Challenges and Thoughts About the Integration of Traditional Chinese Medicine (TCM) and Western Medicine

I recently read an article in Science [Science 346 (6216 Suppl) 2014] about the integration of TCM and Western medicine. In response, I would like to propose the following: TCM and Western medicine have different strengths and independent approaches to understanding and explaining health and disease, and therefore, they have the potential to be complementary. They are in no way mutually exclusive. Nobody will argue with the fact that in an emergent life-threatening situation, the best place to be is in a state-of-the-art American hospital. Western medicine excels at saving lives. TCM excels at treating non life-threatening, subacute and chronic conditions. These two types of medicine use their own sophisticated approaches to reaching a diagnosis and treatment plan. Not all TCM is easily understood in Western medicine parameters. Attempting to identify and isolate active ingredients in formulas is a challenging and potentially rewarding scientific endeavor that could create an improvement in the Western understanding of herbal function. However, if we discard the formula and use the active ingredient(s) only, we will lose the great strengths that define TCM—the systems-based whole-body approach, the balance and safety profile created by the combination of the herbal ingredients, including those not considered primary in function. The goal of TCM research should therefore be to further the understanding of herb function, not to generate pharmaceutical drugs based on the active ingredients.

TCM has a 2,000-year-old history of "medicine based on research evidence" which is "long-established existing medical traditions, supplemented by individual pieces of research" 1 compared to a 100-year-old history of Western medicine that is shifting to "evidence based medicine" which is "based upon the…use of current best evidence, evaluated by a systematic process, in making decisions about the care of individual patients."2 A lot of evidence used in these evaluations is generated from large studies called Randomized Controlled Trials (RCT), where investigators attempt to eliminate variables as much as possible and test new interventions on a study group.

The classic cornerstones of TCM such as the Yellow Emperor’s Inner Classic, (Divine Husbandman’s) Classic of Materia Medica, and Discussion of Cold Damage and Essentials from the Golden Cabinet were all written by the third century. Modern texts that students of TCM study today, such as Bensky’s Materia Medica and Formula and Strategies, use the above-named classics as their point of departure. Bensky states that "even contemporary material medica— our book included—quote from this text [Classic of Materia Medica] to describe some of the functions of various herbs." Regarding Zhang Zhong-Jing's Discussion of Cold Damages and Essentials from the Golden Cabinet, Bensky states "over 150 (about one-quarter) of the formulas in our book, which were selected from texts written during the past 1,800 years, are drawn directly from these works by Zhang Zhong-Jing." These individual pieces of research comprise years’ worth of carefully written observational case studies on the progression of disease, both favorable and unfavorable, and the use of acupuncture and herbal medicine in treating disease. Furthermore, the functions of herbs, individually and together in formulas, is elaborated upon extensively.

Nowadays doctors of TCM in China graduate from TCM medical schools; in which the curriculum includes extensive studies of biomedicine, and TCM. The concept of biomedical disease equivalents and active ingredients in herbal products is standard. Many textbooks are dedicated to the research and study of the pharmacological effects of herbs. However, TCM practitioners are not attempting to disassemble formulas. In America, what is lacking to support the use of TCM in today’s model of mainstream medicine is a large enough number of RCT's, generating a statistically valid evidence base. This could be because of the complexities involved in designing a good enough TCM RCT.

The TCM diagnostic process is pattern-based; one Western based diagnosis may have multiple TCM patterns. Herbal treatments derive from the TCM diagnosis, and for each different TCM pattern of diagnosis, a different herbal formula is prescribed. Historically, herbal formulas are not taught to have a singular biological effect, via a single bioactive compound, that results in a measurable change in biological activity. Herbal formulas have multiple ingredients which exert different effects on various systems of the body. In addition, formulas contain herbal components that are protective and moderating in nature, that bring balance to the body. The authors kept the overall well-being of the patient in mind when they selected the combination of ingredients and not all of them are intended to be the primary active herbs in the formula.

On the importance of understanding herbal medicine, Margaret Chan, M.D. Director-General of the World Health Organization, explains; “nearly a quarter of all modern medicines are derived from natural products, many of which were first used in a traditional medicine (TM) context. TM is thus a resource for primary health care, but also for innovation and discovery.”3 For example the cornerstone of malaria treatment in the world today comes from Artemisiae annua Herba, known in TCM as qinghao, and as sweet wormwood in English. It was first used in a formula by the Chinese in the treatment of malaria. The development of artemisinin-based antimalarials represents one of the more recent innovative discoveries, from herbal based medicine to pharmaceuticals. This use of artemesinin as a stand-alone product, however, is not representative of how formulas treat TCM patterns of disease. This is an example of Western based reductionism, identifying a single bioactive ingredient found to be effective in the treatment of malaria.4

Alan Leshner, Ph.D., CEO, Executive Publisher, Science, states however, that the abundance of historical data to support the use of herbal medicine is not enough to bring herbal medicine into the mainstream. TCM researchers are turning their attention to the latest technologies “in an attempt to standardize traditional treatments, especially through identification and isolation of bioactive compounds and careful analysis of their levels and activities in various herbal remedies.” This idea is intriguing; it would allow for a greater understanding of formula function from a Western-based perspective and hopefully further the effort to integrate TCM and Western medicine. The goal of TCM research, however, should be clearly differentiated from pharmaceutical drug research.

The integration of Western medicine’s reductionism (“breaking down the body into ever-smaller parts in order to understand its inner workings”) and systems biology of TCM (“interactions between systems and networks”) can indeed bring the best of both models of healthcare to patients, Leshner explains. Western biomedicine excels at diagnosis made by measuring biological markers of activity, microbiology and cell biology, and TCM is unparalleled in constructing a multi-dimensional model of systems relationships, by way of including all the patient’s signs and symptoms. Western medicine is disease-based and TCM is pattern-based or Zheng-based. For example, a Zheng-based TCM diagnosis of Kidney Qi deficiency (which may or may not have anything to do with the Kidney organ) can be made for very distinctly different diseases in Western medicine known as arthritis, lupus, chronic obstructive pulmonary disease (COPD) and osteoporosis. Conversely, a diagnosis of any one of the above-mentioned Western diseases are refined by pattern-based diagnosis into a multiple number of subsets, this brings about a personalization of the diagnosis and hence the herbal medicine treatment.

Breaking down systems-biology-based TCM diagnoses into disease-based Western diagnoses—from multi-system to reductionist—is a tall task. It is possible in some cases to explain the effects of formulas based on the identification and isolation of bioactive compounds in the ingredients, but not all. The effects of some formulas go beyond that of the individual herb ingredients as synergies are created by the combination. This is found to be the case in the formula Yu Ping Feng San (Jade Windscreen), where none of the herbs studied alone are found to have as great an effect as they do in the combination. The strength in using a formula as opposed to a single bioactive ingredient is two-fold; it treats the whole body (not just the disease or the symptoms) and it generates less potential for side effects because of the moderating effects of some of the herbs.

The Reductionism of Zheng

In Western medicine a disease is a pathology with a specific set of signs and symptoms, often accompanied by measurable biological markers, that affects a particular part of parts of the body. In TCM a concept known as Zheng, syndrome or pattern, simultaneously affects multiple systems and it includes all the signs and symptoms with which the patient presents. This pattern, moreover, can be dynamic. This is the systems biology model of TCM. Explaining this concept at a reductionist biological and mechanistic level is the driving force behind modern TCM research or Zheng-driven research. Accurate Zheng diagnosis is what leads to effective herbal prescriptions.

In an attempt to find parallels between TCM pattern-diagnosis and Western medicine, researchers are currently attempting to find measurable biological markers to correlate to the eight-parameter TCM diagnostic approach of External-Internal, Heat-Cold, Excess-Deficiency, and Yin-Yang.

Biological mechanisms can indeed sometimes be correlated with TCM Zheng-based patterns in patients diagnosed with Western diseases. Rheumatoid Arthritis, for example, has been categorized in the eight-parameter approach into “hot” and “cold” types and the two patient groups display measurable differences in plasma and urine metabolite profiles. In another study, differences in muscle breakdown were used to distinguish between the “hot” and “cold” subtypes. Other studies of Chinese subtypes of pre-diabetes—namely qi and yin deficiency with or without dampness, and qi and yin deficiency with stagnation—show that the subtypes are characterized by variation in carbohydrate metabolism and renal function. Each of these subsets, of the same Western disease, in TCM Zheng-based medicine is treated with a different strategy and hence a different herbal formula, and patients with either a "hot" or "cold" type Rheumatoid Arthritis, for example, will be given different self-care management strategies.

Designing any good RCT is a lot of hard work, and the study of TCM herbal medicine is additionally challenging in that it requires that the patient population selected be based on the TCM pattern, not just the Western based diagnosis. For example, to study the effectiveness of a TCM formula for diabetes, the pattern the patients in the study present with needs to be specific to the formula being studied—qi and yin deficiency with or without dampness or qi and yin deficiency with stagnation. A single formula is not used in TCM practice for all patterns of the same Western disease, namely diabetes. Once a formula is identified as effective in a study, it needs to be specified as an herbal formula to treat diabetes specifically characterized by the TCM pattern. And thus a TCM diagnostic approach needs to be practiced by the individual dispensing the formula.

In the Science article, Yonghua Wang and Anlong Xu explain: “One particularly striking example is the systematic analysis of blood stasis and qi deficiency syndrome in coronary heart disease and the herbal drugs used to treat the syndromes. The results indicate that the herbs for eliminating blood stasis have pharmacological activity that acts to dilate blood vessels, improve the microcirculation, reduce blood viscosity, and regulate blood lipid, while qi-enhancing herbs have the potential for enhancing energy metabolism and anti-inflammatory activity.”

The Integration of Health Care

Because of the personalized and refined nature of the TCM pattern-based model, the integration of Western and TCM models will give patients and practitioners the ability to shift management styles from one that is disease-centered (reductionist) to one that is health-centered (systems-based). It will give patients the option to use herbal formulas that have fewer side effects and it will give them a whole-body systems-based understanding of their health. In China about 90% of general hospitals include a TCM department and provide TCM services for all patients. TCM medical institutions and Western-based medical institutions are governed by the same national legislation and patients can choose their form of health care, which may include both. I envision that this may take a long time to occur in America because of the complexities discussed. Therefore, in addition to consulting their Western medical healthcare provider, patients will benefit from seeing a TCM healthcare provider for a different but complementary approach to their health.

  1. Chiappelli et al. Evidence-based research in complementary and alternative medicine I: history. Evid Based Complement Alternat Med. 2005 Dec;2(4):453-8. Epub 2005 Nov 7.
  2. Chiappelli et al. Evidence-based research in complementary and alternative medicine II: the process of evidence-based research. Evid Based Complement Alternat Med. 2006 Mar;3(1):3-12. Epub 2006 Feb 5.
  3. Science [Science 346 (6216 Suppl) 2014].http://www.sciencemag.org/site/products/collectionbooks/TCM_Dec_19_issue...
  4. http://www.nytimes.com/2012/01/17/health/for-intrigue-malaria-drug-artem...

Comments

This is a well written and balance presentation of the two approaches to medicine. As one involved in Western healthcare and a patient of both, the author is to be commended in the presentation. The real benefit here is to the patient!!

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