Much like politics, raising the subject of complementary medicine at a dinner party can pose a serious threat to congenial discussion. Dropping like a meteorite into that polarising fray comes a commentary on regulation of Traditional and Chinese Medicine (TCM), published in the Journal of Alternative and Complementary Medicine (JACM).
Its authors, Nadine Ijaz, from the Arts and Science Program at McMaster University, and Heather Boon, from the Leslie Dan Faculty of Pharmacy, University of Toronto, both in Canada, argue that regulating TCM under a western “biomedical model” is not only wrong-headed, but extends the predatory nation-gobbling of European colonialism to the medical arena.
The result, they contend, is that traditional health practices such as moxibustion (burning mugwort over acupuncture points), Ayurveda and Unani (medical systems tracing back to Indian and Hellenic cultures respectively) risk being absorbed by a dominant therapeutic culture that could, ultimately, wipe them out.
“[T]raditional medicine treatments and practices have long been subjugated, devalued, co-opted, and in some cases decimated across the globe within the context of European colonisation,” they write. “Still today, many indigenous healthcare systems remain under threat due to colonisation’s impacts.”
There are plenty of reasons to see that as a problem.
For a start, the authors cite data suggesting up to a quarter of modern medicines are derived from natural products. It’s worth recalling, also, that a 2015 Nobel Prize was awarded to Chinese researchers for extracting a malaria drug from the wormwood herb.
Then there’s the glaring fact that, according to the World Health Organisation (WHO), nearly 100 million Europeans are current TCM users. In Australia, 30 to 40% of GPs use complementary medicine in their practice and 75% refer patients for it.
Moreover, as JACM Editor-in-Chief John Weeks notes in an accompanying editorial, Western medicine has notched up a litany of deaths from medical error, memorably detailed in the landmark US Institute of Medicine report “To Err is Human”, published in 1999. Nor have things improved much.
A 2016 report in the British Medical Journal estimated medical error to be the third leading cause of death in the US, claiming more than 251,000 lives annually.
TCM emerges from all this as a precious, yet threatened, species upon which regulation must tread carefully – a task, the authors argue, facing a bevy of obstacles.
First and foremost, they write, are the “evidentiary tensions that surround traditional medicine’s political subjugation to Western biomedical knowledge systems”. Gold standard evidence in mainstream medicine is the clinical trial, which uses a control arm and randomised patient allocation to aim at a uniform, if aspirational, benchmark.
That format doesn’t fit so well with traditional healing.
“Indigenous knowledges can never be standardised,’’ write the authors, “due to their inherent internal diversity and living dynamic character.” But they also take issue with the very idea that the Western model could ever be an impartial arbiter.
“[B]iomedicine is widely and falsely universalised as ‘culturally neutral’.” they write.
“Far from being an ‘unbiased’ system of healthcare, biomedicine is itself a cultural artefact, rooted in the European scientific revolution and the linear reductionism of Rene Descartes and his contemporaries.”
Descartes saw the workings of the body as something that could be explained, machine-like, by analysing its constituent bits and bobs. Likewise, modern healthcare often cops it for treating people as bags of symptoms, in contrast to the ethos of complementary therapy to treat the “person as a whole”.
And it is precisely because of those cultural roots, the researchers say, that when biomedicine tries to bring traditional health knowledge under its regulatory umbrella, bad things happen.
One of those things has a longish name.
“Paradigm assimilation,” write the authors, is a, “‘predatory’ strategy [that] ‘reinterprets’ a particular healthcare approach from an indigenous system, reframing the approach in biomedical terms.”
The vision conjured is one of Western medicine ingesting, multinational-like, defenceless minnows in the world of healthcare. It is a threat for which the authors invoke high level support.
In its Traditional Medicine Strategy, the WHO stresses the need “to protect the intellectual property rights of indigenous peoples and local communities and their health care heritage.”
Ijaz and Boon make much of this, casting TCM regulation as an intellectual property claim over bodies of indigenous knowledge. The looming threat is one, no less, of “cultural misappropriation — in other words, the abuse of indigenous medical intellectual property”.
The authors call for wide-ranging discussions on how best to protect traditional knowledge and prevent “further misappropriation”, while conceding that “additional work will be needed to elaborate upon how these principles may be operationalised.”
What to make of it all?
At the very least, the commentary raises the gnarly issue of whether knowledge can ever be “relative”. Many people tolerate the idea that cultural values – a tribal predilection to get about naked, for example – are fine for that group, even if we might not be so keen. “Relativism” about values isn’t so hard to swallow.
A lot of those folk would, however, get jittery at the idea that facts – knowledge itself – could be relative. The molecular structure of water, from wherever you look at it, is H2O. Just as chemistry could never be a cultural artefact, the actual effects of a medicine, surely, are discernible irrespective of cultural belief.
On that score, it might also be argued that people tend to vote with their feet when things go down to the wire. A diagnosis of cancer or HIV, for example, can make people especially partial to treatments that have stood the tests of rigorous “biomedicine”.
One wonders, then, if cultural imperialism might be something of a straw man in the argument of Ijaz and Boon.
Few dispute that traditional cultures should be protected and knowledge preserved. But that is a long way from saying that cultural longevity confers legitimacy on a health treatment. By turning the torch on colonialism are the authors sidestepping the awkward fact that the real threat to traditional medicine comes from science, a discipline that bridges the global North and South?
The back-story is that practitioners of traditional medicine (Ijaz is a medical herbalist and shiatsu therapist) have good reason to see the randomised clinical trial (RCT) as a threat. One criterion of the US Food and Drug Administration (FDA) for approving medicines is that they been shown superior to placebo on two RCTs. It’s a standard that could ring the death knell on some TCM practices, should they be compelled to conform to it.
Which, of course, plays to the authors’ point that the Western model threatens to extinguish many venerable and ancient therapies.
Remember, though, that plenty of Western medicines fall at the very same hurdle. An infamous recent example was researcher Irving Kirsch’s use of Freedom of Information to unearth 47 failed antidepressant trials from the FDA, trials subsequently buried by the parent pharmaceutical companies.
If Western medicine is predatory, then, it also eats its own.
Ken Harvey AM, of the School of Public Health and Preventive Medicine at Monash University in Melbourne, Australia, points out the debate has special relevance in his country just now.
The Australian Therapeutic Goods Administration recently issued a determination that means, says Harvey, 86% of over 1000 complementary product claims can be supported by appeal to “traditional” evidence.
That’s a problem because, as Harvey writes in a letter he (and colleagues from lobby group Friends of Science in Medicine) will send to federal senators objecting to the determination, traditional evidence doesn’t rate on the National Health and Medical Research Council’s levels of evidence. Worse, consumers are apt to confuse it with scientific evidence.
“Ultimately, it’s all about ensuring consumers can make informed decisions about conventional, complementary and alternative medical practice and products considering cultural needs, quality, safety and efficacy,” says Harvey. This, he adds, needs “creative regulation and a lot of education.”
Complicating things further is the fact that many complementary, and indeed Western medicines may work via the placebo effect, a mind-body healing mechanism with ever deepening scientific roots.
All of which leaves consumers in something of a quandary. The regulatory morass, varying standards of evidence, and competing claims, can make an answer to their most pressing question seem like a receding dream.
What, when all is said and done, actually works?
Paul Biegler is a philosopher, physician and Adjunct Research Fellow in Bioethics at Monash University. He received the 2012 Australasian Association of Philosophy Media Prize and his book The Ethical Treatment of Depression (MIT Press 2011) won the Australian Museum Eureka Prize for Research in Ethics.
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