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TCM’s integration into modern health system
A philosophical illustration and medical approach to TCM’s role in mainstream healthcare.
by Dr. Loh Cheng Toa Steven

A few days earlier, before the composing of this article, Nobel laureate Tu YouYou and her team announced good news to the world on a breakthrough in finding a temporising solution to “Artemisinin Resistance”.1

CNN International Edition’s coverage on 26 May 2019 reported that a day earlier, the governing body of the World Health Organization, known as The World Health Assembly, formally approved the latest version of its influential global compendium, which includes a chapter on traditional medicine for the first time. This once again put Chinese medicine in the limelight.

Chinese medicine, also known as Traditional Chinese Medicine (TCM), has gained popularity not only in the Asia Pacific region, but in the Western world as well. In Singapore, TCM is gaining wider acceptance as an alternative or complementary medication as the population ages.

It is traditionally viewed as a local remedy, health supplement or health booster, but to the general public at large, they may not be fully aware of its wide spectrum of treatment for illnesses that are highly similar to western medicine.2 In order to get a clearer perspective of TCM’s befitting role in the mainstream healthcare, it would be useful to understand its philosophy and its medical approach.

The philosophical perspective

TCM adopts a unique view of the human body and illness as compared to western medicine. The body consists of meridians, which are energy collective nodes known as acupuncture points (or acupoints).

Qi, in the form of bioenergy, constantly passes through the meridians and at some points they are stored or transferred to a deeper realm where it is used in various organs. At other points, they manifest themselves from latent state and energises an organ-meridian depending on time of day and needs. The concept of organs has wider definition as well. Not only does it encompass the organ itself, but also includes a macro functional behavior of the body.

For example, a person at temperamental moment or under stress, will see their Liver Qi energy blocked, and the build-up energy due to this congestion leads to a rise in heat level, further agitation and eventually cause illness.

Like the binary concept in numerical world, TCM’s world of perception is divided into Yin and Yang, namely the two poles of existence in nature, such as hot and cold, day and night, hyper and hypo etc. Human body, health and illness, mimics the behavior of nature and is therefore subjected to its changes. Likewise, the organs are mapped against the Chinese philosophical description of nature, where all states fall under the five elements in nature: Wood, Fire, Earth, Metal, Water; which also coincides with the five seasons: Spring, Summer, Long Summer, Autumn and Winter, according to the Chinese calendar. The five elements correspond to the five organs: Liver, Heart, Stomach, Lungs, Kidneys, of which, they have close interrelationships of generating and restricting each other.

For example, Wood generates Fire, which in turn generates Earth; on the other hand, Wood restricts Earth which in turn restricts Water, and the cycles goes on. The relationships are mapped in such a way because they exhibit similar patterns of behaviour both physiologically and pathologically, when expressed in terms of Qi, blood, Yin and Yang.3 Active agents in the body such as Blood (circulatory in western science), Qi pathways and Fluid are each characteristically unique, and may coincide with the western science concept in certain areas.

The medical perspective

In the diagnosis process, TCM has a very comprehensive list of questions in addition to pulse taking and tongue reading. Having decided on the type of illness, the physician will then narrow down to the subtypes, also known as differentiations, of the illness. The corresponding treatment will be administered to the patient. If it requires acupuncture, the set of acupoints will be used according to the subtype of illness and the patient’s physiological orientation (Strong, weak, old or young). If internal medicine is required, Chinese medicine (CM) in different forms may be prescribed according to subtypes, duration of illness, physique of patient and other influencing factors.4

The differences between Chinese and western medicine (WM) are outlined below:

  1. Broad based vs Streamlined:
    CM usually deals with multiple symptoms in addition to the main problem; WM most times deals specifically with the main ailment.
  2. Apply to various organs/systems vs local targeting (organ/tissue/nerve/cell):
    Due to the multi-target and multi-level nature of CM, and the principle of tackling a problem from various directions, CM usually adopts a broad base approach as oppose to WM which focus locally.
  3. Drug potencies:
    CM is generally used as it is, brewing and extracting the essence from its herbal state. Comparatively, WM is synthetic with high concentration, giving them higher potencies. This is the reason why CM only takes up the supplementary role instead of being first line medicine when it comes to controlling illnesses such as hyperlipidemia and hypertension.
  4. Drug toxicities:

  5. Some common CM are food grade that are readily found in our daily diet. Considering the most potent drug with the strongest side effect, CM is still far from that of its counterpart. In fact, to be intoxicated by CM, one or few conditions have to exists: i) use of singular herb (which is rare as CM always come in combination formulae); ii) very high dosage (way out of recommended dosage depicted in text books and herbal dictionaries); iii) prolong use (one of the characteristics of CM is the dynamic change in prescription so as to keep up with the progress of treatment and recovery). In other words, a singular herb, at high dosage under prolong use, will lead to adverse effect regardless of the type of herb. After all, toxicology studies in in both east and west, is the most fundamental requirement in prescription.

    Summing the above, we see the intrinsic difference between the two. On a relative scale, CM is slower in effect, milder on potencies, with fewer or no side effects, and provides nourishment/boosting immunities as compared to eliminating pathogens or suppressing conditions in WM. Conceptually in healing, WM adopts a micro-management approach whereas CM follows a macro-management path. It is noteworthy that putting the two together provides the most optimum control, with less side effects while ameliorating overall health conditions.

    On the other hand, due to the nature of illness, both work along the same principle of providing long term control and maintenance in cases of irreversible damage, such as stroke, kidney failure, prolonged and severe cases of hypertension and diabetes etc.

Illustration on optimal combination

Local practice of using both CM and WM will order a two hours gap apart to eliminate possible interactions, if any. The order and sequence of using both medicine, and the proportion of involvement in a treatment process are illustrated in Figure 1 and 2. Figure 3 depicts the use of CM in a sub-health maintenance.

At the beginning of treatment, WM initiates with strong fast control while CM gradually adds on as supplemental aid. Upon control/containment of disease, WD steps down one notch with CM gaining in dosage. Towards elimination of disease, WM withdraws/keeps at minimum level, while CM plateaus at maximum dosage. Maintenance at plateau with CM serves to boost immunity and prevent relapse. At tail end, CM readily reduces, or converts to diet supplement to further strengthen immunity and prevent future reoccurrences.

For typical cases in cancer patients, where standard protocol of surgery followed by chemo/radio therapy is given, the patient experiences very strong side effects from the therapies. CM provides a means to reduce side effects, discomfort, maintains quality of life and boost immunities.5,6 CM are usually given before and after surgery to speed up recovery, and in tandem to chemotherapy to reduce discomfort. This prepares the patient for the next round of therapy and effectively reduce the rate of patients dropping out of the program.

Illustration shows impact of overall health with the use of CM in conjunction with lifestyle changes and psychological/environmental factors. In the initial phase, patient has low quality lifestyle, which includes diet, sleeping, drinking, toilet frequencies and exercise habit.7 CM use will progressively increase over the next two phases, with patient’s conscious effort to improve lifestyle. Overall health improves proportionately with increasing CM and improved habits. Psychological factors such as stress, pressure from work and environment conditions (noise pollution, hygiene factors etc.) remain constant. Phase 4 sees a small reduction in Psy/Env, presumably patient is more resilient to unfavourable external conditions and is experiencing less “stress”. Notably, after patient attains reasonable overall health, CM reduces encouraging the body to “take over”, as well as compelling stronger participation on the patient’s part to further improve lifestyle. Overall health is maintained at optimum level.

Research

As part of the effort to integrate into the mainstream healthcare, whether serving the quest of continual self-improvement or to fulfill social-legal obligations, scientific studies and evidence-based researches are necessary and strongly called for. However, this remains a challenging task.

Due to the nature of Chinese herbal medicine, and its use in combination with various components (ranking of the compositions), knowing its main efficacy for a particular condition is attainable, but to fully understand all relationships and cause-and-effects it has on the body remains a great challenge. Bearing in mind that each herb is multi-targeted, multilevel and multi-link in effect; various herbs in amalgamation will produce a more complex second tier effect; in-vivo absorption will produce a third-tier effect. Notwithstanding the fact that individual difference in age and physique plays an equally important part in the reaction and efficacy of the medicine.

Another characteristic in the application of CM is the dynamic adjustment of prescription during the process of treatment, allowing it to capture the finest change in the body system and target those changes accordingly. In order to avoid missing the forest for the trees, a bird’s eye view and evaluation for the entire timeline of treatment would be crucial.

Studies and methodologies proposed by various experts such as: 1) "targeted drug combination of disease pathophysiology guidance"8; 2) the pharmacokinetic-pharmacodynamic compatibility method9,10; 3) the Global Systems Biology for Integrative Genomics, Proteomics and Metabolomics11,12, synergistically integrated to provide a wider scope, fuller details, and development time-line, may perhaps come close to revealing the full picture of the effects of compatibility prescription.

Establishing a framework that is unanimously accepted by the research community on the study of prescription compatibility in CM (or any medicine for the matter), may help to bridge differences between Chinese and western medicine, synergise philosophies of East and West on drug applications and shed more light to a current predominantly random and scattered research environment.

Conclusion

Singapore being one of the more economically established country among the Asia pacific region, has a good reputation for her medical services. If there is room for improvement, that would be in the further development of TCM, or better, the integration of Chinese and Western medicine.

The practice of CM and WM are currently rather detached, not only in terms of distance (there are only a handful where CM and WM are housed under the same roof), but from a medical practice and administrative perspective. All integrative ideas and proposals mentioned above are only realisable if CM and WM are working on a common pool of patients, on the same platform, with shared medical records and possibly consultation by panel of Physicians and Doctors. For this to happen, an Integrative or Chinese Medicine hospital may be a suitable platform. Excellence can only be achieved with the right support and infrastructure, which in turn provide suitable breeding ground for excellence. The mutually dependent cycle goes on.

Much as there are still great challenges ahead, such as medical, social and research hurdles, one thing can be certain: a synergistic effect of East and West would yield a favourable result of 1+1>2.

References:

  1. Wang, J., et al. (2019). "A Temporizing Solution to “Artemisinin Resistance”." New England Journal of Medicine 380(22): 2087-2089.
  2. 谢建群. Chinese Internal Medicine (International Standard Library of Chinese Medicine) 中医内科学(国际标准化英文版中医教材). 人民卫生出版社. 2013-09-15. ISBN 978-7-117-17255-4/R·17256.
  3. 蒋燕、孟凡毅、李晓海. Basic Theory of Chinese Medicine中医基础理论. 人民卫生出版社. 2016-09-08. ISBN 978-7-117-23158-9/R·23159.
  4. 王天芳、孟凡毅、陈业孟. Chinese Medicine Diagnostics中医诊断学(英文版). 人民卫生出版社. 2019-02-28. ISBN 978-7-117-27663-4/R·27664.
  5. Chen, J., et al. (2018). "Clinical study on postoperative triple-negative breast cancer with Chinese medicine: Study protocol for an observational cohort trial." Medicine (Baltimore) 97(25): e11061.
  6. Pan, B., et al. (2018). "Add-On therapy with Chinese herb medicine Bo-Er-Ning capsule (BENC) improves outcomes of gastric cancer patients: a randomized clinical trial followed with bioinformatics-assisted mechanism study." Am J Cancer Res 8(6): 1090-1105.
  7. Wang, W. and Y. Yan (2012). Suboptimal health: a new health dimension for translational medicine.
  8. 徐砚通. 方剂配伍的现代科学内涵探讨. 中草药. 2015;46(04):465-9.
  9. 王战国, 胡慧玲, 兰轲, 蒋学华. 试论基于代谢组学与方证理论的药效学-药动学方法研究中药复方配伍规律. 中草药. 2009;40(02):169-72.
  10. 王喜军, 张伯礼. 基于药物代谢组学的方剂配伍规律及配伍科学价值揭示. 中国中药杂志. 2010;35(10):1346-8.
  11. Sato Y, Suzuki I, Nakamura T, Bernier F, Aoshima K, Oda Y. Identification of a new plasma biomarker of Alzheimer's disease using metabolomics technology. Journal of Lipid Research. 2012;53(3):567-76.
  12. Roberts MJ, Schirra HJ, Lavin MF, Gardiner RA. Metabolomics: A Novel Approach to Early and Noninvasive Prostate Cancer Detection. Korean J Urol. 2011;52(2):79-89.

Dr. Loh Cheng Toa Steven is senior physician at the Nanyang Technological University (NTU) Chinese Medicine Clinic.

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APBN Editorial Calendar 2019
January:
Taiwan Medical tourism
February:
Marijuana as medicine — Legal marijuana will open up scientific research
March:
Driven by curiosity
April:
Career developments for researchers
May:
What's cracking — Antibodies in ostrich eggs
June:
Clinical trials — What's in a name?
July:
Traditional Chinese medicine in modern healthcare — Integrating both worlds
August:
Digitalization vs Digitization — Exploring Emerging Trends in Healthcare
September:
Healthy Ageing — How Science is chipping in
Editorial calendar is subjected to changes.
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