by Hong Hai
Institute of Advanced Studies, Nanyang Technological University (NTU)
The eminent and iconoclastic physician William Osler famously said: “The good physician treats the disease; the great physician treats the patient who has the disease.” 
Osler held the Regius Chair for medicine at Oxford and was a founder of Johns Hopkins Medical School in America. He would have received positive endorsement from traditional practitioners of Chinese medicine who, though lacking in knowledge of modern etiology (the science of causes of disease), were “patient-centric” like Osler’s “great” physicians, focussing attention on the particular internal imbalances and the qi flow disruptions that they detected in their patients.
The commonly-held view that Traditional Chinese Medicine (TCM) is patient-centric whilst Western medicine is disease-centric marks a persistent distinction between the methods of Chinese and Western physicians in the diagnosis and treatment of illnesses. Indeed it has often been observed, with some amusement, that one can always pick out a Western doctor from a Chinese one, not by the clinical garments that they wear (both wear white coats now in modern clinics), but by the focus of their eyes. One spends most of the consultation session looking at the computer screen as he talks to the patient just within his peripheral vision; the other focuses on looking at the patient and asking questions.
Notwithstanding contrasting styles, ideologies and medical interventions used, the two systems of medicine have in reality much in common, and indeed there is a glimmer of hope that they will eventually converge. This should not be surprising, given that their origins were very similar.
Chinese medicine began many thousand years ago with acupuncture using sharpened stones and records of the therapeutic properties of herbs gathered by the legendary Shen Nong (circa 2500 BC). It then had much in common with Western medicine in antiquity as practised in Greece and Rome by legendary physicians like Hippocrates and Galen. Concepts of humours resembled Chinese ideas of qi 气 and jing 精; some spoke of “affections” (pathe) rather than disease (nosoi), and the major affections like “depletion” and “repletion” were almost identical in nature to the Chinese syndromes of xu 虚 and shi 实 (weakness and excess).
Western medicine underwent a fundamental change around the 17th century AD when the Scientific Revolution in Europe resulted in startling discoveries in medicine like viruses and bacteria, the circulation of blood, synthetic antibiotics, and the unravelling of the molecular structure of cells and the DNA. Western medicine became “reductionist” in the sense of reducing all explanations and treatments to the microscopic level. The cellular and molecular biologists took ownership of medicine, becoming the basis of medical science and its governing ideology.
In China and neighbouring countries like Korea and Japan to which Chinese medicine had spread in ancient times, TCM is now taught through universities using textbooks written in modern language and interpreting ancient medical manuals. TCM also has a large following in Europe, America and Australasia. However, challenges to its scientific credentials persist from a generation of biomedical scientists nurtured in the reductionist medicine and preoccupied with the statistical methods of “evidence-based medicine”. Poor understanding of TCM concepts by biomedical scientists and Western doctors remains an impediment to the potential benefits of incorporating the proven parts of TCM into mainstream medicine.
Ironically, some Western countries have gone further in recognising TCM than some East Asian countries that already have long traditions in Chinese medicine. The TCM department at the renowned Cleveland Clinic in the United States offers herbal and acupuncture treatments despite acknowledging that many of the therapies lacked sufficient evidence from clinical trials of the kind accepted by modern Western medicine, but recognizing that the continued demand for such treatment by patients may well be borne out eventually by such clinical studies. Acupuncture is offered by state-licensed practitioners and eligible for insurance claims in most American states. In Australia, TCM enjoys growing popularity, and patients often need to make appointments more than six months in advance to see well-known Chinese physicians.
Before discussing the essential differences between TCM and biomedicine and conjecturing their convergence, l would like to deal with one of main objections of Western science to TCM, that it is not evidence-based.
The criticism that TCM is not “evidence-based” is not totally without merit. However it is valid only if being evidence-based is defined too narrowly, accepting only evidence that is in accordance with Western medicine's own gold standard of randomized controlled trials (RCTs). Such trials require patients to be distributed randomly among two groups. One group receives the medication, the other gets a placebo and the RCT must show that the group that receives the medication has better outcomes than the placebo group.
While few would disagree that medicine should be evidence-based, there is in fact no universal consensus as to what constitutes satisfactory evidence. In the People’s Republic of China and Taiwan, for example, doctors highly trained in both systems of deem that there is sufficient evidence for TCM medical interventions (acupuncture and herbal medications) for them to be used extensively alongside Western medicine in modern hospitals, even though most of them have not undergone rigorous RCTs.
It is important to recognize that the notion of evidence-based medicine has changed a great deal over time. Chinese and Western medicine have from ancient times been based on clinical experience with careful records kept by physicians. These records were regarded as good evidence, and medical books and training were based on conclusions drawn from such evidence. The great strides of Western medicine in the 19th and the first sixty years of the 20th century were made essentially with evidence derived in this fashion.
From about the 1960s however, there began a movement to apply advanced statistical methods to clinical trials. By the 1990s the term “evidence-based medicine” had taken on a new complexion. Institutions such as the National Institute for Health and Care Excellence (NICE) in UK established a hierarchy of methods for these trials, with the randomized clinical trial RCT at the top of the hierarchy as the gold standard. “Evidence-based medicine” became virtually synonymous with RCTs. But among the larger scientific community, there have been serious reservations over such a narrow view. As prominent of philosopher of science Prof John Worrall of London famously asked, given that the new “evidence-based medicine” was a relatively new movement, “What on earth was medicine based on before?”
Indeed the immense achievements in modern medicine made in the previous century were made without this new so-called “evidence-based medicine”. Ironically, an outstanding leader of evidence-based medicine, eminent British physician Sir Michael Rawlins and past chairman of NICE itself, severely criticized the notion of RCTs as the gold standard of evidence-based medicine. In his Harvein oration of 2008, he opined: “The notion that evidence can be reliably placed in hierarchies is illusory. Such hierarchies place randomized controlled trials (RCTs) at their summit with various forms of observational studies nestling in the foothills. Hierarchies place RCTs on an undeserved pedestal.”
Rawlins pointed out that other methods of evidence such as observational studies based on reliable past data were more appropriate in many situations. This resonates with the view of the World Health Organization that evidence for alternative medicine may have to be in a different form. 
At a more practical level, it is financially challenging for TCM drugs and other interventions to satisfy the requirements of RCTs. Most Chinese medicines are classic formulations with no patents. Large-scale RCTs require substantial funding, in the hundreds of millions of dollars, for a drug to pass drug regulatory tests like those of the FDA. Such costs can be borne by large pharmaceutical companies with deep resources, but they make it commercially infeasible for testing classical Chinese formulations for which no intellectual property rights can be claimed, and therefore there is no opportunity to recover the costs of clinical trials. RCTs, other than small-scale less costly ones, have therefore not been used extensively for TCM interventions. More rigorous use of case records and observational studies would be the more feasible way to go for providing credible scientific evidence for TCM methods, and these should be strongly encouraged. 
Modern medicine and its discontents
The challenges facing Western medicine are quite different, and somewhat more intractable.
In his acclaimed work The Rise and Fall of Modern Medicine, medical practitioner and writer James Le Fanu points out a puzzling paradox. Despite quantum leaps in medical science over the last 60 years since the discovery of the structure of the DNA and dazzling advances in molecular biology, we have failed to answer a basic question: “Reductionism, the explanation of the phenomena of disease at the most fundamental level of the gene and its products, fails to explain the fact that causes of common diseases are either age-determined or biological and for the most part unknown. Medicine’s post-war success, built on the chance discovery of drugs and technological innovation, concealed the fact that its impressive achievements had been won without the necessity to understand the nature or causation of disease. And now medicine still knows the cause of only a fraction of the diseases in the textbooks.”  Among the diseases the Le Fanu cites are multiple sclerosis, rheumatoid arthritis, schizophrenia, and most forms of cancer.
However, Le Fanu’s proposition that most diseases are idiopathic, or of unknown origin, is correct only if we think that only reductionist explanations make sense. TCM provides alternative explanations using its own holistic models and its interpretation of human physiology using its own sets of concepts like qi, meridians and organs. Diseases are caused by imbalances and disturbed flows in the body, which are the results of poor living habits as well as environmental and emotional stress. TCM theory argues that modern man changed his lifestyle and diet which through evolution were adapted to their previous natural environments. In doing so, the groundwork was laid for illnesses to emerge.
Another vexing problem of modern biomedicine is the ongoing controversy among nutritional scientists over what constitutes a healthy diet. Atkins, Noakes and others advocate a low carbohydrate diet with a relatively high content of animal proteins and unsaturated fat, whilst Campbell and Esselstyn claim epidemiological and clinical evidence for vegetarian diets with high carbohydrate and vegetable protein content. The recent USA health guidelines suggest that eggs and saturated fat are acceptable in moderate amounts, debunking the long-held belief that high cholesterol foods result in high blood serum cholesterol, and even casting a shade of doubt on the notion that high blood cholesterol levels increase the risk of cardiovascular disease.
TCM principles may indicate a way out of confusion over diet. TCM prescribes no correct common diet. Diet should be determined by each person’s constitution, his living environment and the syndromes that affect him from time to time, the guiding principle being that diet should help him attain yin-yang balance and smoothen the flow of qi and blood in his body.
That there is no magic common healthy diet for all could not have been better validated than by Buettner’s study of the ‘Blue Zones’ that boast the highest rate of centenarians in the world.  These enclaves of healthy high longevity populations include Sardinian shepherds from Cannonau county who have a high proportion of meat in their diets and drink the polyphenol-rich local red wine four times a day. Adventists in California by contrast thrive on a strict regimen of vegetarian delights and no alcohol. Greeks in the idyllic island of Ikaria feast on the Mediterranean diet rich in olive oil, nuts, vegetables and seafood. And Okinawan centenarians love generous helpings of fat-rich pork with their vegetables. No common dietary factor can account for their longevity. What they have in common is something that looks suspiciously like the Chinese way of life cultivation or yangsheng (养生).
TCM Yangsheng and “The Diseases of Civilisation"
The Chinese art of life cultivation or yangsheng offers a wealth of insights into the prevention of illness and a rich menu of lifestyle and dietary choices that can restore to health a person with a unhealthy constitution that has not yet developed into a serious disease.
In a masterly exposition of the role of lifestyle and diet as the fundamental cause of most chronic illnesses, the American physician Stephen Ilardi points the finger at nothing less than the march of human civilisation itself that has made Man live so differently from how he was adapted by evolution to live.  In so doing, Ilardi rediscovered the wisdom of the East: these illnesses are the ones that the Chinese medical classic Huangdi Neijing 黄帝内经 enjoined us to avoid by following its rules of yangsheng. Here in TCM yangsheng lies the hope of the convergence of Western and Chinese medical thought.
Ilardi depicts diseases ranging from cancer to depression as “diseases of civilisation”, arguing that Man was evolved in nature with natural foods and a high level of physical activity in daily life. Without electricity and household appliances, daily tasks were done by hand, and without trains and motor vehicles, our forefathers relied on their feet, keeping their bones, sinews and cardiovascular system in shape. Stress was largely confined to the occasional threat from a wild animal, which would typically be short and intense, for which we developed the fight-or-flight response of the sympathetic nervous system. All this was replaced in modern civilization with processed foods, little exercise other than short bursts in the gymnasium, and prolonged work and social stresses lasting months and years that wreak havoc on the parasympathetic nervous system.
The solution is to adjust our lifestyles and diets to be as close as possible to those of our forefathers before the industrial revolution and food processing technology changed our lives to be at odds with the environment in which our genes evolved. Ilardi calls the change in modern living environment “radical environment mutation”: the environment mutated but our genes have never caught up with this new environment. His prescription for overcoming the “diseases of civilisation” bears a striking similarity to the injunctions of the Neijing: observance of regularity in living habits, moderation in diet, mastery over emotions, exercises that promote qi and stimulate smooth flows and balance in the body, and the avoidance of climatic stresses. This paradigm in effect prescribes the attainment of health through lifestyles consistent with our evolutionary origins.
A conclusion one can draw from the work of scientists like Ilardi and Le Fanu is that reductionist medicine is inadequate for dealing with some of the most fundamental questions of health such as the cause of disease and the right foods to eat. Holistic medicine such as TCM, no matter how abstract its concepts and simplistic its heuristic models, offer alternative views that may well help.
There is hope in the new science of systems biology. This focuses on interactions within biological systems, and is more holistic than reductionist as its principal aim is to model cells and tissues functioning as a system with complex internal networks. This new dimension of biomedical science holds promise in the longer run for a kind of convergence of biomedicine and TCM.
Part of the materials for this article has appeared in the author’s Principles of Chinese Medicine: A Modern Interpretation, Imperial College Press 2016 and Pursuing the Elixir of Life: Chinese Medicine for Health, World Scientific 2017 (with Karen Wee).
Pursuing the Elixir of Life (Book cover picture) from Hong Hai’s private files
About the Author
Hong Hai is Adjunct Professor and Senior Fellow at the Institute of Advanced Studies, Nanyang Technological University (NTU) and former Dean and Professor at NTU’s business school. Trained originally in engineering and economics, he had an earlier career as chief executive of a pharmaceutical company before studying Chinese medicine and the philosophy of science, graduating with an MD (Beijing University of Chinese Medicine), MPhil (Cambridge) and PhD (London). His doctoral dissertation critically examined the scientific basis for Chinese medical theory. A former member of the Singapore parliament, Professor Hong Hai has chaired the Government parliamentary committee on health, and was a founding member of the Singapore Ministry of Health’s TCM Practitioners Board and chairman of its academic committee. He practises medicine part-time at the Renhai Clinic, which he founded. He has published five books on various aspects of Chinese medicine.
- William Osler Quotes. https://www.brainyquote.com/quotes/authors/w/ william_osler.html (retrieved 8 September 2016).
- Dr Margaret Chan, Director-General of the World Health Organization. Opening remarks at the International Forum on Traditional Medicine ,China, Macao SAR, August 19th, 2015. https://who.int/dg/speeches/2015/traditional-medicine/en/ retrieved Sept 29th, 2016
- A detailed discussion of this subject may be found in Chapter 8 of the author’s Principles of Chinese Medicine: A Modern Interpretation (2nd edition, Imperial College Press, 2016)
- Le Fanu, J (2011). The Rise and Fall of Modern Medicine. New York: Hachette Digital. (The quotation has been slightly edited from several passages on pages 405–495.to read more smoothly.)
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- New York Times (2015) https://well.blogs.nytimes.com/2015/02/19/nutrition-panel-callsfor- less-sugar-and-eases-cholesterol-and-fat-restrictions/. Retrieved Sept 29th, 2015.
- Buettner, D (2008). The Blue Zones. Washington: National Geographic.
- Ilardi, S (2013) “Depression is a disease of civilization”, TED talk May 2013. https://www.youtube.com/watch?v=drv3BP0Fdi8 (retrieved 10th May, 2015)