technique, described by our SBM colleague Kimball Atwood as sounding like a “standard regional technique, most likely an epidural,” and acupuncture was used to treat cramping on second evening after the surgery, which, not surprisingly, resolved, as most postoperative ileus does. Over time, more reports of "acupuncture anesthesia" trickled out of China to a credulous, enthusiastic Western press. Let's just say that, examined critically, these stories are not convincing, and some examples have been cataloged by Kimball Atwood in his “Acupuncture Anesthesia”: A Proclamation from Chairman Mao series (see Part I, Part II, Part III, Part IV, and Part V for the details).

Mao's vision was nothing less than the "integration" of TCM into "Western medicine," as discussed by Atwood through the listing of five party slogans about TCM:

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

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

‘The Unification of Chinese and Western Medicines’ 1950-53 ‘Chinese Medicine studies Western Medicine’

‘Chinese Medicine studies Western Medicine’ 1954-8 ‘Western Medicine studies Chinese Medicine’

‘Western Medicine studies Chinese Medicine’ 1958- ‘The Integration of Chinese and Western Medicines’

Mao’s idea was nothing less than the complete unification of TCM and “Western” medicine, as quoted by Kimball Atwood further from The Private Life of Chairman Mao :

Mao laughed. ‘The theory of yin and yang and the five elements really is very difficult,’ he said. ‘The theory is used by doctors of Chinese medicine to explain the physiological and pathological conditions of the human body. What I believe is that Chinese and Western medicine should be integrated. Well-trained doctors of Western medicine should learn Chinese medicine; senior doctors of Chinese medicine should learn anatomy, physiology, bacteriology, pathology, and so on. They should learn how to use modern science to explain the principles of Chinese medicine. They should translate some classical Chinese medicine books into modern language, with proper annotations and explanations. Then a new medical science, based on the integration of Chinese and Western medicine, can emerge. That would be a great contribution to the world.’

Clearly, we at SBM disagree.

2016: China mandates the integration of Chinese and "Western medicine"

Fast forward to the end of 2016:

China's top legislature on Sunday adopted a law on traditional Chinese medicine (TCM) to give TCM a bigger role in the medical system. The Law on Traditional Chinese Medicine was approved at the end of a seven-day session of the National People's Congress (NPC) Standing Committee which concluded on Sunday afternoon. Huang Wei, deputy director of the NPC Standing Committee commission for legislative affairs, said the law, which will go into effect on July 1, 2017, is a significant step in the development of TCM. It is key to reform of medical and health sectors and the drive toward a "Healthy China." According to the new law, county-level governments and above must set up TCM institutions in public-funded general hospitals and mother and child care centers. Private investment will be encouraged in these institutions. All TCM practitioners must pass tests. Apprentices and previously unlicensed specialists with considerable medical experience may only begin practice when they have recommendations from at least two qualified practitioners and pass relevant tests. With a history of more than 2,000 years, TCM is seen by many as a national treasure in China for its unique theories and practices, such as herbal medicine, acupuncture, massage and dietetics. This is especially the case since Tu Youyou won the 2015 Nobel Prize for her work using artemisinin to treat malaria.

Argh! See what I mean? This is exactly what I was talking about when I pointed out how TCM apologists always point to various medicines that were derived from herbs used in TCM as validation of TCM even when they aren't. They also tend to forget all the hundreds of other TCM herbs that have never been shown to have medicinal properties. I'd also argue that TCM is no more a "national treasure" of China than humoral theory is to any nation in Europe. The two do, after all, share many characteristics, not the least of which is the belief that disease is due to an "imbalance" of various things. In humoral theory, it's imbalances in the four humors. In TCM, it's imbalances in the five elements. In both systems of medicine, vitalism is largely the basis of the concepts that undergird them.

In any case, what the Chinese authorities have done is the equivalent of, say, German authorities mandating homeopathy clinics because homeopathy was invented by a German and is therefore a "national treasure" for its "unique theories and practices" or if, say, 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.

It turns out that TCM has continued to benefit from the policies that Mao instituted to favor it. As Adam Minter observes, TCM is a favored state industry, and the traditional medicines pharmaceutical industry raked in $114 billion in 2015 and represents nearly 29% of China's pharmaceutical industry. In China, TCM is big business. The TCM herbs and concoctions thus sold were dispensed by 452,000 practitioners working out of tens of thousands of clinics—many no more than single-room storefronts.

The law, while mandating the "integration" of TCM into conventional medicine in China (or at least its government support), does increase the regulation of those who practice TCM, but it does so in a way that elevates the status of TCM:

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.

Putting TCM (and all of CAM) on "equal footing" to science-based medicine is what CAM proponents have been striving for all along. It's a large part of the reason why "alternative medicine" was renamed "CAM" and then, more recently, renamed "integrative medicine." As I've described before, "alternative" implied that it isn't real medicine (which the vast majority of alternative medicine is not), and "complementary" implied that standard science-based medicine was the main medicine, and the "complementary" medicine (like TCM and other "alternative medicines") were merely the "icing on the cake," not as important as conventional medicine and, worst of all, not strictly necessary. Renaming the specialty "integrative medicine" and implying that this new specialty "integrates the best of both worlds" were intended to counter that perception and put the woo on equal footing with scientific medicine, just as Mao tried to do nearly 70 years ago and the current Chinese government is trying to do now.

One also can't help but notice that a lot of this new law goes towards protecting the business interests of the TCM industry in a manner that, if it were done for the pharmaceutical company, would provoke howls of outrage from CAM proponents—and rightly so. Worse, the part about "protecting and breeding" of rare or endangered wildlife implies to me that the government will promote the preservation and utilization of these animals for their various body parts that are, barbarically, used in TCM concoctions. For example, we've discussed before how cruelly bears are confined and operated on in order to harvest bear bile for various TCM treatments. We've also discussed how the market for animal parts for TCM remedies is endangering animals and could lead to extinctions as the TCM industry seeks tiger penis and rhinoceros horns to mix into their nostrums. It might well be a good thing if the Chinese government steps in to protect tigers and rhinos, but nothing in this law seems to say anything about ceasing the use of such animal components.

The one good thing about China's new law

The only potentially good thing about the law is the regulation of toxic ingredients. As Minter notes:

This lack of oversight extends to the thriving industry of traditional pharmaceuticals. Last year, a team of scientists found that nearly 90 percent of TCM remedies marketed in Australia contained undeclared ingredients, including antibiotics and decongestants, heavy metals such as lead and arsenic, and a range of plant and animal matter -- not least, the DNA of endangered snow leopards. The situation is almost certainly worse in China, which lacks Australia's (clearly inadequate) screening procedures. A 2013 Greenpeace study found pesticides in 51 of 65 popular herbal remedies marketed in TCM shops in China and Hong Kong. In one case, contamination levels were 500 times the European Union's accepted safety limit. It's impossible to calculate the human toll of shady TCM practices, but there are hints. Several recent studies have found that herbal remedies are the leading cause of drug-induced liver failure in China, accounting for as much as 43 percent of all cases. The problem is equally severe in other countries where TCM is rapidly expanding: Herbal remedies may account for up to 40 percent of drug-induced liver injuries in South Korea and 55 percent in Singapore.

We've discussed this problem before multiple times on SBM (e.g., this discussion of contamination of TCM medicines with heavy metals). If China is going to permit and even encourage the TCM industry, at the very least it has a duty to make sure that the products its companies are selling are not dangerous. This is a duty that Chinese government has thus far failed miserably to live up to, a failure that has been documented on more occasions than I can recount. It is long past time that the Chinese government remedied that failure. I am not, however, optimistic that it will actually do so.

The real cost of traditional Chinese medicine in China and beyond

The law passed by the Chinese government last week is nothing new. China has been trying to "integrate" its prescientific system of national medicine that was cobbled together from various conflicting and internally inconsistent folk medicine traditions ever since Chairman Mao first hatched the idea after the end of World War II. Indeed, as a white paper published by the Chinese government a month ago (no doubt as a justification for the recently passed law), the promotion of TCM by the Chinese government did not end with the death of Chairman Mao in 1976. For example, here's what's been happening lately:

Since the CPC’s 18th National Congress in 2012, the Party and the government have granted greater importance to the development of TCM, and made a series of major policy decisions and adopted a number of plans in this regard. At the National Conference on Hygiene and Health held in August 2016, President Xi Jinping emphasized the importance of revitalizing and developing traditional Chinese medicine. The CPC’s 18th National Congress and the Fifth Plenary Session of the 18th CPC Central Committee both reiterated the necessity to pay equal attention to the development of traditional Chinese medicine and Western medicine and lend support to the development of TCM and ethnic minority medicine. In 2015, the executive meeting of the State Council approved the Law on Traditional Chinese Medicine (draft) and submitted it to the Standing Committee of the National People’s Congress for deliberation and approval, intending to provide a sounder policy environment and legal basis for TCM development. In 2016 the CPC Central Committee and the State Council issued the Outline of the Healthy China 2030 Plan, a guide to improving the health of the Chinese people in the coming 15 years. It sets out a series of tasks and measures to implement the program and develop TCM. The State Council issued the Outline of the Strategic Plan on the Development of Traditional Chinese Medicine (2016-2030), which made TCM development a national strategy, with systemic plans for TCM development in the new era. These decisions and plans have mapped out a grand blueprint that focuses on the full revitalization of TCM, accelerated reform of the medical and healthcare system, the building of a medical and healthcare system with Chinese characteristics, and the advancement of the healthy China plan, thus ushering in a new era of development for TCM.

Two of the goals are:

Equal attention to TCM and Western medicine. Equal status shall be accorded to TCM and Western medicine in terms of ideological understanding, legal status, academic development, and practical application. Efforts shall be made to improve system of administration related to TCM, increase financial input, formulate policies, laws and regulations suited to the unique features of TCM, promote coordinated development of TCM and Western medicine, and make sure that they both serve the maintenance and improvement of the people’s health. Making TCM and Western medicine complementary to each other, and letting each play to its strengths. The state encourages exchanges between TCM and Western medicine, and creates opportunities for Western medical practitioners to learn from their TCM counterparts. Modern medicine courses are offered at TCM colleges and universities to strengthen the cultivation of doctors who have a good knowledge of both TCM and Western medicine. In addition to the general departments, TCM hospitals have been encouraged to open specialized departments for specific diseases. General hospitals and community-level medical care organizations have been encouraged to set up TCM departments, and TCM has been made available to patients in the basic medical care system and efforts have been made to make it play a more important role in basic medical care. A mechanism has been established for TCM to participate in medical relief of public emergencies and the prevention and control of serious infectious diseases.

Now there's a waste of money and effort, using TCM to participate in medical emergencies and the prevention and control of serious diseases. It sounds as though, like homeopaths without borders, there will soon be TCM practitioners without borders. Battlefield acupuncture, anyone? Oh, wait. That's not China. That's the US. One wonders if China is getting ideas from the countries to which it exported TCM to consider using acupuncture and TCM in the emergency department.

Aside from the destruction of endangered species, the poisoning of the unwary by adulterated and contaminated TCM herbs, and the degradation of the science of medicine where TCM is "integrated," there is the opportunity cost of investing in TCM. As Minter notes, TCM sucks up billions of dollars that could be better spent on China's regular health care system, which, he also notes, is "badly lagging." Chinese hospitals are overburdened and underfunded, and there is a shortage of pediatricians that even the government-run press is calling "urgent." Ironically, the reason for this shortage is very similar to the reason why primary care specialties are unattractive in the US. Chinese medical students don't want to become pediatricians because of long hours and low pay; more lucrative specialties such as ophthalmology or cardiology, are much more attractive. One student even says, "In China, we say 'Ophthalmology is gold, the surgical department is silver, and pediatrics is rubbish'. Some of my classmates have pointed out that pediatricians only earn half the average salary of other specialist doctors." Instead of investing hundreds of millions of dollars in TCM, China would do better to bolster its science-based medical system.

On the other hand, remember why Mao promoted TCM: To save money. He didn't have the resources to provide real medicine to all of his people. China in 2017 has the resources, but chooses not to invest them that way. Instead, as its white paper says, China's goal is this:

China will learn from the achievements of modern civilization, uphold the principle of making the ancient serve the contemporary, and strive to promote the modernization of TCM by making every effort to carry on the good traditions and practices of Chinese medicine, and promote the innovative development of TCM for health preservation, so that TCM will be incorporated into the modern outlook on health to serve the people. By 2020, every Chinese citizen will have access to basic TCM services, and by 2030 TCM services will cover all areas of medical care. Meanwhile, China will also actively introduce TCM to the rest of the world, and promote the integration of TCM and other traditional medicine with modern technology, so as to explore a new model of healthcare to improve the well-being of all people of the world, and make a full contribution to global progress and a brighter future for mankind.

This policy is virtually indistinguishable from the one Chairman Mao instituted in the 1950s. The main difference is that this time, it goes much further, in particular to protect the profits of the Chinese traditional pharmaceutical industry, which was not nearly as large or international in Mao's time.

Don't believe me? Listen to Huang Wei, deputy director of the NPC Standing Committee commission for legislative affairs, who puts it this way:

"The new law on traditional Chinese medicine will improve global TCM influence, and give a boost to China's soft power," Huang said.

Yes, the Chinese government is working to complete Chairman Mao's vision by the year 2030, in part to project China's "soft power." If supporters of SBM think it was tough to combat the propaganda promoting TCM before, now we have one of the most powerful nations in the world, one with the second largest economy in the world, stating that its goal is the integration of its favored national quackery with science-based medicine. Our task is about to get a whole lot more difficult.

If there is an afterlife, somewhere, Chairman Mao is smiling.