The World Health Organization (WHO) was founded in 1948 as part of the UN. Among its principles set forth in its constitution is: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The WHO also recognizes that, “Evidence-based medicine vital for health and medical progress”.
So it is extremely disappointing that the WHO, in its latest International Classification of Diseases (ICD-11), has chosen to include a chapter on Traditional Chinese Medicine (TCM) diagnoses. David Gorski wrote about this several months ago, and since then there has been increased backlash against the WHO. Of note, there is an editorial in Nature critical of the decision. While the editorial is good, it does not go far enough, in my opinion.
The ICD codes are, as the name implies, an international standard for medical diagnoses. They are used in the US for billing and epidemiological records; all doctors are familiar with them and many, like David, are not fans. The codes are obsessively at the “splitter” end of the spectrum, and can make an otherwise simple task rather challenging and frustrating. But at least they are based in reality.
With the coming ICD-11, and the chapter on TCM, this is no longer strictly true. There is no way to honestly view the TCM chapter as anything other than a full-throated endorsement of pseudoscience in medicine. It describes the TCM entries as including:
Symptomatology: signs, symptoms or unique findings by traditional medicine diagnostic methods, including inspection such as tongue examination, history taking (inquiry), listening and smelling examination, palpation such as pulse taking, abdominal examination, and other methods.
The specific TCM methods are nothing but superstitious quackery. Tongue examination, smelling, and pulse diagnosis are not valid methods of medical examination, and do not relate to any actual disease or illness. They are the equivalent of the medieval European practice of carefully examining the color of urine in order to make diagnoses. They are as scientific as iridology or phrenology.
The WHO defends itself by saying that these codes are optional, and that they don’t specifically endorse any individual TCM treatment. But I think that they implicitly do, if not explicitly. In fact, listing response to treatment as part of the TCM diagnostic code is optional, but may be included. If you endorse a fake diagnosis that only has fake treatments, then you are endorsing the fake treatments by extension. There are no evidence-based treatments for the imaginary TCM diagnostic codes – so what do they think is the result of legitimizing the diagnoses?
To give an example of how this will be used, Acupuncture Today gave the following case:
TCM pulse: string-like.*
TCM tongue: dusky, thin white coat.*
If my patient is seeking an acupuncture treatment, in my notes I will write down a TCM diagnosis that I may select based on Channel Pattern Identification/Syndrome Differentiation. Migraine due to obstruction of lesser yang meridian.* If my patient is seeking an herbal treatment, in my notes I will write down a TCM diagnosis that I may select based on Visceral Pattern Identification/Syndrome Differentiation. Migraine due to ascendant hyperactivity of liver yang.*
There is simply no way to codify the “ascendant hyperactivity of liver yang” without endorsing the underlying pseudoscience. This patient has typical migraine – trying to understand it as a disorder of the yang meridian by examining the tongue is not science-based, and is completely disconnected from reality. But most importantly, the point of all this is to determine which unscientific treatment to give, such as which pattern of acupuncture to inflict on the patient. It is directly tied to treatment, and the WHO cannot pretend otherwise.
The same acupuncture article gives as a further justification for the ICD-11 (a common talking point for defenders) that it is necessary to capture morbidity and mortality data in countries that use TCM. However, these codes are optional, and the WHO specifically states cannot be used to capture such data. They must be coded in addition to a standard medical diagnosis. So this justification is nonsense – unless, of course, there are plans in ICD-12 to make the TCM diagnoses not optional.
The WHO’s downplaying of the implications of their coding system is also contradicted by the very people who are happy about it’s inclusion. As the Nature editors state:
TCM practitioners around the world have celebrated its incorporation into the document as crucial for the international spread of the system. So has China. On 26 May, a government newspaper called it a “major step for TCM’s internationalization” and a tremendous help in establishing TCM centres around the world.
Of course they are celebrating. I can also tell you, as someone on the front lines of trying to promote science-based medicine and oppose the infiltration of quackery into medicine, the fact that the WHO legitimizes TCM in this way is often used as a debating point to defend pseudoscience. It is also a frequent point of confusion for those who are just trying to understand what is going on. If TCM is not based on science, why does the WHO endorse it? There must be something to it, they reason.
Here is where I quibble with the Nature editorial:
Traditional medicine should certainly not be dismissed: sometimes it is all that’s available in many parts of the world. Some life-saving therapies have come from natural products, and there are doubtless more to be found. Famously, the gold-standard malaria drug, artemisinin, was discovered in China – isolated from sweet wormwood ( Artemisia annua), a herb used in TCM. It is also important to distinguish practices that do harm from those that might not work but are relatively benign, and those that might work but have not been tested rigorously.
This is an example of buying into the framing or propaganda of pseudoscience. The fact that effective drugs have been developed from plant-based or other natural sources is not contested – but it also is not in any way an endorsement of alternative medicine. It does not mean that any TCM diagnosis or treatment is legitimate. The fact that we purified opiates from poppy, or digitalis from foxglove, does not mean that the unscientific use of unpurified herbs to treat imaginary illnesses is in any way valid – let alone all the other treatment that don’t even use herbal drugs, but use magical treatments like yang meridians.
I also object to characterizing any pseudoscientific treatment as “benign”. Sure, treatments that cause direct harm are worse than those that do nothing, like homeopathy, for example. But an unscientific treatment that does not cause direct harm is not benign. There are many ways to cause harm other than direct physical harm, including distracting from and delaying effective treatments, fostering distrust in scientific and medical institutions, wasting resources, instilling false hope, and promoting pseudoscientific belief systems. None of these things should ever be confused with being “benign”.
You also have to be careful when referring to treatments that “might work but have not been tested rigorously”. These treatments may also not work, and may cause harm. If they haven’t been tested rigorously, we don’t know. But also, we can make predictions based on prior probability. I have not rigorously tested the practice of eating spiders in order to treat migraine headaches, and the practice may not cause direct harm, but that does not mean we just don’t know if it works and therefore it’s OK to promote the practice.
To its credit, the editorial also points out that TCM, in addition to promoting unscientific practices, is also a threat to many endangered species whose body parts are values as TCM treatments. So the WHO is now complicit in the threatening of species like the rhino and pangolin, whose parts comprise a multi-billion dollar TCM industry that has exhausted supplies in Asia and is now threatening species in Africa.
The WHO decision to include TCM in their ICD-11 codes is wrong, and should be vigorously criticized and opposed. This is now an important battle line in the struggle between science-based medicine and the promotion of rank quackery presenting itself as just “traditional” and desperate for legitimacy.